Management of rheumatic fever

Question 1

What is the goal of rheumatic fever therapy?

Answer 1

1) Relieving the symptoms (pain, inflammation, arthritis)

2) Eradicating group-A beta-hemolytic streptococcus

3) Give appropriate prophylaxis against future Group A Strep (GAS) infections to prevent the progression of cardiac disease

• There is no therapy that slows the progression of valvular damage in ARF

Question 2

What are the different classes of medications that are used in acute rheumatic fever?

Answer 2

1) Antibiotics (Penicillin G/Benzathine “strep infections are still susceptible to penicillin”)

2) Salicylates & NSAD (like naproxen, which is superior to aspirin as it is safer and easier to use with the same efficacy)

3) Managing CHF (which could be due to the inflammation of the heart and valves)

4) Management of chorea (as patients could be embarrassed by it)

5) IV Immunoglobulins

6) Glucocorticoids

Question 3

What are the two preventative measures for rheumatic fever?

Answer 3

1) Primary (eliminating the streptococcal infection):

• Provide Antibiotics
• Improving the housing conditions to avoid repeated streptococcal infection

2) Secondary

• Repeated doses of antibiotics to prevent the reoccurrence of the infection

Question 4

What is the proper prophylaxis for acute rheumatic fever? (lazem after infection)

Question 5

What is the proper duration for the prophylaxis?

Answer 5

• It depends on each case:

1) Rheumatic fever patients with no carditis:

• 5 years or till 21, whichever is longer

2) Rheumatic fever with carditis but no valvular disease:

• 10 years or till 21, whichever is longer

3) Rheumatic fever with valvular disease:

• 10 years or till 40 whichever is longer

4) Rheumatic fever with severe valvular lesions

• Lifelong

Question 6

Which drug is used to treat fever in rheumatic fever?

Answer 6

Antipyretic (NSAID, Like Naproxin)

Question 7

Which drug is used to treat Polyarthritis in rheumatic fever?

Answer 7

Anti-inflammatory and analgesic (NSAID)

Question 8

Which drug is used to treat Carditis in rheumatic fever?

Answer 8

CORTICOSTEROIDS

Question 9

Which medication should be used to treat the infection of rheumatic heart disease?

Answer 9

Antibiotics (Penicillin)

• Used as a prophylaxis and to eradicate the infection

Question 10

Which drug is used to treat rheumatic fever in patients with mild or no carditis?

Answer 10

Before it was Aspiri, now it i Naproxin

Question 11

Which drug is used to treat rheumatic fever in patients with moderate or severe carditis?

Answer 11

Prednisone (steroid drug)

Question 12

Which drugs are used in the primary anti-streptococcal therapy?

Answer 12

1) Benzathine penicillin G (IM preferable over oral)

Question 13

Which drugs are used as a prophylaxis for group A streptococcal infection?

Answer 13

1) Benzathine penicillin G (IM preferable over oral)

2) Sulfadiazine if allergic to penicillin

• every 21 days

Question 14

Which medication is used to control the chorea?

Answer 14

Dopamine D2 antagonist

Question 15

What are the medications that control cardiac symptoms?

Answer 15

• Diuretics
• ACEI
• Digoxin

Question 16

How can the patient’s response to the therapy be monitored?

Answer 16

1) CPR check

2) Normalization of the inflammatory marker indicates resolution

3) CPR after stopping the therapy

Question 17

What are the risk factors for the reoccurrence of Rheumatic Fever?

Answer 17

1) Poor adherence to secondary prophylaxis

2) Great number of previous attacks (2-3 attacks before treatment = more risk)

3) Short time interval from the last attack

4) Young Age

5) Ongoing exposure to strep A

6) Presence of cardiac involvement

Question 18

What is the mechanism of action of penicillin G?

Answer 18

It inactivates the bacterial transpeptidase, preventing the cross-linking of the peptidoglycan polymers and inhibiting the formation of the cell wall, It further reduces the cell wall integrity by binding to the inactive penicillin-binding proteins and by the action of Autolysins

Question 18

What are the adverse effects of NSAIDs?

Answer 18

1) CVS risk

2) GI symptoms (like Nausea, Dyspepsia, Gastric ulceration, bleeding, and diarrhea, as NSAID reduces the levels of protective prostaglandins via its inhibition of COX-1 enzyme)

3) Renal impairment

4) It can cause premature closure of the ductus arteriosus & linked to premature bith, so contraindicated in pregnancy)
- The use of a proton pump like omeprazole will reduce these side effects

Question 19

What are the contraindicated cases of NSAIDs?

Answer 19

1) Peptic ulcer

2) Hemophilia

3) Pregnancy

4) Children with a viral infection (It can cause Reye’s syndrome)

5) Kidney impairment

• Use Cox-2 inhibitors instead (like celecoxib, and rofecoxib, but it will differ in case of renal effects)

Question 20

What are the adverse effects of penicillin?

Answer 20

1) Hypersensitivity

2) GI upset

Question 21

Which antibiotics should you administer in case of allergy to penicillin?

Answer 21

Macrolides

1) Erythromycin (penetrates to all body fluids but the CSF, active against gram +ve organisms)

2) Clarithromycin

3) Azithromycin

Question 22

What is the mechanism of action of the macrolides?

Answer 22

They inhibit protein synthesis by binding irreversibly to the 50s Bacterial ribosome

Question 23

What are the adverse effects of the macrolides?

Answer 23

1) Allergic cholestatic hepatitis (from oral erythromycin “just stop the drug”)

2) Thrombophlebitis (when erythromycin is administered IV)

3) Toxic accumulation as erythromycin can inhibit the CYP-450

Question 24

When is azithromycin commonly used?

Answer 24

Community-acquired pneumonia and sinusitis

Question 25

What is the most effective drug for legionnaires?

Answer 25

Erythromycin (used also to treat syphilis, mycoplasma pneumonia, corynebacterial infections, and bordetella)