Rheumatic Fever and Bacterial Endocarditis Flashcards
_____ is an inflammatory, immune process that develops as sequelae from untreated or inadequately treated streptococcal pharynx infection (i.e. strep throat)
Rheumatic fever
What causes Rheumatic Fever?
Caused by Group A beta-hemolytic streptococcal infection (GAS)
Rheumatic Fever Epidemiology
● Peak incidence is between ages 5-15 years
● More common in underdeveloped countries
● responsible for 275,000 deaths in young
people worldwide each year
Pathophysiology of Rheumatic Fever
There is a latent period of 2-3 weeks between GAS infection and the start of rheumatic fever symptoms
Rheumatic Fever Diagnosis - Jones Criteria
Diagnosis: 2 major criteria or 1 major + 2 minor criteria
MAJOR CRITERIA
1. Polyarthritis
2. Erythema Marginatum
3. Carditis
4. Subcutaneous Nodules
5. Sydenham Chorea
MINOR CRITERIA
1. Clinical findings
a. Fever
b. Polyarthralgias
2. Lab Findings:
a. ↑ ESR
b. ↑ CRP
c. Prolongation of the PR interval
Usually the 1st symptom that develops for Rheumatic fever
Polyarthritis
Polyarthritis
● Usually the 1st symptom
● More common and severe in teenagers and young adults
● Affects several joints in quick succession, seems to migrate
○ Knees, ankles, elbows, wrists
● Responds well to anti inflammatory medication
● No lasting damage or deformity
T/F there is no lasting damage or deformity with polyarthritis
T
Erythema marginatum
● Rapidly enlarging maculopapular lesions that assume the shape ofrings or crescents with CENTRAL CLEARING.
● Can be raised, confluent and either transient or persistent.
● Blanches w/ pressure, not itchy or painful
Part of the JONES criteria
_____: Inflammation of the myocardium, pericardium, endocardium, and/or valves
Carditis
● Mitral or Aortic murmurs
● Pericarditis
● Cardiomegaly
● Heart failure
Part of the JONES criteria
Subcutaneous Nodules are typically
Small (2 cm or less in diameter), firm,
and nontender
Attached to fascia or tendon sheaths
over bony prominences
Part of JONES criteria
● Small (2 cm or less in diameter), firm,
and nontender.
● Attached to fascia or tendon sheaths
over bony prominences.
○ Elbow most common
● Persist for days or weeks, recurrent
● Smaller and shorter-lived than RA
nodules
Describes what
Subcutaneous Nodules
LEAST COMMON but MOST diagnostic manifestation of acute rheumatic fever
Syndeham Chorea
Describe Syndeham Chorea
Neurologic disorder consisting of
abrupt, nonrhythmic, involuntary
movements, muscular weakness, and
emotional disturbances.
LEAST COMMON finding (3% of cases)
● LONG latent period, 1-8 months after
GAS infection
● Sometimes the only symptom
● More common in girls
_____ is the MAJOR complication of Rheumatic Fever
Rheumatic heart disease
Complications of Rheumatic Fever
- Rheumatic heart disease is the MAJOR complication
- Arrhythmias
- Pneumonitis
- Pericarditis with pericardial effusion
- Heart Failure (severe cases)
Excess fluid between the heart and the pericardium, Can turn into Cardiac Tamponade is called what
Pericardial Effusion
Pericardial Effusion is Excess fluid between the
heart and the _____
pericardium.
Rheumatic Pneumonitis
A pneumonia occurring in severe acute rheumatic fever
● High Mortality Rate
Most common cause of acquired heart valve
disease in the world
Rheumatic Heart Disease
_____ results from single or repeated attacks
of rheumatic fever that produce valvular stenosis and/or regurgitation
Rheumatic heart disease
_____ is attacked in 75-80% of cases of Rheumatic heart disease
Mitral valve
Treatment goals of Rheumatic Fever
- Eradication of group A beta-hemolytic Streptococcus (GAS)
- Symptomatic relief of acute disease manifestations (eg, arthritis, fever)
- Manage rheumatic heart disease (RHD; eg, carditis, heart failure) if present
- Manage chorea if present
- Prophylaxis against future GAS infection to prevent progression of cardiac
disease - Provision of education for the patient and patient’s caregivers
Infection management for Rheumatic Fever
● Intramuscular penicillin G benzathine
● Cefdinir or azithromycin are potential alternatives if allergic
Arthritis management for Rheumatic Fever
● NSAIDs are 1st line
● Alternatives include aspirin and glucocorticoids
● Typically will add PPI to prevent gastritis
Cardiac management of RF
● Monitor EKG, echocardiogram
● Heart failure management if needed
Sydenham chorea management for RF
● Usually self-limited
● Chronic antibiotic therapy to prevent recurrence of ARF
● Anti inflammatory meds can be helpful
● Possible follow up w/ neurologist
Improvement in socioeconomic conditions and public health is critical to reducing effects of ____
RF
1st line treatment for prevention of Recurrent Rheumatic Fever
Benzathine penicillin G IM every 4 weeks.
■ Oral penicillin V (250 mg twice daily) = less reliable than IM
■ If PCN allergic = azithromycin or sulfadiazine dail
Bacterial infection of the valvular or endocardial surface of the heart.
Bacterial Endocarditis
Usually need 2 factors are required for Bacterial Endocarditis
○ Predisposing abnormality of endocardium
○ Bacteremia
Risk factors for bacterial endocarditis
● Underlying valvular disease
● Recent dental, respiratory, urologic and GI diagnostic and surgical procedures
● IV drug users (mostly staph aureus)
● Patients with recent prosthetic valve replacement
How can presentation depend on the infecting organism and the valve(s) that are involved for Bacterial Endocarditis?
● Highly virulent organisms (think staph aureus) tend to produce a rapidly
progressive and destructive infection.
● Subacute bacterial endocarditis often caused by Strep Viridans, less aggressive presentation
● Left side most commonly involved (mitral and aortic valves)
● Only 10-20% of cases involve right side valves (think IV drug use)
Presentation of Bacterial Endocarditis
● Fever, chills, anorexia, weight loss, malaise, night sweats, abdominal pain, dyspnea
● Characteristic peripheral lesions (mostly caused by septic emboli)
● Strokes and/or other major embolic events
● Hematuria and/or Proteinuria
● Changing regurgitant murmur
Characteristic peripheral lesions of Bacterial Endocarditis
○ Petechiae: oropharynx, conjunctiva, or subungual “splinter” hemorrhages
○ Osler nodes: painful, raised (immunologic phenomena)
○ Janeway lesions: nonpainful, flat (vascular phenomena)
○ Roth spots: eye
Osler Nodes
PAINFUL violaceous raised lesions of the fingers, hands, toes and/or feet
Janeway Lesions
PAINLESS, flat, erythematous lesions of the palms or soles
Imaging/Diagnostics for Bacterial Endocarditis
● Chest X-ray
● EKG
● Transthoracic Echocardiography
● Transesophageal echocardiography
● Blood cultures
DUKE Criteria (Major and Minor)
2 major or 1major/3minor or 5 minor
Major:
1. Positive blood cultures from two separate cultures(for bacteremia)
2. Evidence of endocardial involvement documented by echocardiography
3. Development of a new regurgitant murmur
Minor:
1. Predisposition
2. Microbiologic Evidence (single positive blood culture)
3. Fever > 38 C
4. Vascular phenomena
5. Immunologic phenomena
Complications of Bacterial Endocarditis
● Destruction of infected heart valves
● Infection can extend into the myocardium → abscesses →
conduction problems/arrhythmias.
● Embolization
● Pulmonary emboli (PE)
Empiric regimens for bacterial endocarditis while culture results are pending should include agents active against ______
staphylococci, streptococci, and enterococci.
○ Native valve: Vancomycin
○ Prosthetic valve: Vancomycin AND cefepime
● Once culture and sensitivity results are back, switch to targeted antibiotic therapy
T/F you should consult cardiology on ALL cases of bacterial endocarditis
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