Aseptic meningitis as initial presentation of rheumatic fever in an adult man: an extraordinary rare manifestation

To the Editor: Rheumatic fever (RF) is a multisystem disease, involving principally the heart, joints, central nervous system (CNS), skin and subcutaneous tissues (1). Although RF may occur at any age, it is extremely rare in infants and adults (1–3). Chorea is the main clinical manifestation of the CNS involvement. Rheumatic meningitis is an extraordinary rare form of RF presentation (4); physicians must always keep it in mind. We present a case with aseptic meningitis as initial RF manifestation in a 42-year-old man without cardiovascular lesions and previous disease attack. The patient was admitted to the hospital complaining of headache of abrupt onset and neck rigidity accompanied by pain and fever 39.5 °C. Ten days ago, he presented an episode of soar throat, and erythromycin ×4 250 mg was administered. Heart auscultation was normal. Laboratory control showed 16 × 103/mm3 white blood count (normal 5.0–10.0 × 103/mm3) with a left shift. Erythrocyte sedimentation rate was 70 mm first hour (normal <15 mm/h in males, Westergren) and C-reactive protein was 80 mg/l (normal <10 mg/l). Spinal tab on admission revealed a normal cerebrospinal fluid pressure, protein level 1250 mg/l, glucose 3.21 mmol/l and three lymphocytes per mm3 (normal 0–10 WBC/mm3). On the third day, oedema at the left knee joint accompanied by redness was appeared. Paracentesis of the oedematous joint revealed 2.1 × 103/mm3 leucocytes with 85% granulocytes. In the following 2 days, arthritis of the right shoulder, left talocrural and left elbow were sequentially developed. Another spinal tab on the fifth day revealed protein 1180 mg/l, glucose 3.33 mmol/l and 5/mm3 leucocytes. Anti-streptolysin O titres were 166, 166 and 125 Todd units on first, fifth and twelfth day, respectively (normal 12–166 Todd units). Anti-hyalouronidase titre was 1 : 4096 (significant ≥ 128 U/ml). Salicylates were administered on fifth day with dramatic improvement. A week later symptoms were completely subsided. Tests for infectious agents, autoimmune disorders as well as multiple cultures were negative or not diagnostic. Repeated echocardiograms were normal. The patient was discharged on the thirteenth day, free of symptoms receiving salicylates. This case reported rises the question of RF clinical features range among various age groups, so in the initial phase as in its long-term sequelae.