ACUTE RHEUMATIC FEVER

NIKHIL PT
BMCH RC

CLINICAL FEATURES

 Streptococcal sore throat followed by

10 days to 2 weeks
History of sore throat available
in 50% patients

Essential criteria
Evidence of recent streptococcal infection
indicated by
-increased levels of antibodies against
streptococci
-+ve throat culture for group A
streptococcus
Recent scarlet fever

CARDITIS
Occurs in 34-90% of patients with ARF
Carditis is the only manifestation of
rheumatic fever that leaves a sequelae &
permanent damage to the organ
Valvulitis occur in acute phase

Rheumatic carditis is a pancarditis involving

pericardium,myocardium and endocardium

Chronic phase- fibrosis,calcification &

stenosis of heart valves(fishmouth valves)

Pericarditis

Pericordial pain
Pericardial friction rub on auscultation
ECG-ST an T changes
Rheumatic pericarditis associated with
Small pericardial effusion
Patient have additional MR or AR
murmers or both

Pericardial effusion

Myocarditis
1)Cardiac enlargement-on physical exam,
CXR or ECHO
2)Soft S1
3)Protodiastolic (S3)gallop
4)CCF- right or left sided
4)Carey coombs murmer-low pitched
delayed diastolic mitral murmer heard during
the course of acute RF

Myocarditis

Endocarditis
Endocardial inflammation leave
permanent scarring
-sever and common in mitral and aortic
valves
-less common in tricuspid valve
-least in pulmonary valve
Atypical pansystolic murmur of MR (95%)or
Diastolic murmur of AR(25%)
Tricuspid involvement (40%)-uncommon in
first attack

Why heart damage?

Diagrammatic structure of the group A beta hemolytic
streptococcus
Capsule
Cell wall
Protein antigens
Group carbohydrate
Peptidoglycan
Cyto.membrane
Cytoplasm

Antigen of outer
protein cell wall
of GABHS
induces antibody
response in
victim which
result in
autoimmune
damage to heart
valves,
sub cutaneous
tissue,tendons,
joints & basal
ganglia of brain

Arthritis
Flitting & fleeting migratory polyarthritis, involving
major joints
Commonly involved joints-knee,ankle,elbow &
wrist
Tenderness,redness,warmth,swelling,
limitation of movements
In children below 5 yrs arthritis usually mild but
carditis more prominent
Arthritis do not progress to chronic disease

 Polyarthritis- in adults only a single joint may be

affected
Lasts 1-5 weeks
Occurs in 75% or patients
Subsides without residual damage of the joint
Dramatic response of arthritis to therapeutic
doses of aspirin or NSAIDs

Subcutaneous Nodule
Non tender,non adhesive
Small (<2cm in diameter) firm
(pin head size to almond)
Attached to fascia, or tendon
sheaths over bony
prominences like
shin,wrist,elbow,knee
Late manifestation after the
onset of RF(3wks to
6wks)Persist for days or
weeks(upto year)
If Nodules then Carditis

SYDENHAMS CHOREA
Purposeless jerky movements resulting
abnormal speech,muscular
incoordination,dropping of articles,awkward
gait,weakness
Emotional instability
Girls more frequenty affected
Rare in adults
Occur 5-36% of cases-Self limiting
Clinical signs- pronator sign, jack in the box
sign , milkmaids grip

milkmaids grip

Erythema Marginatum
Red spot,pale
center,increase on
applying heat
Reddish,not raised
above the skin,non
itching with
serpigenous margin

Minor Criteria
Clinical
Fever
-90% patients
-Temp 39.5 C
Arthralgia
-Joint pain without physical signs
H/O previous RF or RHD

Minor Criteria
Laboratory
High ESR(remains 4-10weeks in 80% patients)
Anemia, leucocytosis
Elevated C-reactive protien,TLC-10000-15000

Minor Criteria
ECG
prolonged PR interval(non diagnostic criteria), 2nd
or 3rd degree blocks(Wenkebach type),ST
depression,T inversion
2D Echo cardiography
valve edema,mitral regurgitation, LA & LV
dilatation,pericardial effusion,decreased
contractility

Essential criteria
ASO(antistreptolysinO) titre >200 Todd units.
(Peak value attained at 3 weeks,then comes
down to normal by 6 weeks)
Anti-DNAse B test,antihyaluronidase,streptozyme
Throat culture-streptococci(might have RF or
might not)
H/O scarlet fever-desquamation of skin of palms
and soles
Rapid streptococcal antigen test(low sensitivity)

Also there features:

Pneumonia
Epistaxis
Erythema nodosum
Abdominal pain

REQUIRED FOR DIAGNOSIS

Two major criteria OR
One major and two minor criteria

DIFFERENTIAL DIAGNOSIS

Arthritis
Rheumatoid arthritis
Reactive arthritis(shigella,salmonella..)
Serum sickness
Sickle cell disease
Malignancy
SLE
Lyme disease
Gonococcal infection

DIFFERENTIAL DIAGNOSIS

Carditis
Viral myocarditis
Viral pericarditis
Infective endocarditis
Kawasaki disease
Congenital heart disease
Mitral valve prolapse
Innocent murmurs

DIFFERENTIAL DIAGNOSIS

Chorea
Huntington chorea
Wilson disease
SLE
Cerebral palsy
Tics
Hyperactivity

Treatment
Step I - primary prevention
(eradication of streptococci)
Step II - anti inflammatory treatment
(aspirin,steroids)
Step III- supportive management &
management of complications
Step IV- secondary prevention
(prevention of recurrent attacks)

Treatment
PHARYNGITIS
Benzathene penicillin 1.2 million units
( 50,000 units/kg to a max of 1.2 million
units) is injected IM once or
Inj Procaine penicillin 600,000 units once
daily for 10 days
Erythromycin can be substituted
( 40mg/kg/day)

TREATMENT
CARDITIS
Bed rest until temp, ESR, resting pulse rate and ECG have all
returned to normal
Prednisone-2mg/kg/day(4 doses 2-3wks) if there is CCF or
cardiomegaly
POLYARTHRITIS
Anti inflammatory agent - Aspirin markedly reduces fever, joint
pain and swelling
100mg / kg/day in 4-6 divided doses. Can be reduced to
75mg/Kg/day once there is a response . Given for 4-6 weeks
Toxicity includes- tinnitus, vomiting and GI bleeding.
When response to aspirin is inadequate a short course of
prednisone (1 mg/kg/day) orally daily usually causes rapid
improvement of joint symptoms. It is tapered over 2 weeks. Add
aspirin when tapering begins.

Treatment
Sydenham Chorea
Sedatives-Phenobarbitone(16-32mg Q68th hrly PO)
Haloperidol (0.01-0.03mg/kg/day in BD
PO)
Chlorpromazine(0.5mg/kg Q4-6th hrly PO)

Prognosis
Rheumatic fever can recur whenever the
individual experience new Group A bet
hemolytc streptococcal infection,if not on
prophylactic medicines
Good prognosis for older age group & if
no carditis during the initial attack
Bad prognosis for younger children &
those with carditis with valvar lesions

PREVENON OF ARF-PRIMARY
Early and adequate treatment of
Strep. throat infections with a penicillin or
Azithromycin will prevent Rheumatic Fever
Avoidance of overcrowding & improved
hygiene will decrease the incidence of
pharyngitis

PREVENTION -SECONDARY
Those who have had RF can have recurrences
Recurrences are most common in children and in those patients who have had
carditis during their initial episode of RF
Recurrences are prevented by giving Benzathine penicillin 1.2million units IM
every 4 week
OR
Oral penicillin 250 mg bid
Erythromycin 250 mg bid
Azithromycin
Allergic to penicillin? Macrolide or Azalide
Duration controversial:
5 years after last attack or until reaches 21 years, whichever is later
(earlier recommendation: life-long)
Those with cardiac involvement and in high risk grouphealth staff, school teachers, parents of young children- life long prophylaxis