When it comes to sore throats, don’t just know the basics. Master them.
Diagnosing Rheumatic Fever
To diagnose rheumatic fever, you need evidence of a recent strep infection (typically using an ASO titer) and two of the major Jones Criteria. There are major and minor criteria. You can also diagnose with one major and two minor criteria. I’m not enthusiastic about the minors because they’re so nonspecific.
5 Major Jones Criteria
I want you to remember the Jones Criteria with this story: Mr. Jones travels across nations and he brings beef jerky with him. He eats this jerky and it goes to his heart, it goes to a rash, it goes to nodules in his joints.
- Chorea: The patient is literally jerky with involuntary movements.
- Myocarditis: A new first-degree heart block is a flag for rheumatic fever.
- Erythema Marginatum: When it comes to urgent care medicine, there are a number of rashes that are all erythemas. Erythema marginatum kind of looks like a topographical map of a nation. Mr. Jones travels the nations, so the rash is erythema marginatum.
- Subcutaneous Nodules
When you see these criteria, you should think, “Holy cow, maybe they have something bad going on. I better talk to a consultant about this.”
Treating Rheumatic Fever
We have three choices. Penicillin is still the recommended regime. I could use penicillin V, it could be one shot of benzyne penicillin. You can also use amoxicillin or Augmentin. Penicillin is most specific but Sanford’s still recommends amoxicillin as an option. That’s because a lot of times we’re treating rheumatic fever with a suspension and amoxicillin’s suspension tastes good. From what I’m told, penicillin suspension tastes awful. I hear all the time, “My kid won’t take penicillin.” So, we go to the bubble gum amoxicillin. For adults, we treat with penicillin or Augmentin.
Complications from Strep Throat
Rheumatic fever is just one of the complications due to untreated strep throat.
There is also the possibility of poststreptococcal, reactive arthritis (or Reiter syndrome), abscesses or phlebitis. I had someone with an infected jugular vein, which is called Lemierre’s syndrome and is caused by Fusobacterium necrophorum. That’s a scary disease.
Poststreptococcal glomerulonephritis typically occurs in young children. What happens is they get a throat infection and as it’s healing, it fragments. It’s called an allele reaction. It hits the basement membranes of the kidney, which causes the patient to pee out protein, get epididymis and be very fatigued. It’s like nephritic syndrome.