You are rotating on the pediatric wards and are asked to make a diagnosis in a 9-year-old
boy who was admitted for evaluation of abnormal movements of two weeks duration.
On examination his gait is wide based and unstable, much as though he was drunk. Falls
are frequent, and his tongue darts in and out unpredictably. The digits of his hands
contract or extend in an unpredictable fashion. Pictures of the patient and of Lead
II of his EKG are shown below.
DIAGNOSIS: Syndenham's chorea. The child demonstrates an endless series of athetoid
movements in his hands, wrists, lips, face and tongue. The protuded tongue flies back
into the mouth, and he jumps out of bed like a "jack-in-the-box" and often falls.
The disease may complicate acute rheumatic fever (there is a genetic predisposition)
and is most common in children 10-14 years of age. The illness may be subtle, the
child being accussed of being fidgety at school, and may last as long as a year with
no outward signs of arthritis or carditis. The clue that the chorea is rheumatic in
origin in this child is the first degree heart block seen on his EKG.
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