Rheumatic fever

Question 1

JONES criteria

Answer 1

Evidence of Strep + 2 major or 1 major + 2 minor

Low-risk populations
Five manifestations are considered major manifestations of acute rheumatic fever:

Carditis (clinical and/or subclinical)
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules.

Four manifestations are considered minor manifestations of acute rheumatic fever:

Fever (≥38.5°C [≥101.3°F])
Polyarthralgia
Elevated inflammatory markers (ESR ≥60mm/hour and/or CRP ≥28.57 nanomols/L [≥3.0 mg/dL])
Prolonged PR interval on electrocardiogram.

Moderate- to high-risk populations

Five manifestations are considered major manifestations of acute rheumatic fever:
Carditis (clinical and/or subclinical)
Arthritis (monoarthritis or polyarthritis; polyarthralgia can be considered as a major manifestation if other causes are ruled out)
Chorea
Erythema marginatum
Subcutaneous nodules.

Four manifestations are considered minor manifestations of acute rheumatic fever:
Fever (≥38.0°C [≥100.4°F])
Monoarthralgia
Elevated inflammatory markers (ESR ≥30 mm/hour and/or CRP ≥28.57 nanomols/L [≥3.0 mg/dL])
Prolonged PR interval on electrocardiogram.

Question 2

Clinical features

Answer 2

fever (common)
joint pain (common)
recent sore throat or scarlet fever (common)
chest pain (common)
shortness of breath (common)
heart murmur (common)
pericardial rub (common)
signs of cardiac failure (common)
asymmetric joint swelling and/or effusion (common)
migratory arthritis (common)
restlessness (uncommon)

Question 3

Evidence of past Streptococcal infection

Answer 3

Positive throat culture
Rapid strep antigen tests
++ASOT/DNase B titre
Recent scarlet fever

Question 4

Where does EM typically occur

Answer 4

Trunk
Arms
Thigh

Question 5

Investigations

Answer 5

ESR
CRP
WCC
Blood cultures->no growth
ECG->prolong PR
CXR->?CCF?cardiac enlargement
Echo->changes to mitral/aortic valves
Throat culture
Rapid antigen test
ASOT

Question 6

Management

Answer 6

Admit to hospital
Bed rest until CRP normal for 2 weeks
Paracetamol and codeine
Benzathine penicillin IM or 10days phenoxymethyl penicillin

Aspirin for arthritis
Carbamazepine for chorea
Frusemide and spirinolactone for carditis, ?prednisilone
Severe HF->lisinopril
Digoxin for AFib

Education and counselling
Register with local ARF/RHD registers
Good dental hygeine

Question 7

Follow up

Answer 7

Most d/c within 2 weeks
ESR/CRP measured 2/7, then every 1-2 weeks until normalise
Repeat echo in 1 month
R/V in 6 months w/ cardiology if carditis
Importance of secondary prophylaxis-> Penicillin V every 3-4 weeks or BD orally

Question 8

Most common cardiac sequelae

Answer 8

Mostly mitral, then aortic

Question 9

Duration of secondary prophylaxis

Answer 9

If carditis + valve= until 40
If carditis no valve= 10 years
If no carditis= 5 years, or until 21