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Acute rheumatic fever

Cardio vascular Disease, Medicine for dentistry

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Acute rheumatic fever

  1. 1. Cardio-Vascular Disease Dr. Deepak K. Gupta ACUTE RHEUMATIC FEVER
  2. 2. Acute rheumatic fever • Usually affects children (most commonly between 5 and 15 years) or young adults • endemic in parts of Asia, Africa and South America • Triggered by an immune-mediated delayed response to infection with specific strains of group A streptococci – Antigens that may cross-react with cardiac myosin and sarcolemmal membrane protein • Antibodies produced against the streptococcal antigens – inflammation in the endocardium, myocardium and pericardium, as well as the joints and skin.
  3. 3. Clinical Features • Multisystem disorder that usually presents with – Fever – Anorexia – Lethargy – Joint pain • Latent period: 2–3 weeks after an episode of streptococcal pharyngitis. • Diagnosis is made using the revised Duckett Jones criteria – 2 or more major manifestations, – Or 1 major and 2 or more minor manifestations, – along with evidence of preceding streptococcal infection
  4. 4. Revised Jones Criterion
  5. 5. Carditis • Involves the endocardium, myocardium and pericardium to varying degrees • Incidence declines with increasing age - ranging from 90% at 3 years to around 30% in adolescence. • It manifest as – Breathlessness - heart failure or pericardial effusion – Palpitations or chest pain - pericarditis or pancarditis – Other features include tachycardia, cardiac enlargement and new or changed cardiac murmurs. – Aortic regurgitation - 50% of cases but the tricuspid and pulmonary valves are rarely involved. – Syncope: Conduction defects • ECG changes: ST and T wave changes
  6. 6. Arthritis • Most common and early manifestation • Acute painful asymmetric and migratory inflammation of the large joints • Typically affects the knees, ankles, elbows and wrists. • Pain characteristically responds to aspirin • If not, the diagnosis is in doubt
  7. 7. Skin lesions • Erythema marginatum – occurs in < 5% of patients – lesions start as red macules (blotches) that fade in the centre – but remain red at the edges – occur mainly on the trunk and proximal extremities but not the face • Subcutaneous nodules – occur in 5–7% of patients – Small (0.5–2.0 cm), firm and painless – Best felt over extensor surfaces of bone or tendons – typically appear more than 3 weeks after - help to confirm rather than make the diagnosis
  11. 11. Sydenham’s chorea (St Vitus dance) • Late neurological manifestation • Appears at least 3 months after the episode of ARF • all the other signs may have disappeared. • Occurs in up to 1/3rd of cases and is more common in females • Emotional breakdown or changes may be the first feature. • Typically followed by purposeless involuntary choreiform movements of the hands, feet or face. • Speech may be explosive and halting. • Spontaneous recovery usually occurs within a few months
  12. 12. Investigations • ESR and CRP: monitoring progress of the disease • Positive throat swab cultures are obtained in only 10–25% of case. • Echocardiography – Mitral regurgitation with dilatation of the mitral annulus – Prolapse of the anterior mitral leaflet – May also show aortic regurgitation and pericardial effusion
  13. 13. Investigations CXR: cardiomegaly due to carditis
  14. 14. Management • Treatment strategies can be divided into management – acute attack, – management of the current infection – prevention of further infection and attacks. • Management of the acute attack – Single dose of benzyl penicillin 1.2 million U i.m. – Oral phenoxymethylpenicillin 250 mg 6-hourly for 10 days – Penicillin-allergic: erythromycin or a cephalosporin – Analgesia: optimally achieved with high doses of salicylates • Treatment is then directed towards limiting cardiac damage and relieving symptoms.
  15. 15. Management • Bed rest and supportive therapy – Lessens joint pain and reduces cardiac workload. – Duration should be guided by symptoms along with temperature, leucocyte count and ESR – Should be continued until these have settled. – Return to normal physical activity but strenuous exercise should be avoided in those who have had carditis
  16. 16. Management • Cardiac failure • Mild heart failure usually responds to rest and corticosteroid therapy. • Severe carditis: Digoxin, but its use should be monitored closely - AV block • Vasodilators and diuretics also may be used • If heart failure in these cases does not respond to medical treatment, valve replacement may be necessary
  17. 17. Management • Protracted Sydenham chorea has responded to haloperidol • It requires long-term antimicrobial prophylaxis, even if no other manifestations of rheumatic fever evolve. • Complete physical and mental rest is essential because the manifestations of chorea may be exaggerated by emotional trauma.
  18. 18. Management • Aspirin – relieve the symptoms of arthritis rapidly and a response within 24 hours helps to confirm the diagnosis. – Reasonable starting dose is 60 mg/kg body weight/day, divided into six doses. – In adults, 100 mg/kg per day may be needed up to the limits of tolerance or a maximum of 8 g per day. – should be continued until the ESR has fallen and then gradually tailed off. • Corticosteroids – more rapid symptomatic relief than aspirin and are indicated in cases with carditis or severe arthritis. – Prednisolone, 1.0–2.0 mg/kg per day in divided doses, should be continued until the ESR is normal then tailed off.
  19. 19. PREVENTION PREVENTION PRIMARY-10 days course of penicillin therapy; about 30% of patients with acute rheumatic fever do not recall a preceding episode of pharyngitis SECONDARY-Secondary prevention is directed at preventing acute GABHS pharyngitis in patients at substantial risk of recurrent acute rheumatic fever
  20. 20. Primary prevention • It involves eradication of Streptococcus from the pharynx, • Administering a single i.m. benzathine benzylpenicillin
  21. 21. Secondary prevention • Patients are susceptible to further attacks if another streptococcal infection occurs. • Long term prophylaxis with penicillin should be given – Benzathine penicillin 1.2 million U i.m. monthly – Oral phenoxymethylpenicillin 250 mg 12-hourly • Sulphonamides prevent infection but are not effective in the eradication of group A streptococci. • Long-term antibiotic prophylaxis prevents another attack of ARF but does not protect against infective endocarditis.
  22. 22. Secondary Prevention: Duration CATEGORY DURATION Rheumatic fever without carditis At least for 5 yr or until age 21 year, whichever is longer Rheumatic fever with carditis but without residual heart disease (no valvular disease) At least for 10 yr or well into adulthood, whichever is longer Rheumatic fever with carditis & residual heart disease (persistent valvular disease) At least 10 yr since last episode & at least until age 40 yr; sometime lifelong
  23. 23. Complications
  24. 24. Complications
  25. 25. Complications
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