Infectious Disease
Case 4: A Young Patient with Fever and Heart Murmur
CASE
A 14‐year‐old African boy is referred with a 2‐week history of fever and night sweats. He had a sore throat and scarlet fever 2 months ago and recovered from this. In the last 2 weeks he has developed a painful right knee and wrist and noticed a painless nodule on his elbow. His mother was particularly concerned by his clumsiness as he kept on dropping things and unpredictably flinging his arms. This boy had a previously unremarkable childhood and was up to date with all his vaccinations. He has no family history of neurological conditions.
On examination he had a low‐grade fever but was haemodynamically stable. His chest was clear. However, he had a mid‐diastolic murmur. He had a swollen and tender right knee but the signs on the right wrist had resolved. There was a painless mobile nodule on his right elbow. Examination of the central nervous system was unremarkable although occasional involuntary movement of the left hand was observed.
The following results are obtained:
Hb 12.5 g/dL WCC 13 × 109/L(80% neutrophils) Platelets 400 × 109/L CRP 105 mg/L ESR 90 mm/h U&Es Normal LFTs Normal
ANA + rheumatoid factor: negative
Monospot test: negative
X‐ray of right knee: normal
ECG: sinus rhythm, prolonged PR interval
QUESTION 1
Your score this session: 0 of 0
What two further investigations would you request?