rheumatic fever
TRANSCRIPT
Rheumatic Fever
By: DR. SAURAV POUDEL 20th October
2016
• Rheumatic fever is an acute immunologically mediated multi system inflammatory disease that occur 1-4 weeks after an episode of sore throat or pharyngitis by the rheumatogenic strains 3,5,18,19,24 of group A beta hemolytic streptococcus.
• It affects heart, joints and skin.
Aetio-pathogenesis
• After pharyngeal infection with group A beta haemolytic streptococcus,an antibody is produced against the M protien of the streptococcus,which has a antigens similar to those in heart and other tissues so,the antibody produced against bacterial antigen(M protien)cross reacts with heart and other tissues.
Clinical features
• Children usually between 5-15yrs having a history of sore throat 2 to3 weeks back present with :
-fever,anorexia,lethargy and joint pain.
Dr. T. Duckett Jones Criteria • Major criteria• Polyarthritis: A temporary migrating inflammation of the large joints, usually starting in
the legs and migrating upwards.• Carditis: Inflammation of the heart muscle (myocarditis) which can manifest
as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur.
• Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.
• Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.
• Sydenham's chorea (St. Vitus' dance): A characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease for at least three months from onset of infection.
Erythema marginatum
• Minor criteria• Fever of 38.2–38.9 °C (100.8–102.0 °F)• Arthralgia: Joint pain without swelling (Cannot be included if
polyarthritis is present as a major symptom)• Raised erythrocyte sedimentation rate or C reactive protein• Leukocytosis• ECG showing features of heart block, such as a prolonged PR
interval• Previous episode of rheumatic fever or inactive heart
disease
• Essential criteria:a. Evidence of recent streptococcal infection as
indicated by:-recent scarlet fever-raised antistreptolysin O or other streptococcal
Ab.-positive throat culture.
• For diagnosis of rheumatic fever:-2 or more major criteria or- 1 major criteria and 2 or more minor criteria + evidence of preceding streptococcal
infection……….
Management of acute rheumatic fever
Investigation in acute rheumatic fevera) Evidence of a systemic infections:-leucocytosis-raised C-reactive protien-raised ESRb)Evidence of preceding streptococcal infections:-throat swab culture : Group A beta haemolytic streptococci-antistreptolysin “O “ antibodies (ASO titers)rising titers or
level of > 200 units(adult) or >300 units(children)
c) Evidence carditis:Chest Xray: cardiomegaly,pulmonary congestionECG : PR interval prolonged T wave inversion reduction in QRS voltageEchocardiography: cardiac dilatation and valve
abnormalities.
Treatment
A) Symptomatic and supportive treatment:I. Bed rest : till acute phase subsides(ESR,CRP
become normal).II. Arthritis : aspirin 100 mg/kg/day for 2 weeks
and 75mg/kg/day for 4-6 weeks or till the activity of disease subsides(ESR becomes normal ) in 6 divided doses.
III. Carditis or arthritis if not responds to Aspirin:
• Prednisolone 1-2 mg/kg/day in 4 divided doses for 2 weeks and gradually taper by another 2 weeks.
• Aspirin 75 mg/kg/day in 6 divided dose when prednisolone is started or taper.
iv) Chorea : diazepam for mild chorea & haloperidol (0.5-2mg every 8 hr) for severe chorea.
v) Treatment of heart failure and other complication.
B) Antistreptococcal therapy : Penicillin: penicillin V 250 mg 6hrly for 10
days, or single IM inj. Benzathine penicillin G(6 lakhs for children <60 lb & 12 lakhs for children >60 lb).
- Erythromycin 40mg/kg/day or 1st generation cephalosporin's may be used for 10 days in patients who are allergic to penicillin.
C. Prevention of rheumatic fever :I. Primary prevention : prevention
before occurrence of rheumatic fever by early identification and treatment of streptococcal throat infection with penicillin.
ii) Secondary prevention : prevention of recurrence of rheumatic fever after the patient had manifestation of rheumatic fever once. It is done mainly to prevent cardiac involvement and further valve destruction than before.
Inj.benzathine peniciilin 12 lack unit i.m every 3 weeks for 5 years or upto the age of 18 yrs whichever is longer according to WHO criteria.If the weight is less than 30 kg,Benzathine peniciliin 6 lack unit should be given.
oral penicillin v 125-250 mg Alternative to penicillin Sulfadizine 1 gm daily
erythromycin 250 mg PO BD
• Complication :- Congestive heart failure- Arrhythmia- Pericarditis with effusion- Valvular disorder
