Differentation of Post-Streptococcal Reactive Arthritis from Acute Rheumatic Fever

doi:10.1016/j.jpeds.2008.05.044

The Journal of Pediatrics

Volume 153, Issue 5, November 2008, Pages 696-699

https://doi.org/10.1016/j.jpeds.2008.05.044 Get rights and content

Objective

To perform a retrospective study comparing clinical and laboratory aspects of patients with acute rheumatic fever (ARF) and patients with post-streptococcal reactive arthritis (PSRA), to discern whether these are 2 separate entities or varying clinical manifestations of the same disease.

Study design

We located the records of 68 patients with ARF and 159 patients with PSRA, whose diseases were diagnosed with standardized criteria and treated by 8 pediatric rheumatologists in 7 medical centers, using the Israeli internet-based pediatric rheumatology registry. The medical records of these patients were reviewed for demographic, clinical, and laboratory variables, and the data were compared and analyzed with univariate, multivariate, and discriminatory analysis.

Results

Four variables were found to differ significantly between ARF and PSRA and serve also as predictors: sedimentation rate, C-reactive protein, duration of joint symptoms after starting anti-inflammatory treatment, and relapse of joint symptoms after cessation of treatment. A discriminative equation was derived that enabled us to correctly classify >80% of the patients.

Conclusion

On the basis of simple clinical and laboratory variables, we were able to differentiate ARF from PSRA and correctly classify >80% of the patients. It appears that ARF and PSRA are distinct entities.

Section snippets

Methods

We located patients, <16 years old, who received a diagnosis and were treated by 8 pediatric rheumatologists from 7 centers who participated in the Israeli internet-based pediatric rheumatology registry.⁷ We searched for patients in whom ARF was diagnosed with joint involvement and patients with a diagnosis of PSRA between the years 1996 and 2005 (most after 2001). A total of 159 patients with PSRA and 68 patients with ARF for whom there was sufficient analyzable data were found.

ARF was

Results

There was no significant difference in the 2 groups in demographic characteristics. The age of onset was 10.2 ± 3.0 years for ARF and 9.3 ± 3.6 years for PSRA. A total of 63% of patients with ARF and 54% of patients with PSRA were male, and the number of persons in the household was 5.9 ± 1.5 for ARF and 6.5 ± 2.1 for the patients with PSRA. A family history of ARF in first- or second-degree relatives was found in 7.2% of the patients with ARF and 7.5% of the patients with PSRA.

The clinical and

Discussion

Two recent studies attempted to answer whether ARF and PSRA are distinct entities and to validate the diagnostic criteria proposed by Ayoub and Ahmed.⁶ Tutar et al⁹ compared 24 children with PSRA with 20 patients with ARF. The latency period from upper respiratory tract infection was significantly shorter in patients with PSRA; however, 25% of the patients with ARF also had a short latency period. Unresponsiveness of articular symptoms to salicylate therapy was more frequent in PSRA, but also

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Moreover, there can be significant overlap of PSRA and ARF with other disorders such as Lyme disease, serum sickness, and drug reactions [4,25]. Barash et al. [26] compared clinical and laboratory aspects of children with ARF and patients with PSRA. Four variables were found to differ significantly between ARF and PSRA and serve also as predictors: ESR, CRP, duration of joint symptoms after starting anti-inflammatory treatment, and relapse of joint symptoms after cessation of treatment.
Reactive arthritis after Group A streptococcal infection (poststreptococcal reactive arthritis: PSRA) that does not meet the Jones criteria for acute rheumatic fever (ARF) has been reported as a new entity for over a decade. In Japan there are few reports of PSRA. We encountered four children with arthritis accompanied with Group A streptococcal infection in our department. We investigated our cases and the recent Japanese literature. Japanese cases of PSRA are frequently accompanied with uveitis and erythema nodosum, and tonsillectomy resolved their symptoms in some cases. There were overlap cases between ARF, juvenile idiopathic arthritis, and PSRA.
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At baseline, 18% (n = 7) had echocardiography findings such as mild mitral and/or aortic insufficiency or mitral valve prolapse, and 2 patients with a normal baseline echocardiogram may have developed findings after 12 months of follow-up.14 Barash et al. evaluated 152 pediatric patients with PSRA, none of whom developed carditis on follow-up.13 Patients from the ARF group who did not have carditis were reassigned to the PSRA group because of the rare diagnosis and similar clinical features.
Acute rheumatic fever (ARF) and post-streptococcal reactive arthritis (PSRA) are immune-mediated consequences of group A streptococcal pharyngitis. ARF has declined in developed nations. No prevalence survey of PSRA has been conducted. This study evaluated the incidence and characteristics of ARF and PSRA in Japanese children.
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From 323 hospitals (61% response rate), 44 cases of ARF and 21 cases of PSRA were reported. Patients with ARF and/or PSRA were mainly from large cities in Japan. The mean age of ARF occurrence was 8.5 years, and the ratio of female/male patients was 16:28. Major manifestations in the acute phase included carditis, 27 cases (61.4%); polyarthritis, 22 cases (50%); erythema marginatum, 7 cases (15.9%); Sydenham chorea, 3 cases (6.8%); and subcutaneous nodules, 1 case (2.3%). Twenty-one (58.3%) patients had migratory arthritis. During the follow-up period, 6 patients (13.6%) showed mild carditis. For PRSA, the mean age was 8.2 years, and the ratio of female/male patients was 12:9. Six (28.6%) patients had monoarthritis, and 4 (19%) patients had migratory arthritis. No patient had carditis.
Although ARF and PSRA are rare in the Japanese pediatric population, substantial numbers of patients with both conditions were identified in this study. We observed a high incidence of arthritis and carditis in ARF patients. No PSRA case was complicated with carditis. General pediatricians need to have updated information about ARF and PSRA, even in industrialized countries.
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Inflammatory markers (CRP and ESR) are moderately raised as compared with acute rheumatic fever. Another distinguishing feature of PSRA is its poor to moderate response to acetylsalicylic acid or nonsteroidal anti-inflammatory drugs (NSAIDs) [104]. Although the classical triad of symptoms involving the urethra, conjunctiva, and synovium is considered typical of ReA, most patients do not have these complaints [105].
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: Drs Hashkes and Uziel have contributed equally to this study.

: The authors declare no potential conflict of interest.

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Original articleDifferentation of Post-Streptococcal Reactive Arthritis from Acute Rheumatic Fever

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Semin Arthritis Rheum

Post streptococcal disease of childhood: a changing syndrome

Arthritis Rheum

Special writing group of the committee on rheumatic fever, endocarditis and Kawasaki disease of the council on cardiovascular disease in the young, American Heart Association Guidelines for the diagnosis of rheumatic fever: Jones criteria, updated

JAMA

Prognosis of children with poststreptococcal reactive arthritis

Pediatr Inf Dis J

Poststreptococcal reactive arthritis and silent carditis: a case report and review of the literature

Pediatrics

Beta hemolytic streptococci and reactive arthritis in adults

Ann Rheum Dis

Update on the complications of group A streptococcal infections

Curr Probl Pediatr

The Israeli Internet-based registry: novel concept of multicenter data collection in pediatric rheumatology

Ped Rheum Online J

Original article
Differentation of Post-Streptococcal Reactive Arthritis from Acute Rheumatic Fever