RHEUMATIC FEVER

ENDY ADNAN
RHEUMATOLOGY DIVISION
HASANUDDIN UNIVERSITY MAKASSAR
2017
 Introduction
• Acute rheumatic fever (ARF) is a multi system disease
resulting from an autoimmune reaction to infection
with group A streptococcus.
• Although many parts of the body may be affected,
almost all of the manifestations resolve completely.
• The exception is cardiac valvular damage [rheumatic
heart disease (RHD)], which may persist after the
other features have disappeared.
Prevalence
The Immune Response
 CLINICAL FEATURES (1)
• There is a latent period of 3 weeks (1–5 weeks)
between the precipitating group A streptococcal
infection and the appearance of the clinical
features of ARF.
• The exceptions are chorea and indolent carditis,
which may follow prolonged latent periods lasting
up to 6 months.
• The most common clinical presentation of ARF is
polyarthritis and fever. Polyarthritis is present in
60–75% of cases and carditis in 50–60%.
 CLINICAL FEATURES (2)

• The prevalence of chorea in ARF varies substantially

between populations, ranging from <2% to 30%.
Erythema marginatum and subcutaneous nodules
are now rare, being found in <5% of cases
CLINICAL FEATURES (3)
Diagnosis
RECOMMENDATION
TEST FOR ARF
 TREATMENT (1)

Antibiotics
Penicillin is the drug of choice and can be given orally
[as phenoxymethyl penicillin, 500 mg (250 mg for
children ≤27 kg) PO twice daily,
Amoxicillin 50 mg/kg (max 1 g) daily, for 10 days] or as
a single dose of 1.2 million units (600,000 units for chil-
dren ≤27 kg) IM benzathine penicillin G.
 TREATMENT (2)
Aspirin and NSAID
•Initial dose of 80–100 mg/kg per day in children
(4–8 g/d in adults) in 4–5 divided doses is often
needed for the rst few days up to 2 weeks.
•A lower dose should be used if symptoms of
salicylate toxicity emerge, such as nausea, vomiting,
or tinnitus.
•When the acute symptoms are substantially
resolved, the dose can be reduced to 60–70 mg/kg
per day for a further 2–4 weeks.
 TREATMENT (3)
Glucocorticoids
• Remains controversial.
• The studies included in these meta-analyses
all took place >40 years ago and did not use
medications in common usage today. Many
clinicians treat cases of severe carditis
(causing heart failure) → antiinflammation ??
 Other therapies
• Bed rest.
• Chorea
Severe chorea : carbamazepine or sodium valproate are
preferred to haloperidol. A response may not be seen
for 1–2 weeks, and a successful response may only be
to reduce rather than resolve the abnormal
movements.
• Intravenous immunoglobulin (ivig)
Small studies have suggested that IVIg may lead to more
rapid resolution of chorea but has shown no benefit on
the short or long term outcome of carditis in ARF
without chorea.
 Prognosis
Untreated, ARF lasts on average 12 weeks. With treat-
ment, patients are usually discharged from hospital
within 1–2 weeks.
Inflammatory markers should be monitored every 1–2
weeks until they have normalized (usually within 4–6
weeks), and an echocardiogram should be performed
after 1 month to determine if there has been
progression of carditis.
Cases with more severe carditis need close clinical and
echocardiographic monitoring in the longer term.
THANK YOU