Rheumatic fever

Question 1

Rheumatic fever - background

Answer 1

1. This is an important cause of heart disease worldwide
2. Rarely seen in developed countries
3. Acute rheumatic fever (ARF) is a sequela of infection with group A B-haemolytic streptococcus (streptococcal pharyngitis). Has rheumatological, cardiac and neurological manifestations
4. It is seen in children aged 5–15yrs
5. Incidence is highest in those from socially and economically disadvantaged areas

Question 2

Rheumatic fever - clinical features (background - 3)

Answer 2

1. There is a latent period of 2–6wks between onset of symptoms and previous streptococcal infection (e.g. pharyngitis).
2. Symptoms are non-specific.
3. The grouping together of clinical features makes the diagnosis more likely (Jones criteria).

Question 3

Rheumatic fever - Jones criteria (6+6)

Answer 3

Major features

1. Pancarditis (50%): endocarditis/myocarditis/pericarditis
2. Polyarthritis (80%):
   - Flitting—

Question 4

Rheumatic fever - dx (3)

Answer 4

1. Two major features; or
2. One major + two minor features; and
3. Evidence of previous group A streptococcal infection.

Question 5

Rheumatic fever - ix (3)

Answer 5

1. ECG
2. FBE, ESR, CRP
3. ASOT

Other?

Question 6

Rheumatic fever - mx (3)

Answer 6

1. Acute phase (5):
   i. Bed rest
   ii. Anti-infl ammatory drugs (e.g. aspirin)
   iii. Corticosteroids (2–3wks)
   iv. Diuretics/ACE inhibitors if in heart failure
   v. Antibiotics (e.g. penicillin V for 10 days)
2. Long-term therapy (3)
   - Aimed at secondary prevention of further attacks of acute rheumatic fever and the development of chronic rheumatic heart disease
   - Antibiotic prophylaxis = benzathine penicillin (adult and child 20kg or more: 900mg; child less than 20kg; 450mg) IM, every 3-4 weeks
   - Or phenoxymethylpenicillin (all ages) 250mg orally BD (if pts refuse or are unable to have IM benzathine penicillin)
3. Chronic rheumatic heart disease (1):
   - Recurrent bouts of ARF with associated carditis result in scarring and fibrosis of the heart valves (most commonly mitral valve) and may result in incompetent valves requiring replacement