Manifestações articulares atípicas em crianças com febre reumática

Abstract

Objective

The aim of this study was to describe the clinical manifestations and to assess the occurrence of atypical arthritis in patients with acute rheumatic fever attending a pediatric rheumatology service at the Hospital das Clínicas de Ribeirão Preto, São Paulo, Brazil.

Methods

We retrospectively studied the records of 120 attacks of acute rheumatic fever in 109 children, from 3 to 13 years of age, who were seen at our service from January 1990 to December 1995. All children fulfilled the Jones criteria.

Results

Seventy-seven percent of the acute rheumatic fever attacks presented arthritis, 62% carditis, 32% chorea, 2.5% subcutaneous nodules, and 1.3% erythema marginatum. The number of involved joints was one in three episodes of acute rheumatic fever; two to five in 52 cases; six to ten in 30; and more than ten in five cases. An atypical pattern was observed in 43 out of the 92 (47%) acute rheumatic fever episodes with arthritis, based on the following criteria: involvement of unusual joints (cervical spine in 24 children, hip in 15, small joints of the hand in 12, and feet in 13); monoarthritis (in three cases); duration longer than 3 weeks (in 26 patients); incomplete response to salicylates (in 18 children). Association of these atypical features was frequently present. For instance, considering the 24 episodes with cervical spine involvement, the duration of arthritis was longer than 13 weeks in 13 cases, 10 had insufficient response to salicylates, and the hip joint was also involved in other seven cases. The time to reach diagnosis was longer than 4 weeks in 59% of the patients presenting atypical arthritis when compared to 35% in the other patients (P=0.04). Other diagnoses were initially considered in 40% of the 120 acute rheumatic fever attacks, and in 65% of the patients who presented atypical arthritis (P=0.03).

Conclusion

We concluded that atypical arthritis was present in a significant proportion of the acute rheumatic fever attacks, making the diagnosis of this intriguing disease even more difficult.

Resumen

Objetivo

Determinar a prevalência de pneumonias de repetição na demanda de consultas de primeira vez encaminhadas ao ambulatório de Pneumologia Pediátrica do Instituto de Puericultura e Pediatria Martagão Gesteira da UFRJ para esclarecimento diagnóstico e revisar o conceito de pneumonias de repetição na literatura pediátrica. Método: Os dados foram obtidos através da avaliação de consultas de primeira vez atendidas e registradas no livro próprio do Serviço para consultas desse tipo no período de 01/01/95 a 30/04/97.

Método

Os dados foram obtidos através da avaliação de consultas de primeira vez atendidas e registradas no livro próprio do Serviço para consultas desse tipo no período de 01/01/95 a 30/04/97.

Conclusão

Os autores concluíram que o conceito de pneumonias de repetição deve ser melhor esclarecido e difundido entre os médicos pediatras, pois cabe a eles a decisão de encaminhar ao especialista os pacientes com essa queixa. Cabe ressaltar a valorização do exame radiológico normal entre os episódios agudos para a caracterização do quadro de pneumonias de repetição, visando melhor determinação dos pacientes que posteriormente necessitarão de encaminhamento ao especialista para prosseguimento da investigação diagnóstica.