rheumatic fever

rheumatic fever

now rare in developed world
1. but most important cause of heart disease in kids worldwide
  1. incidence highest in those from socially & economically disadv areas
2. due to improved sanitation, use of Abx, changes in strep virulence
caused by group A beta-haem strep
1. in vulnerable ppl there is abnormal immune response to prior infection w/ this pathogen
mainly affects kids 5-15 years
clinical features
1. pharyngeal infection
  1. fb latent interval of 2-6 weeks
    1. then
      1. polyarthritis
      2. malaise
      3. fever
2. Jones criteria for diag
  1. to make diag
    1. 2 major or 1major +2 minor
      1. + supportive evidence of preceding group A strep
        sig raised ASO titre/other strep antibodies
        group A strep on throat culture
  2. major manifestations
    1. pancarditis (50%)
      1. endocarditis
        significant murmur
        valvular dysfunc
      2. myocarditis
        may -> heart failure & death
      3. pericarditis
        pericardial friction rub
        pericardial effusion
        tamponade
    2. polyarthritis (80%)
      1. ankles, knees, wrists
      2. exquisite tenderness, moderate redness & swelling
      3. flitting, lasting < 1 week in a joint
        but moves to other joints over 1-2 months
    3. sydenham chorea (10%)
      1. 2-6 months after strep infection
      2. involuntary movements & emotional lability for 3-6 months
    4. erythema marginatum (<5%)
      1. early manifestation
      2. trunks & limbs
      3. pink macular rash spreading outwards->
        pink border w/ fading centre
        borders can unite to give map-like outline
    5. subcutaneous nodules
      1. rare
      2. painless, pea-sized, hard
      3. on extensor surfaces
  3. minor manifestations
    1. fever
    2. polyarthralgia
    3. raised acute phase reactants
      1. CRP
      2. ESR
      3. leucocytes
    4. prolonged PR interval on ECG
chronic rheumatic heart disease
1. mitral stenosis
  1. commonest form of longterm damage from scarring & fibrosis of valve
  2. mitral valve most freq affected
  3. sx don't develop till early adult life
    1. but if repeated attacks of rheumatic fever w/ carditis
      1. can occur in 20s (age)
2. other valves can be affected
  1. pulmonary valve
    1. most rarely
  2. aortic
  3. tricuspid
3. severity of valvular disease related to no of childhood episodes of rheumatic fever
Mx
1. acute episode
  1. bed rest & anti-inflamm agents
  2. if evidence of active mycarditis
    1. echo changes
    2. raised ESR
    3. bed rest & limitation of exercise are essential
2. acute ep: aspirin
  1. effective at suppressing inflammatory response of joints & heart
  2. high doses needed
  3. monitor serum levels
3. acute ep: symptomatic heart failure
  1. diuretics
  2. ACEIs
4. acute ep: pericardiocentesis
  1. for sig pericardial effusions
5. acute ep:antistrep Abx
  1. if any evidence of persisting infection
  2. e.g. penicillin V for 10 days
6. after acute ep resolves
  1. aim: prevent recurrence
    1. prophylaxis
      1. monthly benzathine penicillin injections
        most effective
      2. oral penicillin
        compliance issues
      3. if penicillin sensitive
        erythromycin
      4. length of Rx debatable
        most recommend treatment to age of 18 or 21 yrs
        more recently lifelong prophylaxis recommended

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	Created by v.djabatey over 10 years ago