Rheumatic fever Flashcards
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Age group
in children and young adults (5- 15 years)
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MOs
Group A beta hemolytic strep pyogenes
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Strep pyogenes can cause
Skin infection
Pharyngitis
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Rheumatic fever occurs after
pharyngitis
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Type of immune reaction seen in RF
Type 2 auto immune
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Type 2 Autoimmune reaction
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)
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Type I Autoimmune reaction
- IgE mediated mast cells.
- histamine
- eg- anaphylaxis
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Type 3 Autoimmune reaction
mediated by Ag- Ab complex. this complex will deposit on cells and activate compliments. This causes the reaction
* Eg- SLE
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Type 4 autoimmune reaction
- delayed- type hypersensitivity by T cells
- Eg- TB, Type 1 Diabetes
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Type 5 autoimmune reaction
- mediated by organ specific Ab
- eg- myasthenia gravis, Grave’s disease
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Aschoff nodules
- Pathognomic
- Multinucleate giant cells sorrounded by T cells and macrophages
- Seen in subacute or chronic RF
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Dx criteria
Revised jones criteria
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Major criteria
- Polyarthritis
- Carditis
- Chorea
- Erythema marginatum
- subcutaneous nodules
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Minor criteria
- fever
- Arthralgia
- Previoys RF or rheumatic heart disease
- increased acute phase reactants
- Prolonged PR interval
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Polyarthritis
fleeting polyarthritis (migratory) affecting large joints
DOES NOT CAUSE PERMANENT DAMAGE
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Carditis
Pancarditis but myocarditis and pericarditis without endocarditis is rare.
MAY CAUSE PERMANENT DAMAGE
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Which side is most commonly affected in carditis
L/S> R/S
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Chorea
- emotional lability
- incoordination
- poor school performance
- uncontrolled movement
- facial grimacing
- milk maid grip
- dancing pupils
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Chorea is affecting
children more than the elderly
Females more than males
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Chorea is seen
- 1- 6 months after the infection.
- late feature
- usually no permanent damage
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Subcutaneous nodules
painless pea shaped hard nodules beneath skin, extensor surface of tendons near bony surfaces
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Erythema marginatum
transient pink rash with raised edges** (which does not involve the face)**
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To Dx RF from revised jones criteria
- 2 or more major
- 1 major + 2 minor + evidence of strep infection
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How to Dx Strep
- positive throat culture for Group A beta hemolytic strep
- Elevated ASOT >250 IU
- Hx of recent scarlet fever
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ASOT
Anti- streptolysin “O” titre
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Rheumatic vegetations
- small
- single/ multiple
- DO NOT EMBOLIZE
- STERILE
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Which side of the heart is affected more
- left side is affected more. MV is affected causing mitral stenosis
- Isolated aortic V involvement is rare
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Does the major and minor criteria vary according to the prevalence
yes
based on high- risk and low- risk countries.
Sri Lanka is a high- risk country
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The vegetations are mainly growing on
chordae tendinae. firmly attached
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Ix
- Throat swab and culture
- ASOT >250 IU
- Anti DNA ase B elevated, antistreptococcal hyaluronidase test
- ESR, CRP
- ECG, Echo, CXR
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ECG findings
Prolonged PR interval
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Echo, CXR findings
may have heart failure
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in myocarditis what needs to be monitored
sleeping pulse rate
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Mx
- Treat the infection
- general Mx
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How to treat the infection
- PO penicillin for 30 days
OR - single dose IM benzathine penicillin
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General Rx
- Aspirin
- Bed rest
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For how long is aspirin given
at least 8 weeks
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aspirin is given for
pts with moderate to severe arthritis and carditis without HF. Tapered slowly
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When is steroids given
only preserved for patients in whom salicylates fail
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Dose of steroids
given for severe carditis and CHF.
Prednisone high- dose is given for 2- 3 weeks then tapered over 3 weeks.
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When is IV steroids given
for fulminant cases
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Chorea Mx
- Phenobarbital
- Valproic acid
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Carditis leading to HF Mx
- Diuretics
- steroids
- Monitor for arrhythmias
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Exceptions where aspirin is given for children
- RF
- Kawasaki
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Why is aspirin avoided in children
Risk of reye syndrome
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Prophylaxis
IM benzathine penicillin 1,2MU 3 weekly
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Prophylaxis for RF with carditis and clinically significant residual heart disease
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
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Prophylaxis for RF with carditis and no residual heart disease aside from a mild MR
ABx for 10 years or until the pt turns 25 years ( whichever is the longest)
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Prophylaxis for RF without carditis
ABx for 5 years or until the patient aged 18-21 years (whichever is longest)
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Patient advice
- 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
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If the patient cannot tolerate penicillin
give erythromycin
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Why is prophylaxis necessary
repeated attacks of pharyngitis can cause repeated attacks of carditis which can affect the MV and causing MR
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Reason for Rx the infection
to prevent the spread of MO. it is carried by the nose.
