Acute Rheumatic Fever with Erythema Marginatum

Acute Rheumatic Fever with Erythema Marginatum
Panel A shows the right forearm; black ink dots indicate the diameter of one lesion 10 hours before the time that the photograph was taken

Erythema marginatum, manifestation of acute rheumatic fever

Erythema marginatum is defined as a cutaneous finding associated with acute rheumatic fever (ARF), a sequel of throat infection by group A streptococci (GAS). Usually, acute RF occurs 3 weeks after infection. Erythema marginatum is a cutaneous finding and is associated with ARF. Typically, the lesion develops 7 days to months after the onset of streptococcal pharyngitis. Rarely in case of streptococcal skin infections. Erythema marginatum is reported in only 10% of cases of ARF. Although the fever is reported less commonly in developed countries, it continues to be a major concern.

Case study

This article describes the case of a 36-year-old man diagnosed with acute rheumatic fever with erythema marginatum. The previously healthy man presented with complaints of fever and pain in both shoulders and knees with a history of 1 month. 2 weeks before the onset of fever, the patient also suffered from a sore throat. Laboratory studies showed a white cell count of “13,800 per cubic millimeter (85% neutrophils), a C-reactive protein level of 26 mg per deciliter (reference value, ≤0.3), and an antistreptolysin O titer of 1478 IU per milliliter (reference value, <241)”.

Doctors further advised a transthoracic echocardiography which showed mild aortic regurgitation.

The patient was prescribed a nonsteroidal anti-inflammatory drug after which his fever and arthralgias abated. However, a week later, the patient returned with painless, nonpruritic, red annular macules on the upper limbs and abdomen. The rash further migrated and faded over the course of a few days and new lesions appeared. The patient was referred for skin biopsy, histopathological findings showed perivascular infiltration of lymphocytes and neutrophils in the dermis.

Based on these findings the patient was diagnosed with acute rheumatic fever with erythema marginatum. Erythema marginatum is a nonpruritic rash and one of the major criteria for diagnosis of acute rheumatic fever. Doctors prescribed the patient with amoxicillin for secondary prophylaxis of rheumatic heart disease. The rash abated 4 months after presentation, whereas antistreptolysin O titer decreased to 246 IU per milliliter 12 months after.

Source: NEJM

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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