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Dr. Andrew Rynne

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Have swelling and pain in knee joint. Tested positive for throat swab. What is the disease?

Answered by
Dr. Anil Grover


Practicing since :1981

Answered : 922 Questions

Posted on Sat, 12 Jan 2013 in Bones, Muscles and Joints
Question: My son is 9 years. He plays gymnastics, got a pair of flat feet. He also has  bad tonsils (ping pong size) . He complained of right knee joint pain then few days later his left knee appeared more swollen and was painful simultaneously with the left knee. ASoT was >800 , throat swab was positive for strept beta hemolytic group A( pyogen),ESR first hour 6 , Hb 14, no leucocytosis, no prolonged PR, normal echo and at no point was he feverish . 
Currently he still has arthralgia, not during walking but during standing from sitting position , one more than the other, it doesn't appear to respond well to burfen. He received ceporex for 6 days then switched to ospen 500 twice daily (wt 33). Please advise as regards diagnosis ( do u think this is post streptococcal arthritis) and if he is at risk of carditis and if he needs long term prevention and at which point he can resume gymnastics .
Answered by Dr. Anil Grover 3 hours later
Hi there,
Thanks for writing in.
I am a qualified and certified cardiologist. I read your question with diligence.
I have seen enough cases of rheumatic fever in endemic an country that is India I would have given hem rheumatic fever prophylaxis for 5 years. For swelling of knee means means arthritis and ASO titre rise (in fact isolation of Group A Streptococcus) would have left me with no choice. It seems like post streptococcal phenomenon and you are doing the right thing in given Ospen twice a day. I would suggest a repeat echocardiographic examination say after a month. To diagnose rheumatic fever we are still missing one more criteria but benefit of doubt should go to the young boy. My reason is also based on World Health Organization report which has put Egypt as as one of the country where rheumatic fever is still present. If you have any more follow up question, I will be too happy to answer.
Dr Anil Grover,
Cardiologist & Internist
M.B.;B.S, M.D. (Internal Medicine) D.M(Cardiology)
http://www/ WWW.WWWW.WW

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anil Grover 5 hours later
Thank you for answering. Do you think Ospen is as good as LAP injections as regards efficacy? And what side effects are the commonest?? I've read about hemolytic anemia, pseudo membranous colitis,,,is this very common?,he's been on ospen for less than a week and is reporting nausea .
I also need to clarify a point. His knee is a bit swollen and both are painful when standing from sitting position , but at no point was there redness, hot ess or tenderness. So do u think it's arthralgia rather than arthritis ? And would you still recommend 5 years prophylaxis ?
Thanks in advance
Answered by Dr. Anil Grover 4 hours later
Thanks for writing back.
To answer your question about side effects: Yes both are reported side effects but I have not seen either of these in dozens of patients in whom oral penicillin was used for ARF (we insist on LAP in India), in my three decades of experience. If monitored and be aware of, chances of occurrence can be further reduced. However LAP is a shade better yes some pain your young one has to tolerate once in three weeks. If not sensitive, I have not seen or read about any other side except allergy with LAP.
Any of the 3: Swelling, Redness, reduction in range of movement along with pain qualifies for being called as arthritis. One odd feature is non migratory nature of joint pain so to that extent treatment for ARF is presumptive as an extra precaution. I am considering arthritis not arthralgia. Though there are reports in medical literature where post streptococcal arthralgia did lead to Rheumatic Heart Disease. But World Health Organization till its last recommendation does not say that we have to give prophylaxis.
If your treating physician has alternative explanation for arthritis like Rheumatoid Factor positive or any other disease to explain it then we have to reconsider the whole diagnosis.
As we are sure heart was not involved so recommendation is for 5 years to till the age of 18 (whichever is later) or a decision of the treating physician(depending upon residence of patient), hence is my suggestion. For your information there will not be any unanimous opinion of cardiologists in your situation. If the child was under my care. I would have kept child under close observation, of course at home. Done echocardiography every 6 months and asked the educated parents (like you) to start penicillin (either single shot of LAP or oral penicillin for 10 days at the first symptom of sore throat without waiting for serological or bacteriological markers to be available) till the child is 15 year old. This recommendation would be subject to revision till we have finally decided about cause of arthritis involving knees.
If you have further question I will be most happy to answer.

Dr Anil Grover
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

The User accepted the expert's answer

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