Rheumatic fever

Rheumatic fever

1. Streptococcal infection of URT

   • M antigens react with T cell and stimulate B cell to produce auto antibodies
     • Recurrent infection of Heart muscles
       • Myocardium - aschoff noduels ~ fibrinoid degenration + lymphocytes & Plasma cells ;
         • Tachycardia, s3 & s4, CHF
       • Endocardium - valvulitis, damaged chordae tendinae, regurgitations - MaTP
         • Mid diastolic murmur (carey coombs),
         • valve thickening, scarring, calcification and stenosis
           • Pansystolic murmur
       • Pericardium - effusion; bread and butter appearance
         • pain, friction rub
     • other Manifestations
       • Joints
         • Large Joint inflammation
           • Migratory
       • Syndenham's Chorea
         • characteristic movements of limbs, head and tongue
           • Manifests late and relsoves in 6 weeks
       • Subcutaneous nodules
         • In severe carditis; Over bony prominences
           • resolves in 2 weeks
       • Erythema marginatum
         • Pink rashes: Clear centre and serpiginous margins

2. Investigations

   • Blood
     • ESR
     • CRP
     • Antistreptolysin O, Anti DNAse B
   • Throoat Swab Culture
   • Chest X-ray
   • ECG

3. REVISED JONES CRITERIA 2 Major/ 1 Major+2 minor / 5 minors

   • Major
     • Carditis
     • Polyarthirtis
       • Major criteria: 2 or more jts, high stretocococcal antibody titre
     • Chorea
     • Erythema marginatum
     • Subcutaneous nodules
   • Minor
     • Fever
     • Arthralgia
     • Prev RHD
     • CRP and ESR raised
     • ECG: Prolonged PR

4. Treatment

   • Bed rest
   • Antibiotics
     • Benzathine penicillin 1.2m units
     • Procaine penicillin 6L units
     • Sensitive cases - Erythromycin 20- 40mg/kg
   • Arthritis
     • Aspirin 60mg-8g
   • CHF
     • Prednisolone
   • Chorea
     • Calm environment, Valproic acid, Immunoglobulins
   • Prophylaxis:
     • Secondary
       • 1.2m units Benzathine penicillin, Oral penicillin 500mg, Amoxycillin 1g/day, azithromycin 500mg/day
         • No carditis
           • For 5 yr or till 18yr age
         • resolved carditis
           • For 10yr or till 25yrs age
         • severe carditis
           • Life long prophylaxis; surgery
     • Primary
       • Benzathine penicillin, procaine penicillin, Erythromycin