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Paediatrics > Acute Rheumatic Fever and Rheumatic Heart Disease > Flashcards

Acute Rheumatic Fever and Rheumatic Heart Disease Flashcards

1
Q

who gets acute rhuematic fever

A

5-14yo
females diagnosed more frequently
ethnicity - indigenous australians, maori, pacific islanders, migrants from low/middle income countries
high risk of recurrance

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2
Q

when does ARF develop

A

develops 1-5 weeks following infection with strep pyogenes

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3
Q

initial strep infection may present as

A

Initial strep pyogenes infection usually presents as pharyngitis (strep throat) but may present as an infection of the skin (cellulitis)

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4
Q

why does ARF develop following strep infection

A

Rheumatic fever develops in susceptible hosts (2% of the population) due to a hypersensitivity reaction against the bacteria (type 2 hypersensitivity)

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5
Q

what kind of bacteria is strep pyogenes

A

group A strep
Gram positive coccus, aerobic/facultative anaeroabe
Catalase negative
Lancefeild group A
Beta-hemolytic
Bacitracin susceptible
100 serotypes defined by surface M protein

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6
Q

clinical syndromes of strep A infection

A

noninvasive: skin, pharynngitis
invasive: bacteraemia, septicaemia, necrotising fascitis, bone/joint, empyema, meningitis
toxin-mediated: toxic shock, scarlett fever
immune-mediated: ARF, RHD, glomerulonephritis

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7
Q

types of evidence of recent group A strep infection

A

positive throat swab
repid streptococcal antigen test
raised antistreptolysin O titre or Anti-DNase B titre
recent episode of scarlet fever

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8
Q

when to use culture of group A strep

A

historic gold standard
most useful for acute infections, especially invasive GAS
less useful for post-infectious complications

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9
Q

serology for group A strep is most useful for

A

most useful for the diagnosis of post-infectious complications

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10
Q

Jones’ criteria

A

evidence of recent group A strep infection (culture or serology)
AND
two major criteria
OR
one major and two minor criteria

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11
Q

major manifestations of acute rhuematic fever

A

polyarthritis
carditis
subcutaneous nodules
erythema marginatum
sydenham’s chorea

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12
Q

acronym for Jones’ criteria

A

J = joints
<3 = heart
N = nodules
E = erythema marginatum
S = sydenham’s chorea

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13
Q

arthritis in acute rheumatic fever

A

most common presentation
classically: asymmetric, migratory, large joints
very responsive to NSAIDs

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14
Q

whats the difference between arthritis and arthralgia

A

arthrtis requres evidence of inflammation
arthritis: swollen, hot joint, with pain in movement
arthralgia: pain on joint movement, no joint swelling or heat

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15
Q

carditis in acute rheumatic fever

A

2nd most common clinical feature
predominantly inflammation of the endocardium (as opposed to myocardium/pericardium) - especially left side valvulitis = mitral valve regurgitation

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16
Q

clinical features of carditis

A

often subclinical
clinical features may include:
- cardiac murmur
- cardiac enlargement
- cardiac decompensation
- pericardial friction rub or effusion

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17
Q

most common valve affected in carditis

A

mitral valve

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18
Q

investigations for carditis

A

ECG: prolonged PR interval
Echo: valvulitis

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19
Q

role of echocardiogram in valvulitis

A

define the severity of mitral aortic and/or tricuspid regurgitation
define the severity of mixed valve disease (mixed stenotic and regurgitant)
identify subclinical evidence of rheumatic valve damage
visualse valvular anatomy and define meechanism of reegurgitation (prolapse, flail leaflet, annular dilatation etc)

20
Q

role of echocardiogra, in cardiac function

A

assess left ventricular size and function

21
Q

chorea as a clinical feature of acute rheumatic fever

A

late presenting sign
if other causes of chorea are excluded, chorea is diagnostic for ARF
can occur after a period of latency
disappears during sleep

22
Q

clinical signs of chorea

A

milkmaids hands - rhythmic squeezing of examiners hands
spooning - flexion of the wrists and extension of the fingeer when the hands are extended
pronator sign - turning outward of the arms and palms when help above the head
inability to maintain protrusion of the tongue

23
Q

subcutenous nodules

A

rare
highly specific for ARF
strong association with carditis
crops of small, round, painless nodules
usually on extensor surfaces - over the lebows, wrists, knees, ankles, achillies tendon, occiput and posterior spinal processes of the vertebrae

24
Q

erythema marginatum

A

extremely rare
diifficult to see in dark skinned populations
occurs as circular patterns of bright ppink macules or pappules on the trunk and proximal extremities, face usually spared
called geogrphical rash - looks like borders on a map with pale centre

25
Q

is erythema marginatum painful

A

not pruritic or painful

26
Q

time course of erythema marginatum

A

evanescent - waxes and wanes during the course of a day
can recur for weeks/months

27
Q

are NSAIDs effective for erythema marginatum

A

NSAIDs and steroids not effective

28
Q

minor JONES criteria

A

polyarthralgia
prolonged PR interval on ECG
Hx of rheumatic fever
fever
raised inflammatory markers
- CRP, ESR, leuks

29
Q

investigations for acute rheumatic fever

A

bedside:
vitals and ECG- for prolonged PR interval
Labs:
FBC - raised WCC
ESR, CRP - raised
troponin - raised in carditis
strep serology (ASOT, antiDNaseB)
dependant on context: throat swab, skin sore swab, blood culture, synovial fluid aspirate
rheumatoid and anti-CCP to rule out other diagnoses
imaging:
Echo to aid carditis diagnosis
chest x-ray to rule out heart failure

30
Q

ddx for joint symptoms

A

juvenile idiopathic arthritis
reactive arthritis
HSP- henoch-schonlein purpura

31
Q

cardiac disease might otherwise be explained by

A

cardiomyopathy
kawasaki disease
infective endocarditis

32
Q

chorea may be otherwise explained by

A

wilson’s disease
adverse drug reactions
huntington’s disease (very rare in children)

33
Q

skin changes may be otherwise explained by

A

advserse drug reactions
Lyme disease/erythema migrans
erythema multiforme

34
Q

treatment for strep throat infection in high risk groups

A

bed rest strongly recommended especilly if myocarditis is present
IM benzaathine benzylpenecillin G (BPG) is the antibiotic of choice, single dose

35
Q

treatment for arthritis

A

paracetamol, tramadol if diagnosis unclear
NSAID if diagnosis confirmed
immobilise

36
Q

carditis treatment

A

diuretics, ACEI
pericardiocentesis to remove fluid collections around the heart (in presence of pericardial effusions) may be needed
treat heart failure as required

37
Q

chorea treatment

A

dizepam, haloperidol,
carbamazepine, valpproate
if functional impairment but this symptom is self limiting

38
Q

complications of acute rheumatic fever

A

carditis
heart fialure
pericardial effusions
valvular disease (especially the mitral valve)
atrial fibrilltion
pulmonary hypertension
thromboembolic events
refractory chorea (plasmapheresis may be required

39
Q

what causes rheumatic heart disease

A

similarities between the streptococcal bacteria and human heart valve tissue lead to autoimmune damage to the hert valves

40
Q

prevelence of rheumatic heart disease

A

peak prevalence in thrid or forth deecades
more common in females
mitral valve most commonly affected
echo: gold standard for diagnosis

41
Q

symptoms of rheumatic heart disease

A

may be asymtpomatic
dyspnoea: on exertion, orthopnoea, paroxysmal nocturnal dyspnoea
fatigue, weakness
angina
syncope

42
Q

signs of rheumatic heart disease

A

heart murmur
heart failure
arrythmia

43
Q

natural history of rheumatic heart disease

A
44
Q

primordial prevention of rheumatic heart disease

A

disease of poverty
overcrowding
washing facilities for people, clothing, bedding

45
Q

primary prevention of rheumatic heart disease

A

regognise strep throat and skin infections and treat with antibiotics

46
Q

secondary prevention of rheumatic heart disease

A

consistent and regular administration of antibiotics to people who have had ARF or RHD, to prevent future GAS infections, ARF recurrence, and thus limit RHD development/progression

use long-acting intramuscular benzathine penicillin G (BPG)

duration depends on: ARF classification, presence of RHD (and its classification), age

47
Q
A

Paediatrics (44 decks)

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