Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
Am J Emerg Med. 2019 Nov;37(11):2118.e5-2118.e7. doi: 10.1016/j.ajem.2019.158414. Epub 2019 Aug 24.
Isolated motor disturbances in the paediatric population are uncommon presentations to the emergency department. Choreiform movements have a broad differential diagnosis and may present insidiously with progressive worsening of asymmetric clumsiness, hypotonia and dysarthria. The incidence of Sydenham's chorea (SC) caused by acute rheumatic fever (ARF) is very rare in developed countries. We report a previously healthy, vaccinated 9-year old male who presented to our ED with intermittent and progressive right sided clumsiness for four weeks. Physical examination findings showed dysdiadokinesis and dysmetric movements of the right side, which varied in intensity and were less pronounced on serial re-examination during the same ED visit. Basic bloodwork, MRI and MRA/V showed no abnormalities, and the patient was discharged home with urgent neurology follow-up. He re-presented to our ED four days later with worsening gait and inability to hold a pencil at school. He was subsequently diagnosed with chorea by the neurology team. The cause of chorea was later determined to be SC, and the patient's throat swab came back positive for group A-beta hemolytic strep (GAS) infection. We explore current literature regarding the various presentations of ARF, differential considerations in acute chorea, and diagnostic studies needed to determine the etiology of acute chorea. With the low incidence of chorea in developed nations, this diagnosis can be easily overlooked. We highlight the importance of this diagnosis, as well as primary and secondary treatment in ARF.
儿科患者孤立性运动障碍并不常见于急诊科。舞蹈样运动有广泛的鉴别诊断，可能会逐渐出现不对称性笨拙、肌张力降低和构音障碍。由急性风湿热引起的风湿性舞蹈病（SC）在发达国家的发病率非常低。我们报告了一例先前健康、接种过疫苗的 9 岁男性，他因间歇性和进行性右侧笨拙而在 4 周前来我们的急诊科就诊。体格检查发现右侧运动不协调和运动障碍，其强度在同一急诊科就诊期间的连续复查中变化不定，且不太明显。基本的血液检查、MRI 和 MRA/V 均未显示异常，患者被送回家中，并紧急进行神经科随访。四天后，他因步态恶化和在学校无法拿铅笔而再次来到我们的急诊科就诊。随后，神经病学团队诊断为舞蹈病。后来确定舞蹈病的病因是 SC，患者的咽拭子检测出 A 组β溶血性链球菌（GAS）感染呈阳性。我们探讨了有关 ARF 的各种表现、急性舞蹈病的鉴别诊断以及确定急性舞蹈病病因所需的诊断研究的当前文献。由于发达国家舞蹈病的发病率较低，因此该诊断很容易被忽视。我们强调了该诊断以及 ARF 中的初级和二级治疗的重要性。
