Acute

Rheumati
c
fever
Paul s mathew

WHAT IS RHEUMATIC
FEVER??
Immunologically mediated multisystem inflammotory
disease that
follows an episode of group a B-hemolytic
streptococcal
pharyngitis after an interval of a few weeks

EPIDEMIOLOGY
AGE
: MOSTLY CHILDREN
YEARS OR
young adults
AGENT

5 15

: GROUP A B- HEMOLYTIC
STREPTOCOCCI serotype

m5
COXACKIE B-4 VIRUS HAS
ALSO BEEN
SUGGeSTED

ETIOPATHOGENESIS
Hypersensitivity reaction
Antibodies against M protien
Molecular mimicry and cross reaction
Fibrinoid degeneration of collagen
(Synovium, cardiac and nervous tissue)

Components of Jones criteria

MAJOR
CARDITIS
MIGRATORY

POLYARTHRITIS

CHOREA
ERYTHEMA

MARGINATUM
SUBCUTANEOUS NODULES

JONES CRITERIA CONTD.

MINOR
FEVER
ARTHRALGIA
PREVIOUS

RHEUMATIC FEVER
RAISED ESR OR C REACTIVE PROTEIN
LEUCOCYTOSIS
FIRST DEGREE OR SECOND DEGREE A-V
BLOCK

CONTD
ESSENTIAL
SUPPORTING

EVIDENCE OF
PRECEDING STREPTOCOCCAL
INFECTION
RECENT

SCARLET FEVER
RAISED ASO TITRES
POSITIVE THROAT CULTURE

1.ACUTE RHEUMATIC
CARDITIS
PANCARDITIS
PERICARDITIS : FIBRINOUS
PERICARDITIS
MYOCARDIUM : ASCHOFF BODIES
ENDOCARDIUM : VALVULAR
INFLAMMATION
WITH
VERRUCOUS
LESIONS

CLINICAL FEATURES: CARDITIS

EARLY MANIFESTATION

OF DISEASE
SEEN IN 50 60 % PATIENTS
HISTORY

BREATHLESSNESS
CHEST PAIN
PALPITATION
MAY HAVE SYNCOPE

C/F CONTD

O/E

TACHYCARDIA (SLEEPING)
PRECORDIAL TENDERNESS
PERICARDIAL RUB
SIGNS OF CONGESTIVE CARDIAC FAILURE
SOFT FIRST HEART SOUND
S3 GALLOP
NEW OR CHANGED MURMER

MURMER

SOFT SYSTOLIC MURMER AT APEX

DUE TO MR

SOFT MID DIASTOLIC RUMBLING

MURMER AT APEX ( CAREY COOMBS)

DIASTOLIC DECRESCENDO MURMER

OF AR IN 3RD TO 5TH LEFT INTERSPACE

2.ARTHRITIS

EARLY FEATURE

ACUTE, PAINFUL,ASSYMETRIC, MIGRATORY

INFLAMMATION OF LARGE JOINTS ( KNEE,
ANKLE, ELBOW,WRIST, SHOULDER)

RED , SWOLEN , TENDER(1-7 DAYS)

LIMITS MOVEMENT

RELIEVED WITH ASPIRIN

Jaccouds Arthritis

Post-RF arthropathy
Deformed fingers and toes
Ulnar deviation of finger
Flexion of metacarpo-phalangeal joint
Hyperextension of proximal
interphalangeal joints.
No inflammatory changes.

3. SKIN LESIONS

1. ERYTHEMA MARGINATUM

EARLY MANIFESTATION
RED NON - PRURITIC MACULE WITH PALE
CENTRE
SEEN ON TRUNK , PROXIMAL EXTREMITIES
SPARES THE FACE
COALESCE TO FORM SERPIGINOUS OR
CIRCULAR BORDERS

SKIN CONTD..

2. SUBCUTANEOUS NODULES

LATE MANIFESTATION (3 WKS)

INDIA ONLY 3-5% PATIENTS
FIRM PAINLESS (0.5 2 cm) ON BONY
PROMINENCES

4. SYDENHAMS CHOREA

Chorea:

Cellular degeneration of cortex,

basal ganglia, substantia nigra
and cerebellum

LATE NEUROLOGICAL
MANIFESTATION
3 MONTHS AFTER ONSET OF
ACUTE RF

PURPOSELESS , JERKY
MOVEMENTS
DERANGED SPEECH, MUSCULAR
INCO-RDINATION AND WEAKNESS
AWKWARD GAIT

MINOR CRITERIA

1.FEVER
ALMOST ALWAYS PRESENT
DOES NOT EXCEED 39.5 C

2. ARTHRALGIA
SUBJCTIVE PAIN WITHOUT INFLAM.

3. PREVIOUS RHEUMATIC FEVER OR

RHD

LAB STUDIES
LEUCOCYTOSIS
RAISED ESR OR RAISED CRP
EVIDENCE OF PRECEDING STREP.
INFECTION
THROAT SWAB CULTURE: GRP.A BHEMOLYTIC STREPTOCOCCI (25%)
ASO TITERS: RISING TITRES OR
>200 U (ADULTS)
>300 U (CHILDREN)

CHEST
RADIOGRAPH

CARDIOMEGALY,

PULMONARY CONGESTION

ELECTROCARDIORAM
FIRST OR SECOND DEGREE A-V
BLOCK
FEATURES OF PERICARDITIS
T-WAVE INVERSION
REDUCTION IN Q RS VOLTAGE

ECHOARDIOGRAM

CARDIAC DILATATION
VALVULAR ABNORMALITIES

DIAGNOSIS
REVISED JONES CRITERIA

TWO OR MAJOR CRITERIA , OR ,

ONE MAJOR AND TWO MINOR CRITERIA WITH
EVIDENCE
WITH EVIDENCE OF PRECEDING
STREPTOCOCCAL INFECTION

Treatment

Principles of treatment

Bed rest
Antimicrobial treatment
Analgesics and anti-inflammatory
treatment
Diuretics and cardiotonic medication
Treatment of chorea

Bed rest
Cardiac status

Management

No carditis

Bed rest: 2 weeks; gradual

ambulation over 2 weeks

Carditis, no cardiomegaly

Bedrest: 4weeks, gradual

ambulation over 4 weeks

Carditis, cardiomegaly

Bedrest: 6 weeks, gradual

ambulation over 6 weeks

Carditis, heart failure

Strict bedrest as long as heart

failure present, gradual
ambulation over 3 months

Basically, bed rest recommended till evidence

of active carditis subsides:

ESR
CRP
Pulse rate during sleep
WBC Count

Antimicrobial treatment

Aim: To eradicate streptococci that may still be in

the pharynx before starting anti-streptococcal
prophylaxis.

AGENT
Benzathine
penicillin G

DOSE

MODE

DURATION

< 27 kg

600,000 units

i.m.

Once

>= 27 kg

1.2 million units

i.m.

Once

Penicillin V

250-500 mg
b.d./t.i.d.

Per oral

10 days

20-40 mg/kg/day

Per oral

10 days

Penicillin
allergy:
Erythromycin

SUPPRESSIVE RXN.
ANALGESIC AND ANTI- INFLAMMATORY.

STEROID---CARDITIS AND FAILURE

DOSE 60 mg/ day IF WT.> 20 Kg
40mg/ day
wt< 20 Kg
for 3 weeks and then taper over 9
months( 5mg/wk)

Contd

Aspirin --- In patients without failure +/carditis

Dose - 90 120 mg/kg/day(max 8 g/ day)
Faster acting than steroid

Diuretics and Cardiotonic

medication

Heart failure not resolving by bedrest and

steroids:
Diuretics
Digitalis
Valve replacement if doesnt improve

Treatment of Chorea

Quiet environment
Bedrest
Sedatives: Phenobarbital 16-32 mg q8h
Haloperidol,Chlorpromazine,valium
Usually self-limiting

Prevention

Primary prevention

Prevention of first attack of RF:

Detection and treatment of strep. Pharyngitis
Must be directed at the general population, especially
the susceptible age group.

Secondary prevention
BENZATHINE

PENICILLIN (PENIDURE)
6 LAC UNITS (CHILDREN)
1.2 M.U. (ADULTS)
ONCE IN 3 WEEKS i.m. injection
Aim- To prevent recurrences

Duration of prophylaxis
Category

Duration

RHD

Lifelong

Carditis, no RHD

Until 40 years of
age

ARF and no
carditis

Until age of 21 or
10 years from
last attack

References

davidson,s textbook of medicine 19th edition

Nelsons essentials ofpaediatrics,4th edn.
Op ghai, essential peadiatrics, 6th edn.
Basic pathology Robbins 7th edn.

Rheumatic fever licks the joints but bites

the heart .!! Lasgue

Thank
you!