PO:28:128 | Rheumatic fever: an atypical case

Giovanni Italiano¹, Melania Coscia¹, Arianna Monteforte¹ | ¹AORN S. Anna e S. Sebastiano Caserta, Italy

R.P., 37 years old, originally from SRI LANKA, was hospitalized at the Internal Medicine Unit of the AORN Sant'Anna and San Sebastiano in Caserta for a clinical-laboratory picture characterized by fever, arthralgias with prevalent functional limitation in the upper limbs and increased inflammation indices. The patient presented febrile. In the anamnesis there was no history of pathology except for an episode of rheumatic fever in pediatric age. Blood chemistry tests showed normochromic normocytic anemia, platelets, neutrophilic leukocytosis, significant increase in inflammation indices, with negative procalcitonin (entry values shown in table 1). Exam Value Hb 10.3 g/dL PLT 403.000/mm3 WBC 14.500/mm3 Neutrophils 11.790/mm3 CRP 25.38 mg/dL SVES 120 PCT 0.83 TAS 309 Table 1 On culture tests, no signs of infection in progress; the Quantiferon test was negative; the results of the Vidal-Wright and other infectious disease tests practiced were also negative. The total body CT scan, performed to exclude paraneoplastic genesis of fever, showed .. to the right kidney nuanced corticomedullary areoles of reduced enhancement in the late phase (nephritic areas?) The urine test showed no signs of pathology. The MRI of the spine as a whole, performed to exclude foci of spondylodiscitis, was normal. Autoimmunity was negative. An echocardiogram was therefore carried out which showed the presence of material deposit at the level of the mitral valve, suspicious of endocarditic vegetation. Empirical antibiotic therapy was therefore undertaken, but without clinical-laboratory benefit. The patient continued to present with fever and diffuse arthralgias. Culture tests were repeated, which were negative: no microorganisms were isolated. Given the positive history of rheumatic fever in pediatric age, the suspicion of exacerbation of rheumatic fever with endocardial involvement was therefore posed. Therefore, steroid therapy was undertaken, with rapid resolution of fever and arthralgias, improvement of general clinical conditions, clear improvement of laboratory parameters (values in table 2) and resolution of the echocardiographic picture: in fact, echocardiographic examination was repeated and it showed the absence of vegetations. Exam Value Hb 10.4 g/dL PLT 342.000/mm3 WBC 10.700/mm3 Neutrophils 5.880/mm3 CPR 2.78 mg/dL VES 25 PCT 0.02 Table 2 The patient was discharged home with an indication to continue low dose of steroid with subsequent tapering until suspension and antibiotic therapy with penicillin to be continued as prophylactic therapy for rheumatic fever. The patient is currently in clinical well-being and continues outpatient follow-up.