A 12-year-old boy presented with breath-lessness, fever and subcutaneous nodules over both knees (Fig. 1). These nodules were firm, painless, round and varying in size from 0.5 cm to 2 cm and skin over nodules was freely movable. There was no sign of inflammation. Further examination of the patient revealed the presence of nodules over both elbows, wrists and spinous processes of thoracic and lumbar vertebrae.

There was antecedent history of sore throat about one month back. However, there was no history of joint pain, rash or chorea. On investigating the child ASO and ESR were raised. A prolonged PR interval and HR of 150 per minute was found in EKG. Moderate MR with thickening of mitral valve and minimal pericardial effusion were detected on echo-cardiography.

Subcutaneous nodules are a major manifestation of acute rheumatic fever. How-ever, they are not pathognomonic of rheumatic fever as they also occur in rheumatoid arthritis and SLE. It is often suggested that subcutaneous nodules are seldom seen in India. It is very important that one should look dilligently for subcutaneous nodules.

Fig. 1. Photograph showing subcutaneous 
nodules on extensor aspects of both knees.

Milap Sharma,
Deepali Sharma,
Department of Pediatrics,
Dr. R.P. Medical College Hospital,
Kangra at Dharamshala (H.P.),
India.