FEVER

&KNEE PAIN
AN 11-YEAR OLD
PRESENTED WITH
FEVER
JOINT PAIN
AND SWELLING
SOB
VS : tachypnea and tachycardia
T 38.2
P 160
RR 32
BP 100/60
SaO2 94%
 Lungs clear
CVS S1S2, pansystolic murmur 3/6
heard at apex with radiation to
axilla
Abdomen Soft, normoactive bowel
sounds
Left knee is swollen and extremely tender with
warmth & Limited ROM. His right ankle is very swollen
and warm. He has limited subtalar motion. Both his
knee and ankle are very tender even to touch.
3 weeks PTC:
History of Enlarged, erythematosus tonsils with exudates
 CNS : No abnormal
movements of arms,
hands, or tongue are
noted. He is unable to walk
due to pain.
P R
CARDIOMEGALY
RHEUMATIC
FEVER

DR IRFAN ZIAD
12 million
are affected by ARF and
CRHD globally

developing countries are

150 times
more susceptible than
the developed countries

5-14 years
is the most frequent age
group
AN INFLAMMATORY DISEASE OF
CHILDHOOD RESULTING FROM
UNTREATED
STREPTOCOCCOCCAL
PHARYNGEAL INFECTION
Group A
-hemolytic
Streptococcus
Rheumatogenic strain
 Group A B-hemolytic
Streptococcus
Rheumatogenic strain

Molecular
mimicry

Immune Heart Brain Skin

response Connective tissue

M types 1,3, 5,6,18,29

Joints (75%)

L- Large joints of extremities

A- Arthritis (painful, tender, swollen)
M- Migratory
P- Polyarthritis
S- Severe pain
Salicylates (prompt relief)
 Skin
-Subcutaneous nodules
-Erythema marginatum
Subcutaneous nodules
Erythema marginatum
CNS
Basal Ganglia
syndenham
CHOREA
aka San Vitus Dance
rapid involuntary
movement affecting
the hands, feet,
tongue and face.
Heart
Myocardium
Pericardium
Endocardium
 Pericardium
Pancarditis Myocardium
Endocardium
 Myocarditis
-heart is enlarged
-may develop CCF

Clinically:
Prolongation of PR interval
S1, S3 and S4 present
 Pericarditis
- Completely resolved
Myocardium
- Heal with adhesion
Clinically:
Endocardium
Pleuritic central chest pain
Pericardial friction
Pericardial effusion

Bread and Butter

Pericarditis
Myocardium
Endocardium
 In patients with critical stenosis, mitral
valvulotomy, percutaneous balloon valvuloplasty,
or mitral valve replacement may be indicated.
polyarthritis
erythema marginatum & nodules
Sydenham chorea
Rheumatic myocarditis & pericarditis
Rheumatic endocarditis
 MODIFIED JONES CRITERIA FOR
ACUTE RHEUMATIC FEVER
MAJOR CRITERIA MINOR CRITERIA
Carditis Fever (Temp>38oC)
Polyarthritis, aseptic ESR > 30 mm/h or
monoarthritis or CRP > 30 mg/L
polyathralgia
Chorea Prolonged PR interval
Erythema marginatum
Subcutaneous nodules
 INVESTIGATIONS

CBC: anaemia, leucocytosis

Throat swab
ASOT
CXR, ECG
Echocardiogram
 How to make the diagnosis
Initial episode of ARF

2 MAJOR CRITERIA

OR
1 MAJOR CRITERIA + 2 MINOR CRITERIA
+ evidence of a preceding group
A streptococcal infection
 How to make the diagnosis
Recurrent attack of ARF
2 MAJOR CRITERIA
OR
1 MAJOR CRITERIA + 2 MINOR CRITERIA
OR
3 MINOR CRITERIA
+ evidence of a preceding group A
streptococcal infection
 Evidence of a preceding group A
streptococcal infection

Increased antistreptolysin O titre (ASOT)

Positive throat culture for GABHS
Positive rapid antigen detection test
J oints - artritis
O bvious - cardiac
N odules - rheumatic
E rythema marginatum
S ydenham chorea

I nflammatory cells (leukocytosis)

T emperature
E SR/CRP elevated
R aised PR interval
I tself (Previous Hx of Rheumatic fever)
A thralgia
TREATMENT

Bedrest
 TREATMENT
Anti-Streptococcal Therapy
IV C. Penicillin 50 000U/kg/dose 6H
or
Oral Penicillin V 250 mg 6H (<30kg),
500 mg 6H (>30kg) for 10 days
Oral Erythromycin for 10 days if allergic to penicillin.
 TREATMENT
Anti-Inflammatory Therapy
mild / no carditis:
Oral Aspirin 80-100 mg/kg/day in 4 doses for
2-4 weeks, tapering over
4 weeks.
 TREATMENT
Anti-Inflammatory Therapy
Pericarditis, or moderate to severe
carditis:
Oral Prednisolone 2 mg/kg/day in 2 divided
doses for 2 - 4 weeks,
taper with addition of aspirin as above.
 TREATMENT
Anti-Inflammatory Therapy
Monitor Aspirin level and LFT
 TREATMENT
Anti-failure medication
Diuretics, ACE inhibitors, digoxin (to be used
with caution).
 TREATMENT
Secondary prophylaxis
IM Benzathine Penicillin 0.6 mega units (<30 kg)
or 1.2 mega units (>30 kg) every 3 to 4 weeks.

Oral Penicillin V 250 mg twice daily.

Oral Erythromycin 250 mg twice daily if allergic to

Penicillin.
 TREATMENT
Secondary prophylaxis
Duration of prophylaxis
Until age 21 years or 5 years after last attack of ARF
whichever was longer
Lifelong for patients with carditis and valvular
involvement.
Summary

Multisystem Disorder

Immune-mediated defective immunity

Inflammatory disease (nonsuppurative)

 Summary

Accurate diagnosis is important.

Jones Criteria is a good guideline
Management include post-strep therapy, anti-
inflammatory therapy, anti-failure therapy and
secondary prophylaxis
ARF is a large physical, emotional and financial
burden.
 In a case of knee swelling..

Dont forget your stethoscope!

References
1. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N
(2007), Robbins Basic Pathology (8th ed.), Saunders Elsevier,
pp. 4036, ISBN 978-1-4160-2973-1.
2. "rheumatic fever" at Dorland's Medical Dictionary
3. Jones, T Duckett (1944). "The diagnosis of rheumatic
fever". JAMA 126(8):481. doi:10.1001/jama.1944.02850430015005.
4. Ferrieri, P (2002). "Proceedings of the Jones Criteria
workshop".Circulation (Jones Criteria Working Group) 106 (19):
25213.doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554.
5. Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP,
FACEP. Retrieved 2007-07-14.
6. Malaysian Paediatric Protocol, 3rd Edition