Cardiology - Rheumatic Fever

Question 1

Definition

Answer 1

2-4 week pharyngeal infection with group A - β-haemolytic Streptococcus pyogenes.
Rheumatic heart disease usually occurs after recurrent episodes.

Question 2

Epidemiology

Answer 2

Childhood and adolescence : peak age 5-17 years old
Developing world
Malnutrition
Overcrowding
Family history of rheumatic fever
HLA class II

Question 3

Signs (J<3NES)

Answer 3

• Joint pain: Tender joints: usually not swollen
• <3: Heart murmur: strongly associated with mitral stenosis (chronic) and regurgitation (acute) and aortic regurgitation , palpitations
  -Nodules (subcutaneous)
• Erythema marginatum: pink or red macules (flat) and papules (raised) with a clear centre on the trunk or limbs
• Syndenham’s Chorea

Question 4

Symptoms

Answer 4

• Recent sore throat or scarlet fever: occurs 2-4 weeks before chest pain
• Chest pain: pleuritic
• SOB
• Fever and rigours
• Joint pain: oligo- or poly- arthritis
  = severe pain
  = often involves the lower limbs
• Non-pleuritic rash
• Syndenhams chorea
  = rapid, uncoordinated jerking movement of the face, hand and feet
  = occurs up to 6 months after initial infection

Question 5

Criteria

Answer 5

JONES CRITERIA: 2 major criteria or 1 major and 2 minor criteria
- Evidence of recent strep infection:
= rapid group A streptococcal antigen test: positive
= throat culture: positive
= recent scarlet fever

• Major criteria (J<3NES)
  = Joint pain/arthritis: migratory polyarthritis MC larger joints
  = <3 carditis: pericarditis with the endocardium most typically affected, Px may have a new murmur +/or HF
  = Nodules (subcutaneous)
  = Erythema marginatum
  = Sydenham’s chorea

Minor criteria (CAFEPAL)
= CRP > 3mg/dL
= Arthralgia
= Fever >38.5 (>38 degs high risk )
= ESR > 60mm/h (>30mm/h high risk)
= Prolonged PR interval due to risk of heart block
= Anamnesis suggestive of rheumatism
= Leukocytosis

Question 6

Diagnosis

Answer 6

Chest X ray: cardiomegaly + CHF
Echo: aortic valvular pathology, pericarditis or pericardial effusion
Blood cultures: if Px pyrexial

Question 7

Treatment

Answer 7

Conservative: bed rest, analgesia, immobilise joints in severe arthritis
Antibiotics: BENZYLPENICILLIN IV STAT, followed by oral PHENOXYMETHYLPENICILLIN for 10 days
Severe Syndenham’s chorea: HALOPERIDOL

Question 8

Secondary prophylaxis

Answer 8

Long term, regular Abx = IM benzylpenicillin
Duration dependant on Px factors:
- No carditis or rheumatic heart disease = min 5 years after attack or until 18 years old (which ever is longer)
- Documented carditis or RHD = min 10 years after attack or until 21 years old (which ever longer)
- Moderate to severe valvular disease = LIFE
- Chronic carditis = LIFE
- Artificial valves = LIFE A

Question 9

Complications

Answer 9

Rheumatic heart disease = 30-50% of patients mc affecting mitral valve, 2nd mc aortic valve
- mc cause of mitral stenosis
Heart failure = chronic or recurrent cases
Infective endocarditis
Atrial fibrillation