Lec 10 Rheumatic Fever and Rheumatic Heart Disease

Question 1

Acute diffuse inflammation of connective tissues of the heart, joints, brain, blood vessels & subcutaneous tissues

Answer 1

Rheumatic Fever

Question 2

What happens to heart valves in RHD?

Answer 2

fibrosis

Question 3

Major criteria for the Diagnosis of Acute RF (Modified Jones Criteria)

Answer 3

1. Carditis
2. Polyarthritis
3. Chorea
4. Subcutaneous nodules
5. Erythema marginatum

Question 4

Minor criteria for the Diagnosis of Acute RF (Modified Jones Criteria)

Answer 4

1. fever
2. arthralgia
3. Prolonged PR interval on ECG (1st deg AV block)
4. Elevated acute phase reactants (ESR & CRP)

Question 5

 Most common major manifestation (overall) for RF –

 Most common manifestation for hospitalized RF patients

Answer 5

 Most common major manifestation (overall) – ARTHRITIS

 Most common for hospitalized patients - CARDITIS

Question 6

Bacteria most associated with Rheumatic Fever

Answer 6

Group A β-hemolytic Streptococcus (GAS)

Question 7

True of Antistreptococcal Antibody Titers:

a. Reflect past & not present immunologic events
b. No value in the diagnosis of acute pharyngitis
c. Valuable for confirmation of previous streptococcal infections in patients suspected of having acute RF or PSGN
d. Helpful, in prospective epidemiological studies, for distinguishing patients with acute infection from patients who are carriers
e. All of the above.

Answer 7

e. AOTA

Question 8

Carditis with mild cardiomegaly and mild CHF is classified as:

a. MILD
b. MODERATE
c. SEVERE

Answer 8

b. MODERATE

Classification of Carditis:

MILD - No cardiomegaly, No CHF

MODERATE - Mild cardiomegaly, mild CHF

SEVERE - Cardiomegaly with severe pulmonary congestion or edema

Question 9

Distinctive non-pruritic transient rash of Acute Rheumatic Fever with pale centers with round or serpiginous margin that blanches; appears on the trunk & proximal extremities but, not the face and often induced by heat

Answer 9

Erythema Marginatum

Question 10

Usual CBC finding in patients with Rheumatic Fever

Answer 10

Anemia - due to hemolysis of RBC or dilution of blood due to cardiac failure.

Question 11

Describe the murmur in patients with Rheumatic Carditis:

a. Apical systolic murmur (Mitral regurgitation)
b. Apical mid-diastolic murmur (Carey-Coomb’s)
c. Basal diastolic murmur (Aortic regurgitation)
d. Basal systolic murmur (Tricuspid regurgitation)
e. AOTA

Answer 11

e. AOTA

AUSCULTATION IN PATIENTS WITH RHEUMATIC CARDITIS:

o Apical systolic murmur (Mitral regurgitation)

o Apical mid-diastolic murmur (Carey-Coomb’s)

o Basal diastolic murmur (Aortic regurgitation)

o Basal systolic murmur (Tricuspid regurgitation)

Question 12

How to manage patients with Acute Rheumatic Fever

Answer 12

1. Antibiotic: to eradicate Streptococcus

o PCN VK - 250-500 mg BID-TID x 10 days

o Benzathine PCN - 0.6-1.2 MU IM

o Erythromycin - 250 mg TID x 10 days

2. Anti-inflammatory agents: 6-8 weeks

o ASA - 80-100 mg/kg/day

o Prednisone - 1-2mg/kg/day

3. If allergic to Penicillin, give Erythromycin
4. Complete bed rest and modified activity
5. Anti-heart failure drugs

Question 13

What is the duration of Secondary RF Prophylaxis for patients diagnosed with RF with carditis and persistent valvular disease?

a. 10 years or until 21 years of age, whichever is longer
b. 5 years or until 21 years of age, whichever is longer
c. 10 years or until 40 years of age, sometimes life-long prophylaxis
d. AOTA

Answer 13

C. 10 years or until 40 years of age, sometimes life-long prophylaxis

Duration of Secondary RF Prophylaxis

RF with carditis and residual heart disease (persistent valvular disease) - 10 years or until 40 years of age (whichever is longer), sometimes life- long prophylaxis

RF with carditis but no residual heart disease (no valvular disease) - 10 years or until 21 years of age (whichever is longer)

RF without carditis - 5 years or until 21 years of age (whichever is longer)

Question 14

Most common lesion in patients with Rheumatic Heart Disease

Answer 14

Mitral regurgitation - 10-30% associated with MS - PE: LV heave, soft S1, apical holosystolic murmur to axilla (classic murmur of MR) - ECG o LAE, LVH - CXR o LAE, LVH; pulmonary congestion o In lateral view: LA pushes the esophagus - Echo o Thickened valve and dilated MV annulus o Parasternal long axis view: Mitral valve thickened, LA dilated - Natural History: o Asymptomatic o CHF o Atrial arrhythmias o Pulmonary hypertension o Infective endocarditis o Thromboembolism

Question 15

Differentiate Rheumatic Fever and Rheumatic Heart Disease in terms of chamber enlargement.

Answer 15

RF: No Chamber enlargement

RHD: Severe Chamber enlargement

Question 16

Corrigan’s pulse, Musset’s & Quincke’s signs are manifestations of what RHD lesion?

a. Mitral Stenosis
b. Mitral Regurgitation
c. Aortic Stenosis
d. Aortic Regurgitation

Answer 16

d. Aortic Regurgitation

• Murmur is soft if not severeo not recognized most of the time
• Rarely isolated (mostly accompanies MR)
• PE:o LV heaveo Basal diastolic blow to apexo Prominent carotid pulseo Wide pulse pressureo Musset’s & Quincke’s signso Corrigan’s pulse
• ECG: LVH +/- strain pattern
• CXR: LVH; dilated aorta
• Echo: Thickened leaflets with prolapse
• Natural history:o CHFo Chest paino Infective endocarditis