Rheumatic fever

Question 1

What is the typical timing between strep pharyngitis and acute rheumatic fever?

Answer 1

Streptococcal pharyngitis typically precedes the onset of acute rheumatic fever by 1 to 5 weeks

Question 2

Which type of streptococcal infection is typically responsible for acute rheumatic fever?

Answer 2

Group A Beta Hemolytic Strep

Question 3

What’s the diagnostic criteria for acute rheumatic fever?

Answer 3

Revised Jones Criteria

2 Major or 1 Major and 2 Minor criteria

AND

Evidence of preceding group A streptococcal infection.2 Evidence to support an antecedent group A strep infection include:
* Positive throat culture or rapid streptococcal antigen test
* Elevated or rising streptococcal antibody titer

N.b. may not have this evidence in low-resource setting

Question 4

What are the Major criteria in Modified Jones for diagnosis of ARF?

Answer 4

Modified Jones Major Criteria
1. Carditis
* Clinical and/or subclinical

2. Arthritis
* Monoarthritis or polyarthritis
* Polyarthralgia (if other causes have been excluded)

N.b. Monoarthritis is only included in moderate-high risk populations and polyarthritis only for low-risk populations

3. Chorea

4. Erythema marginatum

5. Subcutaneous nodules

Annular erythema on trunk/upper arms/legs almost never face/palms/soles

Question 5

What are the Minor criteria in Modified Jones for diagnosis of ARF?

Answer 5

Modified Jones Minor Criteria
1. Monoarthralgia (moderate-high risk populations) or polyarthralgia (low-risk populations)

2. Fever (≥38 C)

3. Elevated acute phase reactants (ESR ≥30 mm/hr and/or CRP >3.0 mg/dl)

4. Prolonged PR interval on electrocardiography, after accounting for age variability (unless carditis is a major criterion)

Question 6

What’s the typical management of acute rheumatic fever?

Answer 6

ARF management
* Anti-inflammatorie - aspirin
* Prednisolone for severe carditis
* Heart failure treatment as needed
* Chorea - sodium valproate
* Penicillin for any remaining streptococcal organisms even if not currently with symptoms of sore throat

Question 7

What is the recommendation for secondary prevention of subsequent attacks of ARF after an initial diagnosis?

Answer 7

Secondary prevention in ARF
* Benzathine benzylpenicillin ever 2-4 weeks

Duration
* Without carditis - 18 years of age or 5 years after last attack, whichever is longer
* Mild mitral regurgitation/healed carditis - 25 years of age or 10 years after last attack, whichever is longer
* Severe valvular disease/valve surgery - lifelong

Nb Lidocaine can be used to make the injection less painful