Rheumatic fever

Question 1

RF

Age group

Answer 1

in children and young adults (5- 15 years)

Question 2

RF

MOs

Answer 2

Group A beta hemolytic strep pyogenes

Question 3

RF

Strep pyogenes can cause

Answer 3

Skin infection
Pharyngitis

Question 4

RF

Rheumatic fever occurs after

Answer 4

pharyngitis

Question 5

RF

Type of immune reaction seen in RF

Answer 5

Type 2 auto immune

Question 6

RF

Type 2 Autoimmune reaction

Answer 6

Mediated by Ab. Body produces Ab againts the M protein on MOs. The body itself has proteins similar to M protein. So the Ab will attack the body’s Proteins ( Molecular mimicry)

Question 7

RF

Type I Autoimmune reaction

Answer 7

• IgE mediated mast cells.
• histamine
• eg- anaphylaxis

Question 8

RF

Type 3 Autoimmune reaction

Answer 8

mediated by Ag- Ab complex. this complex will deposit on cells and activate compliments. This causes the reaction
* Eg- SLE

Question 9

RF

Type 4 autoimmune reaction

Answer 9

• delayed- type hypersensitivity by T cells
• Eg- TB, Type 1 Diabetes

Question 10

RF

Type 5 autoimmune reaction

Answer 10

• mediated by organ specific Ab
• eg- myasthenia gravis, Grave’s disease

Question 11

RF

Aschoff nodules

Answer 11

• Pathognomic
• Multinucleate giant cells sorrounded by T cells and macrophages
• Seen in subacute or chronic RF

Question 12

RF

Dx criteria

Answer 12

Revised jones criteria

Question 13

RF

Major criteria

Answer 13

• Polyarthritis
• Carditis
• Chorea
• Erythema marginatum
• subcutaneous nodules

Question 14

RF

Minor criteria

Answer 14

• fever
• Arthralgia
• Previoys RF or rheumatic heart disease
• increased acute phase reactants
• Prolonged PR interval

Question 15

RF

Polyarthritis

Answer 15

fleeting polyarthritis (migratory) affecting large joints
DOES NOT CAUSE PERMANENT DAMAGE

Question 16

RF

Carditis

Answer 16

Pancarditis but myocarditis and pericarditis without endocarditis is rare.
MAY CAUSE PERMANENT DAMAGE

Question 17

RF

Which side is most commonly affected in carditis

Answer 17

L/S> R/S

Question 18

RF

Chorea

Answer 18

• emotional lability
• incoordination
• poor school performance
• uncontrolled movement
• facial grimacing
• milk maid grip
• dancing pupils

Question 19

RF

Chorea is affecting

Answer 19

children more than the elderly
Females more than males

Question 20

RF

Chorea is seen

Answer 20

• 1- 6 months after the infection.
• late feature
• usually no permanent damage

Question 21

RF

Subcutaneous nodules

Answer 21

painless pea shaped hard nodules beneath skin, extensor surface of tendons near bony surfaces

Question 22

RF

Erythema marginatum

Answer 22

transient pink rash with raised edges** (which does not involve the face)**

Question 23

RF

To Dx RF from revised jones criteria

Answer 23

• 2 or more major
• 1 major + 2 minor + evidence of strep infection

Question 24

RF

How to Dx Strep

Answer 24

• positive throat culture for Group A beta hemolytic strep
• Elevated ASOT >250 IU
• Hx of recent scarlet fever

Question 25

# RF ASOT

Answer 25

Anti- streptolysin "O" titre

Question 26

# RF Rheumatic vegetations

Answer 26

* small * single/ multiple * **DO NOT EMBOLIZE** * **STERILE**

Question 27

# RF Which side of the heart is affected more

Answer 27

* left side is affected more. **MV is affected causing mitral stenosis** * Isolated aortic V involvement is rare

Question 28

# RF Does the major and minor criteria vary according to the prevalence

Answer 28

yes based on high- risk and low- risk countries. Sri Lanka is a high- risk country

Question 29

# RF The vegetations are mainly growing on

Answer 29

chordae tendinae. firmly attached

Question 30

# RF Ix

Answer 30

* Throat swab and culture * ASOT >250 IU * Anti DNA ase B elevated, antistreptococcal hyaluronidase test * ESR, CRP * ECG, Echo, CXR

Question 31

# RF ECG findings

Answer 31

Prolonged PR interval

Question 32

# RF Echo, CXR findings

Answer 32

may have heart failure

Question 33

# RF in myocarditis what needs to be monitored

Answer 33

sleeping pulse rate

Question 34

# RF Mx

Answer 34

* Treat the infection * general Mx

Question 35

# RF How to treat the infection

Answer 35

* PO penicillin for 30 days OR * single dose IM benzathine penicillin

Question 36

# RF General Rx

Answer 36

* Aspirin * Bed rest

Question 37

# RF For how long is aspirin given

Answer 37

at least 8 weeks

Question 38

# RF aspirin is given for

Answer 38

pts with moderate to severe arthritis and carditis without HF. Tapered slowly

Question 39

# RF When is steroids given

Answer 39

only preserved for patients in whom salicylates fail

Question 40

# RF Dose of steroids

Answer 40

given for severe carditis and CHF. Prednisone high- dose is given for 2- 3 weeks then tapered over 3 weeks.

Question 41

# RF When is IV steroids given

Answer 41

for fulminant cases

Question 42

# RF Chorea Mx

Answer 42

* Phenobarbital * Valproic acid

Question 43

# RF Carditis leading to HF Mx

Answer 43

* Diuretics * steroids * Monitor for arrhythmias

Question 44

# RF Exceptions where aspirin is given for children

Answer 44

* RF * Kawasaki

Question 45

# RF Why is aspirin avoided in children

Answer 45

Risk of reye syndrome

Question 46

# RF Prophylaxis

Answer 46

IM benzathine penicillin 1,2MU 3 weekly

Question 47

# RF Prophylaxis for RF with carditis and clinically significant residual heart disease

Answer 47

ABx for a minimum of 10 years after the latest episode. Prophylaxis is given until the patient is at least 40- 45 years of old and usually continued for life

Question 48

# RF Prophylaxis for RF with carditis and no residual heart disease aside from a mild MR

Answer 48

ABx for 10 years or until the pt turns 25 years ( whichever is the longest)

Question 49

# RF Prophylaxis for RF without carditis

Answer 49

ABx for 5 years or until the patient aged 18-21 years (whichever is longest)

Question 50

# RF Patient advice

Answer 50

* strict bed rest - avoid HF * IM benzathine penicillin to stop recurrent pharyngitis * If pharyngitis develops- PO penicillin 10 days * Decrease the chances of infection * Good oral hygiene * serial echos

Question 51

# RF If the patient cannot tolerate penicillin

Answer 51

give erythromycin

Question 52

# RF Why is prophylaxis necessary

Answer 52

repeated attacks of pharyngitis can cause repeated attacks of carditis which can affect the MV and causing MR

Question 53

# RF Reason for Rx the infection

Answer 53

to prevent the spread of MO. it is carried by the nose.