Rheumatic Fever

Question 1

Rheumatic fever is the leading cause of

Answer 1

ACQUIRED heart disease in NZ
Rheumatic fever can develop after a ‘strep throat’ – a throat infection caused by a Group A Streptococcus (GAS) bacteria.

Most strep throats get better and don’t lead to rheumatic fever. However, in a small number of people an untreated strep throat leads to rheumatic fever one to five weeks after a sore throat. This can cause the heart, joints, brain and skin to become inflamed and swollen.

While the symptoms of rheumatic fever may disappear on their own, the inflammation can cause rheumatic heart disease, where there is scarring of the heart valves.

Question 2

Why has it decrease so significantly in places like Denmark

Answer 2

Houses, lifestyle

Question 3

Who gets Rheumatic fever

Answer 3

Kids, burden carried by PI and maori.

Question 4

NZ deprivation score shows maori and PI at the bottom of the spectrum. What does this mean in terms of Rheumatic fever distributions

Answer 4

30% increase risk with a high dep score, explains the uneven distribution of maori and PI vs pakeha

Question 5

Why should we treat Rheumatic fever?

Answer 5

its PREVENTABLE, at a HIGH RATE and INEQUITABLE

Question 6

Complications of rheumatic heart disease and surgery

Answer 6

• congestive heart failure
• drug side effects: warfarin, hepanin
• Pneumonia
• Cardiac arrhythmias
• endocarditis
• strokes
• death

Question 7

How do we diagnose Rheumatic fever.

Answer 7

An assessment of probability.

Kid will come in
-sore, swollen, large joints

• Restless in school; poor handwriting (chorea, DD behaviour)
• Short of breath; severe carditis

think of their deprivation level!

Question 8

Common pathway to Rheumatic fever/heart disease

Answer 8

1) Strep. pharyngitis (sore throat)

2) Rheumatic fever

Question 9

What do ALL patients require for at least 10 year

Answer 9

Benzathine penicillin.

Question 10

Rheumatic fever is really a _________ to strep. pharyngtis

Answer 10

Autoimmune response

Question 11

MAJOR DEALS of Jones Criteria

Answer 11

• Carditis (heart)
• Polyarthritis (joints)
• Chorea (brain)

Question 12

MINOR DEALS of Jones Criteria

Answer 12

-elevated acute phase reactants
(nodule)

-Erythrocyte sedimentation rate

Question 13

What (within Jones criteria) is essential to diagnose Rheumatic fever?

Answer 13

2 major signs OR 1 major + 2 minor

and

supporting evidence of the strep infection as a precursor (throat swab ~50% reliable)

Question 14

Carditis usually affects

Answer 14

Mitral or aortic valve

Question 15

Arthritis

Answer 15

Extreme pain:

• suppressed by aspirin/NSAIDs, can make it harder to diagnose
• use paracetamol until diagnosed

Question 16

Chorea

Answer 16

Very subtle
Abnormal movements:
-Can't keep limbs still
-writing deteriorated
-usually bilateral

Hard to diagnose

Question 17

Is rheumatic fever genetically derived

Answer 17

There is evidence, but it seems it can be overcome by environment

Question 18

Treatment options if there is NO CURE

Answer 18

Penicillin: Prevention

Acute RF: use paracetamol when diagnosis uncertain

Question 19

Consequences long-term to Rheumatic Fever

Answer 19

Heart failure, atrial fibrillation, surgery, strokes, pregnancy issue
Long term issues!!!

Question 20

Risk Factors for Rheumatic Fever

Answer 20

Social: housing/crowing, education

Economic: poverty

Health: Access to healthcare

Ethnic: disparities = poverty

Question 21

Gold standard to prevent rheumatic fever?

Answer 21

injection of benzathine penicillin every 28 days

Question 22

Why do we want to prevent recurrence

Answer 22

risk of carditis increases very every recurrence

Question 23

How long do you have to do prevention of rheumatic fever after 1st attack (do diminish carditis)

Answer 23

for 10 years, or until 21.

This has greatly reduced hospital admission

Question 24

Why did RF go away in developed countries??

Answer 24

USA: clear public health message “sore throats matter”
improved socio-economic status

EUROPE, NZ, AUSSIE

Question 25

Strep. Pharyngitis is the only trigger!

Answer 25

Penicillin prevents rheumatic fever by treating strep throats.

Most patients pre rheumatic fever had a sore throat

Question 26

Low risk vs high risk

Answer 26

Avoid antibiotics in low risk.

Look clearly at high risk, treat until diagnoses, look at siblings

Question 27

Best way to treat sore throat is GAS +?

Answer 27

10 days po penicillin BD (oral)

Question 28

access to healthcare is an issue in NZ. Acute RF is known to be reduced by good healthcare

Answer 28

clinical schools (27) vs control school (27)

~12,000 kids each group

Clinical schools: trained lay workers (classroom visits), throats swabbed, .

Underpowered so study couldn’t be finished!

Question 29

School based RF prevention

Answer 29

Focused on increasing healthcare access!
-transport, prescription costs, mild short illness in a busy house

Mainly in North Island

Question 30

60% cases in auckland, mainly in decile 1 schools. This is just an indicator of

Answer 30

• health care access
• house crowding
• health knowledge

Question 31

Primary care- to treat

Answer 31

Manaz kids, sore throat GP clinics

Question 32

Antibiotic stewardess

Answer 32

make sure to avoid AB overuse

Question 33

Other options for the future?

Answer 33

early prevention: in schools

Vaccines: very complicated, too many emm types, not anywhere near ready

Question 34

More CHALLENGES

Answer 34

RHD in young adults undetected

RHD in pregnancy

Science questions (auto-immune, vaccines etc, but a lack of interest)

Burden of disease in the developing world, so how will fund?