ARF

1. NINAMA JAYDIP
LECTURER
SCON,ZUNDAL

3.  Occurs as a result of complex interaction between
GROUP A STRAPTOCOCCUS a susceptible host and
environment.
 An abnormal immune response to a GAS infection
leads to an acute inflammatory illness that most
commonly affects the joints , heart, brain or skin.
 Major public health problem among children and
young adults in developing countries.
 Most imPortant acquired heart disease in children.

4. IT is most important acquired heart
disease in children and commonly found in
4 to 15 years of age with incidence rate 5.0
/ 1000 approximately.

5.  The incidence of rheumatic fever is closely related the
incidence of group A STREPTOCOCCAL PHARYNGITIS.
 AGES: 5-15 YEARS ARE MOST SUSCEPTIBLE
 RARE: <3 YEARS
 GIRLS/ BOYS :BOTH SEXES ARE EQUALLY AFFECTED.
 COMMON:3 WORLD COUNTRIES
 ENVIRONMENTAL FACTORS: OVERCROWDING, POOR
SANITATION, POVERTY,…..
 INCIDENCE MORE DRING: WINTER SEASON,
FALL,TMPERATURE.

6.  “ ACUTE RHEUMATIC FEVER IS AN ACUTE AUTOIMMUNE
COLLAGEN DISEASE OCCURS AS A HYPERSENSITIVITY
REACTION TO GROUP A BETA HEMOLYTIC
STREPTOCOCCAL INFECTION. IT IS CARACTERIZED BY
INFLAMMATORY IESIONS OF CONNECTIVE TISUE AND
ENDOTHELIAL TISSUE. IT AEECECTS THE
HEART,JOINT,BLOOD VESSELS AND OTHER CONNECTINE
TISSUE”.

7.  The etiology of rheumatic fever is not clear.
 GROUP A BETA HEMOLYTIC STREPTOCOCCAL INFECTION.
 Delayed non- suppurative Squeal URTI with GAB
STREPTOCOCCI.
 Diffuse inflamatory disease of connective tissue.
 Primalily involving heart,, blood vessels, joints ,subcutaneous
tissue and CNS.

8.  Most common age group involved in 5 to 15 years.
 Both sexes are equally affected.
 PREDISPOSING FACTORS : low socio economic status
 overcrowding
 poor nutrition
 poor hygiene
 low immunological status
 increasing susceptibility
 MANDELIAN RECESSIVE PATTERN HAS ALSO BEEN
SUUGGESTED AS A GENETIC PREDISPOSITION.

9.  The exact etiopathogenesis or ARF is not well understood.
 Preceding streptococcal infection may not always critically manifest.
It is considered as a sort o f hypersensitivity reaction.
 There is an antigen antibody reaction usually following
streptococcal sore throat.
 Ant streptococcal antibody titer elevated in majority of the patients
,although the streptococci have never been isolated from rheumatic
lesions in joints, heart or in the blood –stream.
 The auto antibodies attack the myocardium, pericardium and cardiac
valves.

10.  Asch offs bodies develop on the valve, especially on the mitral
valve and leading t permanent valve dysfunction.
 Severe myocarditis may result dilation of the heart and hear
failure.
 The antibodies may react with striated muscle, vascular
smooth muscle and nervous tissue resulting joint
inflammation,invluntary movements as chorea and lesions in
blood vessels and other connective tissue

11. Environmental factors especially
overcrowding
Preceding
eventinfection with a
strain of group a
straptococcus
carrying specific
virulence factor
Repeated group
astraptococcus
infection
Susceotible Host
First episode
Of
ARF

12. First episode
Of
ARF
Repeated or on going infections possybly diving
The valvular inflammatory response
RHD
Episode of recurrent
ARF
Molecular mimicry
between
Group a streptococcus
and host
Exaggerated T- cell
mediated immune
responce
Genetically Determined
Host facters

13. CLINICAL MANIFESTATIONS
MAJOR MINOR ESSENTIAL
OTHER

15.  CARDITIS: EARLY MANIFESTATION
EXAMPLE: PERICARDITIS, ENDOCARDITIS, MYOCARDITIS
EVIDENCED AS PRESENCE OF SIGNIFICANT- MURMUR,ECG
CHAGES, CARDIAC ENLARGEMENT,, FRICTION RUB,

20.  Migratory type of joint inflammation s/s- pain, decrease ac tive
movements, warm tenderness, redness and swelling.
 Two or more joints are affected.
 Commonly knees, ankles and elbow are involved, but .smaller joint
may also be affected.

22.  PURPOSELESS INVOLUNTARY, RAPID MOVEMENTS
USUALLY ASSOCIATED WITH MUSCLE
 WEAKNESS,INCORDINATION,INVILUNTARY FACIAL
GRIMACE, SPEECH DISTURBANCE, AWKWARD GAIT AND
EMOTIONAL DISTURBANCES.

24.  Ii is found as firm painless movements nodule over the extensor surface of
certain joints.
 Joints- elbow, knee, wrists.
 Occiput and vertebral column.

27.  Pink macular non-itching rash
 Found mainly over the trunk, sometimes on the extremities but never
on face
 It is transient and brought out only by heat and migrates from place
to place.

30. FEVER ARTHRALGIA
PREVIOUS
ATTACK OF
ARF
ECG
CHANGES
ELREVATED
ESR

31.  Increase in body temperature is common
findings.
 It rarely goes above 39.5 c.

34.  Pain in the joints occurs in about 90 percent of
cases.
 It present along with arthritis.

37.  Previous attack of rheumatic fever or rheumatic heart
disease.
 Applicable for a second attack of rheumatic fever.

38.  ECG CHANGES WITH PROLONGED P-R INTERVAL IS
CONSIDERED AS MINOR CRITERION.
 IT IS NOT DIAGNOSTIC OF CARDITIS.

40. ELEVATED ESR OR PRESENCE OF C-
REACTIVE PROTEIN MAY BE
CONSIDERED AS MINOR CRITERIA.

41. Elevated antistreptolysin-o –titer indicates
previous streptococcal infection.
NORMAL= 200 IU /ML
Positive throat swab culture may show
streptococcal infection.( sore throat, scarlet
fever etc..)

42. PRECORDIAL PAIN

63.  Artificial subcutaneous nodule
 Doppler echocardiography
 Endomyocardial biopsy
 Chest x-ray
 Electrocardiography
 Blood test for ESR,WBC counts.

64.  JUVENILE RHEUMATOID ARTHRITIS
 OTHER COLLAGEN DISORDERS- SYSTEMIV=C LUPUS
ARTHRITIS,INFECTIONS ARTHRITIS, SERUM SICKNESS.
 ACUTE ARTHRITIS DUE TO VIRUS- EX-RUBELLA,HEPATITIS B,
VIRUS.
 HEMATOLOGIC DISORDERS- SICKLE CELL ANEMIA,LEUKEMIA

65.  CHRONIC RHEUMATIC HEART DISEASE-
MOST COMMON COMPLICATIONS
 HEART FAILURE
 ENDOCARDITIS
 PERICARDIAL EFFUSION
 PERMANENT CARDIAC DAMAGE

66. AORTIC IVOLVEMENT MAY BE
OBSERVED AS AORTIC
INCOMPETENCE.
PERMANENT CARDIAC DAMAGE

67. INVESTIGATIONS –History collection
 - physical
examination
 complete blood count
Acute phase reactants
Throat swab culture
Antistreptolysino titer
Chest radiograph
Electrocardiogram
echocardiography

68. BED REST
DIET
ANTIBIOTIC THERAPHY, PENICILLIN
COUNSELLING
ANTIINFLAMMATORY THERAPY- Aspirin,
Steroid

69. Physical and emotional stress should be
reduced.
Injection of benzathine penicillin
Anti inflammatory drugs not needed in
isolated chorea.
Severe cases- phenobarbitone
 Haloperidol
 Chlorpromazine,
diazepam carbamazine

70. NURSING ASSESSMENT- VITAL SIGNS,
CARDIAC MONOTORING, PAIN
ASSEESSMENT AND OTHER
ASSOSIATED PROBLEMS.

71.  Decreased cardiac output related to carditis.
 Pain related to polyarthritis
 Risk for injury related to involuntary
movements in chorea.
 Anxiety related to disease process
 Knowledge deficit related to long term
treatment and prognosis o f the acquired
heart disease.

72. IMPROVING CARDIAC OUTPUT-
 Provide rest
 Nursing care
 Maintain normal body temperature
 Provide bland diet
 Administering medication
 Monitoring cardiac output

73. anti-inflammatory analgesics
Providing comfortable position
Arranging divisional activities
Play materials

74. Removing hard and sharp objects
Assisting the child in feeding, ambulation
and other fine motor activities
Administration of drug- to control chorea
Explaining about self limiting course of the
condition and Importance about physical
and mental rest.

75. Explaining the duration of treatment
Follow up
Continuation of school performance
Instructing about preventive measures.

76. PRIMARY PREVENTION
- health education the people to avoid
streptococcal sore throat and elimination
of predisposing factors of the disease.
Treatment of streptococcal pharyngitis with
penicillin or other medications.

77. Patient with documented histories of rheumatic
fever, heart disease and also isolated cases
of chorea must receive prophylaxis.
DURATION: every 3 weeks till the age of 25 to
30 years.
After the age of 30years fever is not known to
occur.

78. Long acting BENZATHINE PENICILLIN
given to 6,00,000 units to be given to
patient weighing 27 KG.
Less 1.2 million units for patients weight-
more than 27 kg.
Route: intramuscularly
DURATION: every 21 days.

79. ERYTHROMYCIN- 40 MG / KG/ 24 HOURS TO BE GIVEN ONCE A DAY
ORAL SULFADIAZINE- 0.59 ONCE A DAY FOR LESS THAN 27 KG AND 1 G ONCE A
DAY FOR those more than 27 kg.

80. Prognosis of rheumatic fever depend upon
the age, presence of heart lesions, stage
of detection of the disease, available
treatment facilities and number of previous
disease.
Prognosis is worst in patients with carditis
is an early childhood.