Case Report

Rheumatic Fever

Musdalifa Andi Ahmad C11113059

Ferry Mendilla C11113332
Councelor :
dr. Rani Silondae

Division of Rheumatology
Departement Of Internal Medicine
Medical Faculty of Hasanuddin University
Makassar 2017
 Patient Identity
• Name : Ms. D
• Age : 21 years old
• Address : Makassar
• Occupation : Student
• Religion : Moeslem
• Ethnic : Buginese
• Marital Status : Single
History Taking
• Chief complaint : Joints pain
A 21 year old woman was admitted to the hospital because of joints pain for 1
month ago, and got worst since 3 days ago. He had a painful at waist, knee,
wrist, leg, and fingers joint. She felt weak and difficult to walk. No fever, but
there was history of fever about 7 days with sore throat, malaise, and myalgias.
She has history of acute tonsilopharyngitis 4 months ago. Now she complains
pain when swallowing meal.
No history of hair easily fall out, no rash on the face, no weight lost. Not
smoking, not drinking alcohol. She has history using antibiotic drugs and
antipiretic drugs (paracetamol) but not regularly.
Physical Examination
General Description
General condition : Moderate illness
Nutritional state : Normoweight
(BW: 50 Kg, BH: 166 cm, IMT: 19.53 Kg/m2 )
• Vital Signs
• Consciousness : Compos mentis (GCS 15)
• Blood pressure : 120/70 mmHg
• Heart rate : 98 x/min, regular
• Respiratory rate : 22 x/min
• Temperature : 36,5°C (axilla)
 Physical Examination
• Head : Normocephal, hair loss (-)
• Face : Malar rash (-)
• Eyes : Isocor pupils, normal light reflex, normal conjungtiva, no icteric sclerae
• Ear : No abnormalities, otorrhea (-)
• Nose : No abnormalities, epistaxis (-)
• Lips : No abnormalities, cyanosis (-)
• Tonsils : T2-T2, hiperemis (-)
• Pharynx : Hiperemis (-)
• Oral cavity : Oral trush (-),
• Throat : No abnormalities
• Neck : JVP R+2 cmH2O, no lymphadenopathy
Physical Examination
• Lung
• Inspection : Symmetrical left and right
• Palpation : No mass, normal tactile fremitus
• Percussion : Sonor
• Auscultation : Vesicular breathing sounds,no ronchi, no wheezing
• Heart
• Inspection : Ictus cordis unseen
• Palpation : Ictus cordis unpalpable
• Percussion : heart border within normal limits
• Auscultation : heart sound I / II regular, no murmur
• Abdomen
• Inspection : Convex
• Auscultation : Bowel peristaltic (+) normal
• Palpation : No ascites, no organomegaly
• Percussion : Tympani
Rheumatological Status
• Gait : Unable to walk
• Arm : Wrist joint (D/S) >> Color(-), dolor (-), rubor (-), bony enlargement
(-), Tenderness (+)
• Leg : Genu (D/S) : color (-), dolor (-), rubor (-),
bony enlargement (-), crepitation (-),
tenderness (+), limited ROM
Ankle joint (D/S) : color (-), dolor (-), rubor (-),
tenderness (+), limited ROM
• Spine : Normal
Laboratory Finding
WBC 9.000 / mm3 PLT 191.000 /mm3
RBC 3.240.000/ mm3 NEUT 74,8%
HGB 14,0 gr/dl LYMP 16,4%
HCT 25,7%
MON 5,9%
MCV 82 fl
EOS 2,4%
MCH 28 pg
BASO 0,5 %
MCHC 35 g/dL
CRP 6,95 mg/dl
ESR 75 mm/h
GOT/GPT 22/22
ASTO positive albumin 3.7
Ur/cr 45/0.9 Na/K/Cl 138/4.1/102
Assessment Planning Diagnostic Planning Therapy
• Rheumatic Fever - Bed rest
Based on Jones criteria: - Salisilat 100 mg/kg/day
1 major + 2 minor : - Benzatin penicillin 1,2 m
• Polyartralgia migrans
• Increased of ESR IU/IM
• Increased of CRP
Discussion
Definition

Rheumatic fever is a systemic inflammatory disease

affecting the peri-arteriolar connective tissues and can
occur after an untreated Group A Beta haemolytic
streptococcal pharyngeal infection.
Epidemiology
Most common among children age 5-15 years old. It
is rarely occurs among age > 35 years old.

Commonly, incident rate of rheumatic fever is 50

cases per 100,000 people.

ARF does not have clear cut sexual predilection.

Risk of RF occured after an episode of Streptococcal

infection is between 0,3-3%.
Etiopathogenesis
Clinical Manifestation
Diagnosis
Laboratory
•Increased or rising anti-streptolysine O (ASTO) titer or other streptococcal antibodies (anti-DNASE B).
A rise in titer is better evidence than a single titer result.

•A positive throat culture for group A β-hemolytic streptococci remains as the criterion standard for
confirmation of group A streptococcal infection.

•A positive rapid group A streptococcal carbohydrate antigen test in a child whose clinical presentation
suggests a high pretest probability of streptococcal pharyngitis.

•Histological findings : Aschoff Body

•ESR and CRP is usually elevated at the onset of ARF and serve as a minor manifestation in the Jones
criteria.

•Echocardiography may demonstrate valvular regurgitant lessions in patients with ARF who do not
have clinical manifestation of carditis.
 Treatment
• Bed rest
• Anti streptococcal therapy
– Benzatin Peniciline IM 1,2 M once / Penicilline oral 10 days
– If allergic to penicillin, erythromycin 20mg/kgBB/day up to 800mg for 10 days
• Anti inflammatory agents
– Aspirin 100mg/day in 4-6 weeks
– Corticosteroids 1-2 mg/kgBB/day if presence of carditis and must be tapered off
Primary
Prevention
Secondary
Prevention
Secondary
Prevention
Prognosis
Quad ad vitam :Dubia ad malam
Quad ad sanationam :Dubia ad malam
Quad ad Functionam :Dubia ad malam
THANK YOU