Acute Rheumatic Fever

Question 1

Diagnosis of ARF

Answer 1

Major Manifestations
- Carditis
- Polyarthritis
- Sydenhams Chorea
- Erythema Marginatum
- Subcutaneous Nodules (Near tendons or above boney surface or prominence

Minor Manifestations
- Monoarthralgia
- Fever >= 38C
- ESR > 30 or CRP > 30
- Prolonged PR interval

Initial epidose - Two major, one major + 2 minor + Preceding S.pyogenes infection

Recurrent episode - Two major, one major + 2 minor, 3 minor with preceding S. pyogenes infection.

Question 2

Treatment of ARF

Answer 2

IM Benzathine Benzylpenicillin 1.4million Units for adults. Lower doses based on weight

Can consider PO Phenoxymethylpenicillin 15mg/kg PO BD x 10 days if adherence likely

Severe penicillin allergy? Azithromycin 12mg/kg up to 500mg PO OD x 5 days

Analgesia
- 1 - Naproxen 625mg (5-10mg/kg) PO BD
- 2 - Ibuprofen 10mg/kg PO TDS PRN
- 3 - Aspirin 50mg/kg daily in 4 to 5 divided doses. Beware of Reye’s Syndrome - 90% of cases Linked to Aspirin use with rapidly progressive brain disease and liver toxicity.
- Continue NSAID until symptom free for 1-2 weeks. Typical duration of therapy 6 weeks

Follow up with prophylactic long-term penicillin. Monthly IM benzathine benzylpenicillin.
- 21 day interval recommended for
- Severe rheumatic heart disease
- History of cardiac valve surgery
- Confirmed breakthrough of ARF despite 28 day IM benzathine benzylpenicillin.
Penicillin allergy? Erythromycin 250mg PO BD

Cessation of secondary prophylaxis should be based on clinical and echocardiographic assessment made in conjunction with a specialist with expertise in rheumatic fever.

Question 3

Investigations for ARF

Answer 3

In all Cases
FBC
ESR
CRP
Streptococcal ASOT
Streptococcal anti-DNAse B
ECG

Consider
- Throat swab (Tonsilar erythema or exudate)
- Blood cultures
- Synovial fluid aspirate.
- Pregnancy test
- Echo if PR prolongation on ECG