ACUTE RHEUMATIC FEVER

Dr Richard Ssenyondo
CLINICAL FEATURES
• Streptococcal sore throat followed by
10 days to 2 weeks
• History of sore throat available
in 50% patients
 Essential criteria
• Evidence of recent streptococcal infection
indicated by
• -increased levels of antibodies against
streptococci
• -+ve throat culture for group A
streptococcus
• Recent scarlet fever
 CARDITIS
• Occurs in 34-90% of patients with ARF
• Carditis is the only manifestation of
rheumatic fever that leaves a sequelae &
permanent damage to the organ
• Valvulitis occur in acute phase
Rheumatic carditis is a pancarditis involving
pericardium,myocardium and endocardium
 Chronic phase- fibrosis,calcification &
stenosis of heart valves(fishmouth valves)
 Pericarditis
• Pericordial pain
• Pericardial friction rub on auscultation
• ECG-ST and T changes
• Rheumatic pericarditis associated with
Small pericardial effusion
• Patient have additional MR or AR
murmurs or both
Pericardial effusion
 Myocarditis
1)Cardiac enlargement-on physical exam,
CXR or ECHO
2)Soft S1
3)Protodiastolic (S3)gallop
4)CCF-– right or left sided
4)Carey coombs murmer-low pitched
delayed diastolic mitral murmer heard during
the course of acute RF
Myocarditis
 Endocarditis
• Endocardial inflammation –leave
permanent scarring
-sever and common in mitral and aortic
valves
-less common in tricuspid valve
-least in pulmonary valve
• Atypical pansystolic murmur of MR
(95%)or Diastolic murmur of AR(25%)
• Tricuspid involvement (40%)-uncommon in
first attack
 Why heart damage?
Diagrammatic structure of the group A beta hemolytic
streptococcus

Capsule Antigen of outer

protein cell wall
Cell wall of GABHS
induces antibody
Protein antigens response in
victim which
Group carbohydrate result in
autoimmune
Peptidoglycan damage to heart
Cyto.membrane
valves,
sub cutaneous
tissue,tendons,
Cytoplasm joints & basal
ganglia of brain
 Arthritis
• Flitting & fleeting migratory polyarthritis, involving
major joints
• Commonly involved joints-knee,ankle,elbow &
wrist
• Tenderness,redness,warmth,swelling,
limitation of movements
• In children below 5 yrs arthritis usually mild but
carditis more prominent
• Arthritis do not progress to chronic disease
• Polyarthritis- in adults only a single joint may be
affected
• Lasts 1-5 weeks
• Occurs in 75% or patients
• Subsides without residual damage of the joint
• Dramatic response of arthritis to therapeutic
doses of aspirin or NSAIDs
 Subcutaneous Nodule
• Non tender,non adhesive
• Small (<2cm in diameter) firm
(pin head size to almond)
• Attached to fascia, or tendon
sheaths over bony
prominences like
shin,wrist,elbow,knee
• Late manifestation after the
onset of RF(3wks to
6wks)Persist for days or
weeks(upto year)
• “If Nodules then Carditis”
 SYDENHAM’S CHOREA
• Purposeless jerky movements resulting
abnormal speech,muscular
incoordination,dropping of articles,awkward
gait,weakness
• Emotional instability
• Girls more frequenty affected
• Rare in adults
• Occur 5-36% of cases-Self limiting
• Clinical signs- pronator sign, jack in the box
sign , milkmaids grip
milkmaids grip
 Erythema Marginatum
• Red spot,pale
center,increase on
applying heat
• Reddish,not raised
above the skin,non
itching with
serpigenous margin
 Minor Criteria
• Clinical
Fever
-90% patients
-Temp 39.5 C
Arthralgia
-Joint pain without physical signs
H/O previous RF or RHD
 Minor Criteria
Laboratory
•High ESR(remains 4-10weeks in 80% patients)
•Anemia, leucocytosis
•Elevated C-reactive protien,TLC-10000-15000
 Minor Criteria
• ECG
prolonged PR interval(non diagnostic criteria), 2nd
or 3rd degree blocks(Wenkebach type),ST
depression,T inversion
• 2D Echo cardiography
valve edema,mitral regurgitation, LA & LV
dilatation,pericardial effusion,decreased
contractility
 Essential criteria
• ASO(antistreptolysin”O”) titre >200 Todd units.
(Peak value attained at 3 weeks,then comes
down to normal by 6 weeks)
• Anti-DNAse B test,antihyaluronidase,streptozyme
• Throat culture-streptococci(might have RF or
might not)
• H/O scarlet fever-desquamation of skin of palms
and soles
• Rapid streptococcal antigen test(low sensitivity)
• “Also there” features:
• Pneumonia
• Epistaxis
• Erythema nodosum
• Abdominal pain
REQUIRED FOR DIAGNOSIS
• Two major criteria OR
• One major and two minor criteria
 DIFFERENTIAL DIAGNOSIS
• Arthritis
• Rheumatoid arthritis
• Reactive arthritis(shigella,salmonella..)
• Serum sickness
• Sickle cell disease
• Malignancy
• SLE
• Lyme disease
• Gonococcal infection
 DIFFERENTIAL DIAGNOSIS
• Carditis
• Viral myocarditis
• Viral pericarditis
• Infective endocarditis
• Kawasaki disease
• Congenital heart disease
• Mitral valve prolapse
• Innocent murmurs
 DIFFERENTIAL DIAGNOSIS
• Chorea
• Huntington chorea
• Wilson disease
• SLE
• Cerebral palsy
• Tics
• Hyperactivity
 Treatment
• Step I - primary prevention
(eradication of streptococci)
• Step II - anti inflammatory treatment
(aspirin,steroids)
• Step III- supportive management &
management of complications
• Step IV- secondary prevention
(prevention of recurrent attacks)
 Treatment
PHARYNGITIS
Benzathene penicillin 1.2 million units
( 50,000 units/kg to a max of 1.2 million
units) is injected IM once a month or
Inj Procaine penicillin 600,000 units once
daily for 10 days
Erythromycin can be substituted (
40mg/kg/day)
 TREATMENT
CARDITIS
• Bed rest – until temp, ESR, resting pulse rate and ECG have all
returned to normal
• Prednisone-2mg/kg/day(4 doses 2-3wks) if there is CCF or
cardiomegaly
POLYARTHRITIS
• Anti inflammatory agent - Aspirin markedly reduces fever, joint
pain and swelling
• 100mg / kg/day in 4-6 divided doses. Can be reduced to
75mg/Kg/day once there is a response . Given for 4-6 weeks
• Toxicity includes- tinnitus, vomiting and GI bleeding.
• When response to aspirin is inadequate a short course of
prednisone (1 mg/kg/day) orally daily usually causes rapid
improvement of joint symptoms. It is tapered over 2 weeks. Add
aspirin when tapering begins.
 Treatment
• Sydenham Chorea
• Sedatives-Phenobarbitone(16-32mg Q6-
8th hrly PO)
• Haloperidol (0.01-0.03mg/kg/day in BD
PO)
• Chlorpromazine(0.5mg/kg Q4-6th hrly PO)
 Prognosis
• Rheumatic fever can recur whenever the
individual experience new Group A bet
hemolytc streptococcal infection,if not on
prophylactic medicines
• Good prognosis for older age group & if no
carditis during the initial attack
• Bad prognosis for younger children &
those with carditis with valvular lesions
 PREVENON OF ARF-PRIMARY

• Early and adequate treatment of

Strep. throat infections with a penicillin or
Azithromycin will prevent Rheumatic Fever
• Avoidance of overcrowding & improved
hygiene will decrease the incidence of
pharyngitis
 PREVENTION -SECONDARY
Those who have had RF can have recurrences
Recurrences are most common in children and in those patients who have had
carditis during their initial episode of RF
Recurrences are prevented by giving Benzathine penicillin 1.2million units IM
every 4 week

OR
Oral penicillin 250 mg bid
Erythromycin 250 mg bid
Azithromycin
Allergic to penicillin? Macrolide or Azalide
Duration controversial:
5 years after last attack or until reaches 21 years, whichever is later
(earlier recommendation: life-long)
Those with cardiac involvement and in high risk group-
health staff, school teachers, parents of young children- life long prophylaxis
IMPORTANT!!

The complication of untreated, or

inadequately treated Acute rheumatic
fever is
RHEUMATIC HEART DISEASE