Rheumatic Fever Flashcards
How do these children present?
Signs and symptoms appears 2-3 weeks post pharyngeal infection in age 5-15 children Fever Tiredness Heart failure Painful joints Poor appetite/weight loss
Jones Criteria
Major Carditis Polyarthritis Syndenham chorea Erythema marginatum Subcutaneous nodules
Minor Prolonged PR interval on ECG Arthralgia Previous Hx or evidence of RF fever Acute phase reactants : increase CRP, ESR, WBC
How do you treat GAS pharyngitis?
Benzathine penicillin G
- <30kg 600 000 IU stat IMI
- > 30kg 1.2mil IU stat IMI
Penicillin V
- 50mg/kg/day in 3 doses before meals po for 10 days (compliance)
Penicillin allergy - erythromycin <30kg 125mg qid po x 10 days >30kg 250mg qid po x 10 days - cephalexin 25-100mg/kg/day in 3 doses po - cephaloridine 30-50 mg/kg/day in 3 doses IMI
What is the secondary prevention against rheumatic fever?
RF prophylaxis
Benzathine penicillin G IMI
Penicillin VK - 250mg bd po
Erythromycin 250mg bd po
What is rheumatic fever?
An overreaction of body’s immune system to it’s own tissue after GAS throat infection
Which antibodies are produced in rheumatic fever and against which tissues?
M protein - heart, joint (glycoproteins)
Cell wall polysaccharide - cardiac valves
Hyaluronate capsule - joints (human hyaluronate)
Membrane antigens - smooth + cardiac mm, dermal fibroblasts, neurons of caudate nucleus
Which children get rheumatic fever?
5-15yo
Poverty
Genetic predisposition
What is a differential for rheumatic fever?
Arthritis Infection (TB, HIV, IE) Autoimmune Cancer (leukemia) Drug reaction
What is the primordial prevention against rheumatic fever?
Socioeconomic upliftment (housing, healthcare)
What is the primary prevention against rheumatic fever?
Diagnose GAS throat infections and treat
What is the tertiary prevention against rheumatic fever?
Manage chronic RHD
F/U
Ensure compliance and screen for complications
How do patients with GAS pharyngitis present?
Fever Sore throat Halitosis Tonsillar hypertrophy Red pharynx Follicle
Discuss treatment of acute rheumatic fever
- Antibiotic
- Benzathine penicillin G
<30kg 600 000 IU stat IMI
>30kg 1.2mil IU stat IMI
- Pen V
50-100mg/kg/day in 4 doses x 10 days - Bedrest
- Anti-inflammatories
- aspirin 80-120mg/kg/day in 4doses po
- prednisone 1-2mg/kg/day in 2-4 doses po - Monitor disease activity
- Manage chorea
- Manage CCF
- Surgery if needed
When can a child start walking again during ARF treatment?
Joints normal
No cardiomegaly
Normal resting pulse
Name side effects of aspirin
Tinnitus Dizziness Vomiting Gastric bleeding Pulmonary oedema
Name side effects of prednisone
Cushingoid appearance Hypertension Hyperglycemia Immunosuppression Insomnia Emotional lability
What bloods should you do to monitor rheumatic fever?
FBC U+E ESR CRP ASOT Blood culture
How do you treat chorea?
Haloperidol 0.025 - 0.05 mg/kg/day po
Risperidone 0.01-0.5 mg/kg/dose bd po
How do you manage CCF
- Decr preload
- lasix 1-4mg/kg/day in 2-4 doses IV
- aldactone 2-3mg/kg/day in 2-3 doses po - Incr contractility
- digoxin 0.01mg/kg/day bd po
- dopamine/dobutamine in ICU - Decr afterload
- Captopril 0.5-6mg/kg/day in 3-4 doses po
What do you need to add if you give lasix?
Potassium supplement
Which is preferable: a valve replacement or a valve repair?
Valve repair - no warfarin needed!
Replacement - warfarin lifelong and repeated every 15-20y
How does rheumatic fever appear on histology?
Inflammatory cell infiltration
Proliferation of plump macrophages ( Anitschkow cells)
Results in formation of Aschoff nodules
What do you need to diagnose RF?
- Evidence of GAS infection
2. 2 major/1 major + 1 minor criterion
Why are beta blockers contraindicated in children?
Drop BP
Blocks compensatory tachycardia
What is the duration of secondary prophylaxis?
RF, no carditis, no valvular - 5y or until 21yo
RF w/ carditis, no valvular - 10y to adulthood
RF w/ carditis + valvular - 10y to age 40
CRHD - lifelong
