1
Department of Medicine, AIIMS, Rishikesh, India.
2
Department of Pathology, AIIMS, Rishikesh, India.
Abstract
The clinical features of acute rheumatic fever (ARF) are mainly the results of post-streptococcal mimicry. One of the major criteria to diagnose ARF is erythema marginatum. However, the involvement of erythema nodosum has not been reported yet. A middle-aged woman without comorbidities or addiction presented with breathlessness (NYHA-II) of 1 year’s duration with acute exacerbation in the preceding 7 days with fever, dry coughs, bilateral chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, bilateral leg swellings, and multiple tender faint red maculopapular rashes over bilateral shins and posterior ankle regions. Two-dimensional echocardiography confirmed rheumatic heart disease (RHD) and showed mild mitral stenosis, mild-to-moderate mitral regurgitation, severe tricuspid regurgitation, moderate pulmonary arterial hypertension, and an approximate left ventricular ejection fraction of 60%. A skin lesion biopsy showed chronic inflammatory lesions, suggesting erythema nodosum. The patient’s antistreptolysin O (ASO) titer was elevated, suggesting a prior streptococcal infection. Most of the major clinical criteria of ARF are the consequence of the molecular mimicry of Streptococci, especially such skin manifestations as erythema marginatum and subcutaneous nodules. Therefore, erythema nodosum, which also manifests itself as a delayed hypersensitivity reaction to Streptococci, can be considered a major criterion for diagnosing ARF/RHD. (Iranian Heart Journal 2023; 24(1): 108-112)
Andrew Steer. Acute Rheumatic Fever: Clinical manifestations and diagnosis; In: UpToDate (Updated on March 10, 2022). https://www.uptodate.com/contents/acute-rheumatic-fever-clinical-manifestations-and-diagnosis
Sika-Paotonu D, Beaton A, Raghu A, et al. Acute Rheumatic Fever and Rheumatic Heart Disease. 2017 Mar 10 [Updated 2017 Apr 3]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425394/
Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016; 2:15084. doi:10.1038/nrdp.2015.84
Majmundar VD, Nagalli S. Erythema Marginatum. 2021 Nov 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32491767.
Hafsi W, Badri T. Erythema Nodosum. [Updated 2021 Dec 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan
Scarpa R, Scognamiglio A, Casaburo G, Oriente A, Biondi Oriente C, Oriente P. L'eritema nodoso: epidemiologia, etiologia, patogenesi, quadro clinico e terapia [Erythema nodosum: epidemiology, etiology, pathogenesis, clinical picture and therapy]. Recenti Prog Med. 1989; 80(11):615-620.
Gewitz MH, Baltimore RS, Tani LY, et al. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association [published correction appears in Circulation. 2020 Jul 28;142(4):e65]. Circulation. 2015; 131(20):1806-1818. doi:10.1161/CIR.0000000000000205
Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Aug 19; 7(2):7-11. doi:10.1136/heartasia-2015-010648.
Kaplan EL. Pathogenesis of acute rheumatic fever and rheumatic heart disease: evasive after half a century of clinical, epidemiological, and laboratory investigation. Heart. 2005 Jan; 91(1):3-4. doi: 10.1136/hrt.2004.034744.
Wallace Mark R; Rheumatic Fever Clinical Presentation; In. Medscape (Updated in March 23, 2021). https://emedicine.medscape.com/article/236582-clinical
Yadav, C., Ranka, R., Panda, P., & Phulware, R. (2023). Erythema Nodosum: A Possible Criterion for Diagnosing Acute Rheumatic Fever. Iranian Heart Journal, 24(1), 108-112.
MLA
Chunnu Kumar Yadav; Rajat Ranka; Prasan Kumar Panda; Ravi Hari Phulware. "Erythema Nodosum: A Possible Criterion for Diagnosing Acute Rheumatic Fever". Iranian Heart Journal, 24, 1, 2023, 108-112.
HARVARD
Yadav, C., Ranka, R., Panda, P., Phulware, R. (2023). 'Erythema Nodosum: A Possible Criterion for Diagnosing Acute Rheumatic Fever', Iranian Heart Journal, 24(1), pp. 108-112.
VANCOUVER
Yadav, C., Ranka, R., Panda, P., Phulware, R. Erythema Nodosum: A Possible Criterion for Diagnosing Acute Rheumatic Fever. Iranian Heart Journal, 2023; 24(1): 108-112.
)