Rheumatic Fever and Infective Endocarditis

Question 1

Rheumatic fever epidemiology, pathophy and aetiology:

Answer 1

E: Rare in the developed world but remains the most important cause of heart disease in children world wide. Mainly affects children aged 5-15 years.

A: Group A beta-haemolytic streptococcus
RF: poor sanitation - favour streptococcal spread

It is an abnormal immune response to a preceding infection with Group A beta-haemolytic streptococcus in SUSCEPTIBLE INDIVIDUALS.

Question 2

Clinical presentation of rheumatic fever?

Answer 2

Typically presents after a latency period of 2-6 weeks following pharyngeal infection. Fever, polyarthritis and malaise typically develop.

Question 3

Diagnosis of rheumatic fever?

Answer 3

• Jones criteria - 2 major OR 1 major and 2 minor criteria plus evidence of preceding Group A strep infection e.g. Scarlet fever: 1) Markedly raised ASO titre (or other strep antibodies), 2) Group A strep on throat swab.

Question 4

Clinical presentation of rheumatic fever? (MAJOR SYMPTOMS)

Answer 4

MAJOR:

1) Carditis - 1 of: changed murmur (endocarditis), heart failure (myocarditis), friction rub (pericarditis).
2) Polyarthritis - pain in 1 joint lasting <1 week but moving to other joints over 1-2 months.
3) Sydenhams chorea - Involuntary movements and emotional lability lasting 3-6 months (2-6 months after streptococcal infection)
4) Erythema marginatum (<5%) - rash on trunk and limbs - pink border with fading centre
5) Subcutaneous nodules (rare)

Question 5

Clinical presentation of rheumatic fever? (MINOR SYMPTOMS)

Answer 5

MINOR:

1) Fever
2) Polyarthralgia - pain no swelling (DO NOT COUNT if polyarthritis is a major symptom)
3) Prolonged PR interval on ECG
4) Raised ECR/CRP
5) Previous rheumatic fever or rheumatic heart disease

Question 6

Treatment of rheumatic fever?

Answer 6

1) Bed rest/immobilisation helps joints and heart
2) Heart failure with diuretics (furosemide) and ACE-inhibitor (Captopril)
3) Anti-inflammatory - Aspirin
4) Oral corticosteroids - Prednisolone

Prevention: Monthly injections of antibiotics e.g. IV Benzathine penicillin or Oral Erythromycin (if allergic to penicillin) until 18-21 year old, or even life long

Question 7

Chronic rheumatic heart disease summary:

Answer 7

The most common form of long-term damage from scarring and fibrosis of the valve tissue is MITRAL STENOSIS.
If there has been repeated attacks of rheumatic fever with carditis, this may occur as early as the second decade of life - usually symptoms do not develop until early adult life.

Question 8

Infective Endocarditis (epidemiology, aetiology & RF):

Answer 8

• All children with congenital heart disease (except secundum ASD) are at risk of infective endocarditis.
• Should be suspected in any child/adult with a sustained fever, raised ESR, unexplained anaemia or haematuria

Aetiology:

• Alpha-haemolytic streptococcus: Streptococcus Viridans (MOST COMMON)
• Staphylococcus aureus

Risk Factors: Turbulent blood seen in VSD, coarctation of the aorta, PDA, prosthetic material from surgery

Question 9

Clinical presentation of Infective Endocarditis?

Answer 9

1) Fever
2) Anaemia and pallor
3) Splinter haemorrhages
4) Clubbing
5) Necrotic skin lesions
6) Splenomegaly
7) New murmur
8) Microscopic haematuria

Question 10

Diagnosis of Infective endocarditis?

Answer 10

1) Blood cultures
2) Echo - may see vegetations - consist of fibrin and platelets + containing infective organisms
3) ESR & CRP raised

Question 11

Treatment of infective endocarditis?

Answer 11

1) High dose penicillin: IV Benzylpenicilline + amino glycoside (IV Gentamycin) for 6 weeks
2) If there is infected prosthetic material (e.g. prosthetic valve or VSD patches - surgical removal may be required)

Question 12

Prophylaxis of infective endocarditis?

Answer 12

GOOD DENTAL HYGEINE!!!!!
This should be encouraged in ALL children with infective endocarditis.
GOOD DENTAL HYGEINE!!!!!