1
Forth stage
Medicine
Lec-7
د.جاسم محمد
9/10/2015
ACUTE RHEUMATIC FEVER
-Multisystem disorder typically follows an episode f strep.pharyngitis(2-3 weeks) and
usually presents with fever ,anorexia ,lethargy and joint pains.
with
)
pharyngeal infection not the skin infection
(
Autoimmune consequence of infection
-
Group A beta haemolytic streptococcal infection
affecting brains, joints, skin, subcutaneous tissues & the
inflammatory response
Generalized
heart.
Supporting evidences:
history of an
About 66% of the patients with an acute episode of rheumatic fever have a
3 weeks before
-
upper respiratory tract infection 2
of acute rheumatic fever closely parallel those
15 yrs) & seasonal incidence
-
The peak age (6
of GABHS infections.
Predisposing factors:
1-Family history of rheumatic fever
2-Low socioeconomic status (poverty, poor hygiene, medical deprivation)
3-Age: 5-15 years.
4-Very rare in developed counteries while still endemic in developing counteries.
fibrinoid degeneration in collagen CT
,
Histologically
-
-Aschoff nodules are pathognomonic ,only in the heart(multinucleatd gaint cells surronded
by macrophage and T lymphocytes).
Clinical manifestation:
-No pathognomonic clinical or laboratory finding for acute rheumatic fever
to aid in diagnosis & to limit overdiagnosis
Duckett Jones in 1944 proposed guidelines
-
-Jones criteria for the diagnosis of acute rheumatic fever 2 major criteria or 1 major & 2
f recent GABHS
o
(microbiologic or serologic)
evidence
minor criteria pluse supporting
infection.
2
DIAGNOSIS(JONES CRITERIA):
Supporting evidence of
antecedent group A
streptococcal infection
Minor manifestation
Major manifestation
-elevated or increasing
streptococcal antibody
titer ( antistreptolysin O)
-positive throat culture or
rapid streptococcal
antigen test or
streptococcal sore throat
or recent scarlet fever
Clinical features:
arthralgia , fever ,
previous rheumatic fever
carditis
Laboratory features :
elevated acute phase
reactants : ESR , C-
reactive protein ,
prolonged PR interval
leucocytosis
polyarthritis
Erythema marginatum
Subcutaneous nodules
chorea
Major Manifestation
1-Arthritis :
-Most common (75%)
-Usually an early feature
-Involves larger joints: the knees, ankles, wrists & elbows
-Rheumatic joints: hot, red, swollen & exquisitely tender (friction of bedclothes is
uncomfortable
migratory in nature
The joint involvement is characteristically
-
-A dramatic response to even small doses of salicylates is another characteristic feature
of the arthritis
2-Carditis :
-Carditis & chronic rheumatic heart disease: most serious manifestations of acute
rheumatic feve ,Occurs in 50% of patients
-pancarditis with active inflammation of myocardium, pericardium & endocardium
-May manifest as SOB,palpitations or chest pain.
3
-Other features , tachycardia out of proportion to fever, cardiac enlargment & cardiac
murmurs(soft systolic murmur ,soft mid diastolic murmur Carey coombs), aortic
regurgitation in 50%, other valves rarely involved.
-Pericarditis may cause chest pain ,pericardial rub.
-ECG changes are common ST,T wave ,conduction defects.
-Echocardiographic findings: pericardial effusion, decreased ventricular contractility &
aortic &/or mitral regurgitation
-The major consequence of acute rheumatic carditis is chronic, progressive valvular disease
3-Chorea :
-Sydenham chorea: one third of patients with acute rheumatic fever
-More in females
) between streptococcal pharyngitis & the onset of chorea
6 mo
-
1
long latency period (
A
-
-Begins with emotional lability & personality changes (poor school performance).
-Followed in 1-4 weeks by characteristic spontaneous, purposeless involentery chorea
movement of the hands ,feet or face (lasts 4-8 months) followed by motor weakness
-Recovery within few monthes ,1/4 will develop chronic rheumatic valve disease.
4-Erythema Marginatum :
-A rare (<5% of patients with acute rheumatic fever) but characteristic rash of acute
rheumatic fever
-It consists of erythematous, serpiginous, macular lesions with
pale centers that are not
pruritic
-It occurs primarily on the trunk & extremities, not on the face
the skin
can be accentuated by warming
it
4
5-Subcutaneous Nodules :
-A rare (5-7%% of patients with acute rheumatic fever) finding
,
Consist of firm ,painless
nodules approximately 1 cm in diameter along the extensor surfaces of tendons near bony
prominences
A correlation between the presence of these nodules & significant
rheumatic heart
disease
Minor manifestations :-
Clinical:
1. Arthralgia (in the absence of polyarthritis as a major criterion)
2. Fever (typically temperature ≥102°F & occurring early in the course of illness)
Previous rheumatic fever
Laboratory minor manifestations:
1.Elevated acute-phase reactants (C-reactive protein, erythrocyte sedimentation rate,
polymorphonuclear leukocytosis)
2. Prolonged PR interval on electrocardiogram (1st degree heart block)
ESSENTIAL CRITERIA
An absolute requirement for the diagnosis of acute rheumatic fever is supporting evidence of
a recent GABHS infection
5
Differential diagnosis :
1-Arthritis
2-reactive arthritis (shigella , salmonella , yersinia)
3-serum sickness
4-sickle cell disease
5-malignancy
6-SLE
7-lyme disease ( borrelia burgdorferi )
8-gonococcal infection (N,gonorrhoeae)
Treatment :
till symptoms and markers of
oint pains and cardiac workload
reduce j
:
Bed rest
-
1
inflammation settled
2-Antibiotic Therapy:
or a single intramuscular injection
penicillin or erythromycin
10 days of orally administered
to eradicate GABHS from the upper respiratory tract
benzathine penicillin
of
Afterwards, the patient should be started on long-term antibiotic prophylaxis
3-Anti-inflammatory Therapy:
Aspirin relieve symptoms of artheritis and prompt response helps to confirm the diagnosis.
mg/kg/day in
, followed by 75
6 days
mg/kg/day in 6 divided doses PO for
starting dose 100
6 divided doses PO for6 wk or till
off.
ESR has fallen then gradually tailed
4-Corticosteroids : are Indicated in cases of carditis or sever artheritis
Prednisone 1 mg/kg/day in 4 divided doses for 2-6 wk or till the ESR IS NORMAL then
tailed off gradually .
carditis include digoxin, fluid
for patients with moderate to severe
Supportive therapies
-
5
& salt restriction, diuretics & oxygen
The cardiac toxicity of digoxin is enhanced with myocarditis
Prevention :
PRIMARY-10 days course of penicillin therapy; about 30% of patients with acute
rheumatic fever do not recall a preceding episode of pharyngitis
SECONDARY-Secondary prevention is directed at preventing acute GABHS pharyngitis in
patients at substantial risk of recurrent acute rheumatic fever , for how long ?
6
Duration
category
At least for 5 yr or until age 21 yr .
whichever is longer .
without carditis
Rheumatic fever
At least for 10 yr or well into adulthood ,
whichever is longer
Rheumatic fever with carditis but without
residual heart disease (no valvular disease )
At least 10 yr since last episode & at least
until age 40 yr , sometimes lifelong
Rheumatic fever with carditis & residual
heart disease ( persistent valvular disease)
What method of prophylaxis should be used?
Drug
Dose
Route
Pemicillin G benzathine
600,000 u for children , < or
=27kg
1.2 million u for children >27
kg , every 4 weeks
Intramuscular
or
Penicillin V
250mg twice a day
oral
or
Sulfadiazine or Sulfisoxazole 0.5g once a day for patients <
or = 60 lb , 1.0g once a day
for patients >60lb
oral
SH.J
7