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Rheumatic Fever

Rheumatic fever is a delayed, autoimmune reaction to the streptococcus bacteria. It can be prevented with prompt diagnosis, and treatment of strep throat with antibiotics.

Symptoms of rheumatic fever


The symptoms of rheumatic fever usually start about one to five weeks after infection with group A beta streptococcus bacteria. The following are the most common symptoms of rheumatic fever. However, each child may experience symptoms differently.

Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.

small nodules or hard, round bumps under the skin a change in the child's neuromuscular movements (this is usually noted by a change in child's handwriting and may also include jerky movements)

Rash - a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs. fever weight loss fatigue stomach pains

Those at risk for developing rheumatic fever are: Children ages 5 to 15, particularly if they experience frequent strep throat infections. Rheumatic fever is also more common in children who have a family history of the disease.

There is an increased prevalence of rheumatic fever in the winter and spring, as strep throats occur more frequently during these seasons. Strep infections are contagious, but rheumatic fever is not.

Diagnosis
In addition to a complete medical history and physical examination, rheumatic fever is diagnosed based on the presence of criteria found in the revised modified Jones criteria diagnostic tool (standard guidelines for diagnosis of rheumatic fever):

Major criteria include:


carditis (inflammation of the heart) polyarthritis (inflammation of more than one joint) chorea (unusual jerky movements, most often involving the face and hands)

subcutaneous nodules (small, painless bumps under the skin, often over bony areas) rash (a red, irregular rash on the trunk)

Minor criteria include:


Fever arthralgia (pain in one or more joints) previous rheumatic carditis (inflammation of the heart) changes in the electrocardiogram (EKG) pattern abnormal sedimentation rate

The diagnosis of rheumatic fever is made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of a streptococcal infection. A throat culture is the only method by which an accurate diagnosis of streptococcal infection of the throat can be made.

There is no definitive test to diagnose rheumatic fever. Blood work is also usually done to assist in making a diagnosis ECG.

Treatment for rheumatic fever:


Treatment for rheumatic fever, in most cases, combines the following three approaches:

Treatment for streptococcus infection the immediate goal is to treat the infection with antibiotics such as penicillin, sulfadiazine, or erythromycin. This is done even if the throat culture is negative. Following the initial treatment for strep infection, the patient may continue to receive monthly doses of antibiotics to help prevent further complications.

Anti-inflammatory medications Based on the patients condition, prescription of medications such as aspirin or corticosteroids to reduce inflammation & decrease the swelling that occurs in the heart muscle, as well as to relieve joint pain. Aspirin is maintained at antiinflammatory doses until the signs and symptoms of acute rheumatic fever are resolved or subsiding (6-8 wk).

Bed rest the length of bed rest will be based on the severity the disease and the involvement of the heart and joints. Bed rest may range from two to twelve weeks.

prognosis
Rheumatic fever is likely to reccur in people who don't take low-dose antibiotics continually, especially during the first 3 -5 years after the first episode of the disease. heart complications may be severe, particularly if the heart valves are involved.

Complications of rheumatic fever.


Rheumatic heart disease. During a first rheumatic fever attack, about half of people develop heart inflammation, but this doesn't always result in permanent damage. Most people with rheumatic fever recover fully after six weeks. In some cases, however, one or more of the heart's valves may be scarred. Permanent heart damage due to rheumatic fever is known as rheumatic heart disease.

Rheumatoid arthritis. Often, several joints are affected with painful swelling, redness and sensation of heat.

Sydenham's chorea. If acute rheumatic fever affects the brain, loss of coordination and uncontrolled movement of the limbs and face may occur. Chorea occurs in about one in 10 rheumatic fever cases. Chorea usually subsides or disappears within weeks to months.

erythema marginatum. broad patches or, irregularly, round, faint pink or red areas on the skin. Lumps or nodules may occur beneath normal-appearing skin.

RHEUMATIC HEART DISEASE


RHD results directly from rheumatic fever caused by group A beta streptoccocal infection. The disease affects all bony joints , producing a polyarthritis , the heart is also a target organ and is where the most serious damage occurs.

PATHOPHYSIOLOGY
The heart damage and the joint lesions of rheumatic inflammation are not infectitious in origin, in the sence that these tissues are not invaded and directly damaged by destructive organisms; rather they represent a sensitivity phenomenon or reaction occuring in responce to hemolytic streptococci. Leukocyte accumulate in the affected tissue and form nodules which eventually are replaced by a scar.

The myocardium is certatin to be involved in this inflammatory process i.e rheumatic myocarditis develops, which temporarily weakens the contractile power of the heart. The pericardium likewise is affected i.e. rheumatic pericarditis also occurs during the acute illness.

These myocardial and pericardial complications usually are without serious sequelae, but rheumatic endorcarditis however results in permanent and often crippling effects.

Rheumatic endocarditis, permanent heart damage can occur as endocardium and valves become involved in the inflammatory process.

tiny translucent vegetations or growths which resemble pinhead-sized beads arranged in a row along the free margins of the valve flaps (primarily mitral and aortic).

These tiny beads looks harmless enough and may disappear without injuring the valve leaflets, more often however they have serious effects & they are the starting point of a process that gradually thickens the leaflets rendering them shorter and thicker than normal resulting in valvular incompetencey and stenosis. Months or years later these vegetations can be a site for bacterial colonization leading to bacterila endorcarditis.

Clinical manifestations
Acute rheumatic carditis may first manifet itself by the appearnce of the heart murmurs of either mitral or aortic regurgitation with the most common type been mitral regurgitation.

Eventually these murmurs of regurgitation, stenosis or both become audible on auscultation and in some patients detectable thrills on palpation. signs and symptoms of pericarditis and of heart failure may be present Occasssionally arrhythimas ,may be present,.

Diagnosistic findings
The four major criteria for the clinical diagnoses of rheumatic carditis are: A heart murmur or murmurs not previously present Enlargement of the heart Heart failure Pericardial frictioin rub

No specific test indicates the presence of rheumatic fever but rheumatic fever almost always follows a streptococcal infectioin of the naso pharynx and a careful patient history should be taken.

Prevention
Rheumatic endorcarditis is prevented through early and adequate treatment of streptococcal infections A firt line approach in preventing initial attacks of rheumatic endorcarditis is to recognize streptococccal infections , treat them adequately and control epidemics in the community. Every nurse should be farmiliar with signs and symptoms of steptococcal pharyngitis.

Medical management
The objectives of medical management are to eradicate the causative organisms and prevent additional complications. Long term antibiotic therapy is the treatment of choice . Penicillin administered parenterally remains the medication of choice

Medical therapy is directed toward eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure.

Oral penicillin V remains the drug of choice for treatment of group A streptococcal pharyngitis. When oral penicillin is not feasible or dependable, a single dose of intramuscular benzathine penicillin G is therapeutic. For patients who are allergic to penicillin, administer erythromycin or a first-generation cephalosporin.

Other options include clarithromycin for 10 days, azithromycin for 5 days, or a (first-generation) cephalosporin for 10 days. As many as 15% of penicillinallergic patients also are allergic to cephalosporins.

For recurrent group A streptococcal pharyngitis, a second 10-day course of the same antibiotic can be repeated. Alternate drugs include narrowspectrum cephalosporins, amoxicillin-clavulanate, dicloxacillin, erythromycin, or other macrolides.

patients with acute rheumatic fever and congestive heart failure should include: digoxin, diuretics, supplemental oxygen, bed rest, sodium and fluid restriction.

Treatment of the acute inflammatory manifestations of acute rheumatic fever consists of administering salicylates and steroids. Aspirin in anti-inflammatory doses effectively reduces all manifestations of the disease except chorea, and the response typically is dramatic. In fact, if rapid improvement is not seen after 24-36 hours of therapy, the diagnosis of rheumatic fever should be questioned.

If moderate-to-severe carditis is indicated by cardiomegaly, congestive heart failure, oral prednisone should be added to salicylate therapy. Prednisone should be continued for 2-6 weeks, depending on the severity of the carditis, and tapered during the last week of therapy.

Surgery is indicated to decrease valve insufficiency when heart failure persists or worsens during the acute phase after aggressive medical therapy. Mitral valve repair has also been shown to be feasible in children with chronic rheumatic mitral valve disease.

Preventive and prophylactic therapy is indicated after rheumatic fever and rheumatic heart disease to prevent further damage to valves.

The initial course of antibiotics given to eradicate the streptococcal infection also serves as the first course of prophylaxis. An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4 weeks is the recommended regimen for secondary prevention for most patients.

Surgical Care
When heart failure persists or worsens after aggressive medical therapy for acute rheumatic heart disease, surgery to decrease valve insufficiency may be life-saving.

In patients with critical stenosis, mitral valvulotomy, percutaneous balloon valvuloplasty, or mitral valve replacement may be indicated. Due to high rates of recurrent symptoms after annuloplasty or other repair procedures, valve replacement appears to be the preferred surgical option.

Nursing management
A key nursing role in infective endorcarditis is teaching the patient about the disease and its prevention and treatment Susceptible patients need to know about long term oral antibiotiscs therapy or more commonly about the need to take prophylactic antibiotic before any invasive procedure such as dental work examinations that can introduce infections.

Diet
The diet should be nutritious and without restrictions except in the patient with congestive heart failure, whose fluid and sodium intake should be restricted.

Activity
Initially, patients should be placed on bed rest followed by a period of indoor activity. Full activity should not be allowed until the acute phase has resolved.

Patient Education
Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever with each patient.

Further Outpatient Care


Patients usually show significant improvement after initiation of antiinflammatory therapy. They should not be allowed to resume full activities, however, until all clinical symptoms have abated and laboratory values have returned to normal levels.

The importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever should be emphasized with each patient. Each recurrent episode of rheumatic carditis produces further valve damage and increases the likelihood that valve replacement will be required. Patients should remain on antibiotic prophylaxis at least until their early twenties. Many physicians believe that lifelong prophylaxis is appropriate.

Patients should be examined regularly to detect signs of mitral stenosis, pulmonary hypertension, arrhythmias, and congestive heart failure.

Complications
Potential complications include: heart failure from valve insufficiency or stenosis.

atrial arrhythmias, pulmonary edema, recurrent pulmonary emboli, infective endocarditis, intracardiac thrombus formation, and systemic emboli.