Rheumatic

fever
Rheumatic fever
is acute systemic disease of
the connective tissue immune
inflammatory genesis,
characterised mainly by
arthritis, carditis, chorea,
subcutaneous nodules and
erythema marginatum.
Rheumatic fever (RF)

is common world-wide and is
responsible for many causes
of damage heart valves.
Etiology:
Group A, hemolytic streptococcus
(strains 3,5,18,24,28,49 ) is the maine
etiologycal factor. RF occurs about 2
weeks after exudative tonsilitis
(quinsy,soa throat), scarlet
fever,streptodermia or other
streptococcus infections, if it goes
without treatment.

Person who has high hyperensitivity to
immune system on streptococcus
suffered more frequently. This
hypersensibility of immune system
genotype determinate with HLA system
antigen A
11
, B
27
, B
35
, CW
2
, CW
5
, DR
5
,
DR
7
.

Pathogenesis:

On the basis of pathogenesis RF is
immunoinflamatory reaction
(reaction antigen-antibody) with
edema,
hyperemia,

lymphocyte infiltration of
connective tissue heart (valvule,
endocardium, myocardium,
pericardium), brain, vessels,
synovial membrane of joints,skin,
other organ and formatione
rheumatic granuloma (Aschoffs
nodule) in connective tissue.
Immunoinflamatory reaction (reaction
antigen-antibody) is always
accompanied by elimination of
inflammatory mediators: histamine,
bradikinin, prostaglandin E2 and
other.Histamin is dilated capillares and
bring on oedema, hyperemia,
infiltratione connective tissue with
cells of immune response
(lymphocytes, plasmatic cells, mast
cells, eosinophils, basophils).
Prostaglandin E2 - cause
increase t
o
C.
Cluster circulate immune
complex in connective tissue
is cause formation of
pointing necroses in
particular area.
during immunoinflamatory
reaction morphologically we are
different 4 stages:

mucoid swelling;
fibrinoid swelling;
granulomatosis;
sclerosis and hyalinosis.
Outcome of the
immunoinflammatory reaction
are sclerosis,hialinosis,
deformation,calcification
valvulas and formatione
anatomical defects (valvula
heart disease) .

Sclerosis of myocardium -
myocardiosclerosis (cardiac
insufficiency heart failure,
arrhythmias, blockades).
Clinical PICTURE

symptoms and signs arise 2 weeks
after pharyngitis or tonsillitis (soa
throat) or scarlet fever.


major criteria (manifestation)
of RF are:
1.Migratory polyarthritis
2.Carditis
3.Chorea
4.Subcutaneous nodules
5.Erythema marginatum

minor criteria of RF are:
high t
o
C;
abdominal pain, anorexia;
heart failure;
epistaxis;

pneumonia;
asthenia;
malaise;
fatigue.

Migratory polyarthritis is the most
common clinical manifestation,
monoarthritis can also occur. Joints
become painful and tender ,red, hot,
swollen, sometimes with effusion.

Knees, elbows or wrists are most
commonly involved. It leaves no
permanent joint deformility.
Carditis

(involves 2 or 3 wall of heart)
endocarditis+myocarditis=
rheumocarditis:



Rheumatic myocarditis, mature Aschoff nodule


CLINICAL SIGNS OF CARDITIS:
Cardiac failure
Changes heart sounds
Cardiac enlargement

Murmurs;
1. systolic myocardial murmur;
2. murmurs of VS, MI, AS, AI.
pericardial rub.
Chorea
SydenhamS chorea
emotional instability,
muscular weakness and
rapid, uncoordinated jerky
movements affecting
primarily the face, foot and
hands.
Subcutaneus nodules
These are firm,
colorless, painless
nodules 1-2 cm in size,
near the tendens or
bony prominences of
joints, especially elbow.
Subcutaneous nodules (rheumatic fever
nodules/Aschoff nodules)

Erythema marginatum
This is a nonpruritic, flat,
circular or serpigious rash
on thoraxic trunk and near
joints.


DIAGTOSTICS

For diagnostic we use:

* major and minor rheumatic criterias
* rheumatic anamnesis
* markers of streptococcus infection
* laboratory findings
* ECG
* Doppler USG of heart.

2 major criteria or one major criteria
and 2 minor criteria with markers of
streptococcus infection are basement
for support the diagnosis of RF.
NB!
LABORATORY FINDINGS:


General blood analysis (blood test)
anemia, leycocytosis, shift in leycocyt formula
left, accelerated erythrocyte sedimentation rate
(ESR);

biochemical blood analysis:

reumoprobs:
Level of C-reactive protein;
Level of Seromucoids
Level of Glycoproteins
positive throat culture;

elevated level of antistreptolisin O,
antistreptokinaze or other streptococcal
antibody.
ECG findings:
PQ prolongation more than 0,18-0,20 sec;
Signs of enlargement of atria or
ventricules;
Signs of pericarditis.
Doppler USG heart:
Thickening of walls
Patological blood flows
(regurgitatione)
Enlargement atrium or ventricles;
Signs of effusion in pericardium.
Treatment
regimen the patient must take rest
before normalizaton of his temperature ;
Diet N10;
Ethyologycal treatment: :
- antistreptoccocal antibiotics
- Benzilpenicillini-natrii 1,2 1,5 million U
per day,
- Benzathine penicillini G 1,2 million U per
day

Or Amoxicillin 0,5 - 4 times per day;
Ampicillin 0,5 - 4 times per day
If the patient have allergic to penicillin
we use:
Erytromicinum
Cephalexin 50mg/kg
Cephadroxil 50mg/kg
2 times per day
Azithromycin 15mg/kg
Clarithromicin 15mg/kg

One of this antibiotics administer
during 10 day, than we change
antibiotic and prescribe prolongate
antibiotics:
Bicillinum-3 (1,5 million U for
one injection weeks;
Or Bicillinum-5 (1,5 milliom U
one jnjectione for 3 weeks
during the year)
4. Anti-inflammatory drugs: (NON
STEROID ANTI INFLAMMATORY
DRUGS) NSAID This drugs
blocked Pr a
2
.NONSELECTIVE:

1) Salicylic Acid:
Acetylsalicylic acid;
Sodium salicylate; Mg salicylate.
2) Antraylic acid
- Mefenamic acid 0,25 0,5;
- Flufenamic acid;
- Meclofenamic acid.
3) Arylbenzene acids
-Diclofenac Sodium ( Voltaren,
ortofen ) - tablets 0,025 0,05;
-ampules 0,075; suppository 0,05;
gel 1 %;
-Alclofenac;
-Fenclofenac;
- Fentiazak.
4) Propionic acids:
Ibuprofen ( brufen ) Dragee 0,2;
Florbiprofen Dragee 0,05;
Ketoprofen;
Naproxen;
Fenoprofen;
Fenbufen;
Piridofen.

INDOL DERIVATIVES :
Indomethacin ( Metindol, Indosid )
Dragee 0,025 Suppository 0,05;
Sulindac Tablets 0,2.
PYRAZOLE DERI VATI VES :
Butadion ( Phenylbutazone );
Analgin;
Amidopirin.
SELECTIVE COX2
BLOKERS:OXICAMS
Piroxicam ( Felden ) Tablets 0,01
Izoxicam
Sudoxicam
Meloxicam ( Movalis )

COXI BS :
Celecoxib ( Celebrex, Rancelex
Rofecoxib ( Rofica )
5. Corticosteroid therapy:

Prednizoloni 0,5-1 mg/kg orally 3
times daily(during 3-5 week) with
decrease dose step by step on
regime 5 mg for weeks.
6. Symptomatical therapy:
If the patient have signs of carditis and
heart failure we administrate:
diuretic drugs:
furosemid 20-40 mg orally daily in the
morning before meal;
Hypothyazidi 50-100 orally daily.

- Cardiotonic drugs such as
Digoxin 0,0001 1-2 times orally
daily.

If the patient has arrhythmias
ahtiarrhythmic drugs.
If the patient has signs vasculitis we
are administed ac. Ascorbinici 0,5 3
times orally daily.
Prognosis:
In case of initial RF with advantage arthritis
and initial carditis prognosis will be favourable
if the patient receive adequate therapy.
In cases severe RF with arthritis, severe
carditis, chronic rheumatic disease, heart
valvule diseases are observed.
If RF is not treated, chronic rheumatic disease
and heart valvule diseases are always occur.
Arthritis, chorea, subcutaneous nodulus
erythema marginatum have favorable outcome.

Prophylaxis (prevention):
Primary prevention:is prevention from
streptococcal infection (tonsilitis,
pharingitis, scarlet fever).

Secondary prevention:
---Antistreptococcal prophylaxis should
be conducted after attack of acute RF in
order to prevent recurrence.

---Bicillini-5 1,5milliom U (or Benziline
penicillin 6 1,2 million) one injection for
month due to 3 month
---Aspirini 0,5 4 times daily
orally during 3 weeks or other
NSAID.