migratory polyarthritis

In acute rheumatic fever the arthritis typically affects large joints — knees, ankles, elbows, wrists — asymmetrically and sequentially, is exquisitely painful and dramatically responsive to salicylates or NSAIDs, and resolves without deformity; it is the most frequent major Jones criterion but, unlike carditis, leaves no permanent damage. There is an inverse relationship worth remembering: the more prominent the arthritis, the less likely severe carditis. Rheumatic fever follows group A streptococcal pharyngitis, not skin infection, by two to four weeks, and is mediated by molecular mimicry between streptococcal M protein and cardiac myosin and other tissues; treatment is anti-inflammatory therapy plus penicillin to eradicate the organism, followed by long-term secondary prophylaxis. Other causes of a migratory pattern include disseminated gonococcal infection, where arthritis accompanies tenosynovitis and pustular skin lesions; early Lyme disease; and the arthritis of subacute endocarditis. Contrast with the additive, symmetric small-joint arthritis of rheumatoid disease and the monoarticular presentation of septic arthritis and gout.