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Senoir paeds > Acute Rheumatic Fever & Rheumatic Heart Disease > Flashcards

Acute Rheumatic Fever & Rheumatic Heart Disease Flashcards

1
Q

Acute Rheumatic fever (ARF)

• Definition: ARF is a/an (infectious or non infectious?) complication of
__________________________________.

• A ____________ ___________________ disorder that can involve the _______,______,________, and __________.

A

non infectious

Group A streptococcus (GAS) pharyngitis.

multi-organ ; inflammatory

heart, joints, skin and brain.

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2
Q

ARF is Now rare in developed countries but still major public health problems in developing countries.

T/F

A

T

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3
Q

Epidemiology of ARF

• Age – Can occur at any age but most cases occur between _______ years.
• Females and males are affected but some studies have found a (male or female?) preponderance.

A

5-15 years.

female

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4
Q

Recurrence of RF is common in the absence of ______________________, especially during the 1st _____ yrs. after the 1st episode.

Heart complications may be long-term and severe, particularly if _________ are involved.

A

maintenance of low dose antibiotics

3-5

valves

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5
Q

Pathogenesis of RF

• RF is a (immediate or delayed?) ______________ response to ____________________________ , and the
clinical manifestation of the response and its severity in an individual is determined by
– host ________________
– the ________ of the infecting organism
• Strep M protein types such as 1, 3, 5, 6, 14, 18, 19 and 24 have been associated with RF
– a conducive environment

A

Delayed ; autoimmune

Group A streptococcal pharyngitis,

genetic susceptibility

virulence

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6
Q

Pathogenesis of RF

• Both the __________ and _________ host defenses of a genetically vulnerable host are involved.

• The patient’s immune responses (both B- and T-cell mediated) are unable to ___________________________________________.

• T ___________ and cytokine ______ appear to be key mediators of RHD.

A

humoral and cellular

distinguish between the invading organism and certain host tissues (molecular mimicry)

helper 1 ; Th17

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7
Q

Pathogenesis of ARF

• In ARF, the cross-reactive immune response results in the clinical features of rheumatic fever, including

–__________
– ____________
– ________
– _________ manifestations

A

carditis

transient arthritis

chorea

skin manifestations

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8
Q

Pathogenesis of clinical features of RF

– carditis, due to ____________ and infiltration of _________

– transient arthritis, due to the formation of __________

– chorea, due to the binding of _________ to ___________

– skin manifestations, due to a delayed
_________________

A

antibody binding ; T cells

immune complexes

antibodies ; basal ganglia

hypersensitivity reaction

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9
Q

Pathology

• In ARF, cardiac lesions can be found in _______ layer of the heart and is hence called _________
• Characteristic ________ bodies can be seen on light microscopy following heart muscle
biopsy

A

any; pancarditis

Aschoff

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10
Q

Aschoff bodies

composed of swollen _______________ surrounded by __________ and __________

A

eosinophilic collagen

lymphocytes and macrophages

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11
Q

History in an ARF patient

History of ______________ ~ __________) before onset of symptoms.

The latent period may be as long as 2-6
months in cases of ______________
• No preceding symptoms of Strep. pharyngitis in _____% of patients.
• ±Family history of rheumatic fever-it is a
(Weakly or highly?) inheritable disease.

A

streptococcal pharyngitis; 3 weeks

Isolated chorea; 30

Highly

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12
Q

Clinical manifestation/Diagnosis of
ARF

• There is no single confirmatory test for ARF.
Instead, the diagnosis of initial or recurrent
ARF relies on patients fulfilling a set of clinical criteria.

• The ___________ criteria- Comprises of _____
major manifestations, _____ minor criteria and evidence of ___________________

A

revised Jones; 5

4

preceding Group A Streptococcal
infection.

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13
Q

Definition of populations
• Low risk population
– ARF incidence ≤___ per 100,000 school aged children or all age RHD prevalence of ≤____ per 1000 population year

• Moderate or high risk population
– Children not clearly from a low risk population.

A

≤2

≤1

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14
Q

List the 5 major criteria for ARF

A

Carditis
Arthritis
Chorea
Erythema marginatum
Subcutaneous nodules

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15
Q

Difference between major criterias in low VS moderate/high risk population?

A

Only in arthritis

Low- polyarthritis only

Moderate/high- mono , poly arthritis, poly arthralgia

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16
Q

What nullifies prolonged PR interval as a criteria

A

If carditis is a major criteria

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17
Q

Difference between minor criterias in low VS moderate/high risk population?

A

Low- poly arthralgia
Mod/high- mono arthalgia

Low-38.5
Mod/high- 38.0

Low-ESR >60mm/hr
Mod/high- >30mm/hr

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18
Q

List the minor criteria for ARF

A

arthralgia
ESR
Prolonged PR interval
Fever

19
Q

Carditis

• Clinical - significant __________ or
____________ or ________
• Subclinical or silent carditis- Pathological _______ involvement found by ___________
without clinical signs of carditis.

• MI or AI commonly. __________ and ________________ may emerge years after the acute attack (generally at adult ages).

A

new murmur ; Pericarditis ; CCF

valve ; echocardiogram

Mitral stenosis ; aortic stenosis

20
Q

• Most common presenting symptom of ARF is ????

A

Arthritis

21
Q

Arthritis

• Classified as _________ of the _________ in the presence of two or more of the following:
– _________ of movement, _________ of the joint and _________ in the joint and/or _________.

A

swelling ; joint

limitation ; hotness ; pain ; tenderness.

22
Q

Typically, the arthritis of ARF is (mildly or extremely?) painful

(Small or Large?) joints are usually affected, especially _________ and _________

A

Extremely

Large; knees; ankles

23
Q

Polyarthritis is usually (symmetrical or asymmetrical?) and _________ but
can be _________.

Highly responsive to _________ and ___________ therapy - usually responds within _______________

A

asymmetrical; migratory

additive

salicylate and NSAID

3 days

24
Q

Subcutaneous nodules

(Common or Uncommon?)
(Highly or Not?) specific for ARF
Appears with a ————- of ARF
Occurs in crops over the elbow, wrists, knee, ankle, spine

A

Uncommon
Highly specific for ARF
few weeks of ARF

25
Q

Erythema marginatum

(Common or Uncommon?)
(Highly or Not?) specific for ARF
(Itch or Not itchy?) or (painful or painless
Occurs on ________ and _______, rarely _______
Comes and goes for several month

A

Uncommon
Highly specific for ARF
Not itchy and painless
Occurs on trunks and limbs, rarely face
Comes and goes for several month

26
Q

_______ major criteria can be used alone to confirm ARF diagnosis

A

Syndenham’s chorea

27
Q

Investigations of ARF

• Acute phase reactants: ______ and ______

•SCANS: ________,________,________
•________ swab for ________ culture
• ________________ (anti-streptolysin O
titer and anti-deoxyribonuclease B titer)
• Rapid GAS antigen test

A

C-reactive protein and ESR

Echocardiogram, Electrocardiogram, Chest radiograph

Throat; bacterial

Streptococcal serology

28
Q

Complications of ARF

• _____________
• Heart ________
• _____________ disease

A

Congestive cardiac failure

block; Rheumatic heart

29
Q

Rheumatic heart disease
• Definition: A _____-term _______ damage caused by either a _____________ or ___________________ of ARF.

A

long; cardiac

single severe episode

multiple recurrent episodes

30
Q

____________ is the most common cause of acquired heart disease in children and young adults globally.

A

RHD

31
Q

Commonest Valvular lesions in RHD is ??

A

MR

Mitral Regurgitation

32
Q

Pathology of RHD

• In RHD, Heart Valvular damage occurs:

Mostly ________ , less commonly ________, and rarely the ________ and ________ valves.

• The cardinal anatomic changes of the valve include leaflet ________, commissural ________, and ________ and ________ of the ________.

A

mitral ; aortic

tricuspid ; pulmonary valves.

thickening ; fusion ; shortening

thickening ; tendinous cords.

33
Q

Clinical presentation of RHD
• General
–_______: Majority.
–___________ except for ___________ or
excessive precordial activity.

A

CCF

Asymptomatic

palpitations

34
Q

Mitral regurgitation
• Signs of MR (commonest lesion in children)
– ____________
–________ apex
–________ apex beat
–_____
–__________ loudest at the apex and
radiating to the left axilla, ±Mid diastolic murmur (Carey coombs murmur - short and does not extend into late diastole).
–_________ if pulmonary hypertension has developed.

A

Active precordium; Heaving

Displaced; Thrill; Pan Systolic murmur

Loud P2

35
Q

Aortic regurgitation

Symptoms
• Asymptomatic
• Features of ________
• _________
• ___________
• ___________

A

• Features of LV failure
• Easy fatigability
• Dyspnoea
• Orthopnoea

36
Q

Aortic regurgitation

Signs
• __________ pulse
• ______ pulse pressure
• ____________ apex
• _________ apex
• _____________ murmur

A

• Collapsing pulse
• Wide pulse pressure
• Laterally displaced apex
• Thrusting apex
• Early diastolic murmur

37
Q

Investigations for RHD

• CXR- to see __________
• ECG- for ________,________
• Echo.

A

Cardiomegaly

Tachycardia, heart block.

38
Q

Screening by __________ may seriously
underestimate disease prevalence

Recent studies including one in Lagos (Ekure et al) have shown that _________________
detects heart valve damage more reliably (10 times as many cases of RHD than
auscultation).

A

auscultation

echocardiography

39
Q

Treatment
• Medical –
– Rx CCF
– _____________ for patients with atrial fibrillation, hx of embolization and/or mechanical prosthetic valves.
– Adequate monitoring of anticoagulant therapy.
• Surgical – __________ or valve replacement
in severe valvular heart disease.

A

Anti-coagulant

Annuloplasty

40
Q

Prevention of ARF/RHD
• ‘Primordial prevention’ refers to the
_____________________________________________ of populations at risk of ARF and RHD.

A

improvement of environmental, social, and
economic conditions

41
Q

Prevention

– Primary: Rx of __________ within _______ of the infection with ___________ or __________ if pt. is allergic to penicillin to reduce
incidence of RF.

– Secondary: use of ________________ to reduce the recurrence of RF in people with a history of RF or RHD and, therefore, limit disease progression and allow disease resolution.

– Tertiary: refers to _________ and ___________ treatment of the _________ of RF and RHD.

A

acute Strep. pharyngitis

a week; penicillin or erythromycin

antibiotic prophylaxis (Penicillin)

complications

42
Q

Prevention
• A _____________ is required for effective
population-level primary prevention of RF.
• A potential global vaccine is yet to be
identified due to the widespread diversity
of S. pyogenes strains and cross reactivity of streptococcal proteins with host tissues.
• Research is ongoing.

A

GAS vaccine

43
Q

Prognosis
•______________ is the most common
cause of death in children with ARF

• 40% of patients with acute rheumatic heart disease subsequently develop______ as adults.

A

Severe heart failure

mitral stenosis

Senoir paeds (15 decks)

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