Rheumatic fever–recognizing the clinical features

Question 1

What bacterial infection is rheumatic fever most likely to be associated with?

Answer 1

it is caused by group A Streptococcus and almost always due to pharyngitis, rarely though it may be caused by scarlet fever. It is not associated with skin infections.

Question 2

What are the 3 ways using the Jones criteria to diagnose rheumatic fever?

Answer 2

1. Patient meeting 2 of the major joints criteria
2. Patient meeting 1 major and 2 minor Jones criteria
3. patients having a previous history of acute rheumatic fever or rheumatic heart disease and meeting 3 minor criteria.

Question 3

To diagnosis rheumatic fever what type of infection must be proven and how?

Answer 3

Group A strep infection, avoid streptococcal screening or culture since carriers can be positive or the pharyngitis may have resolved and the screen is negative. Instead order ASO titers or streptozyme

Question 4

What are the exceptions to the Jones criteria?

Answer 4

They include chorea alone in the context of a recent strep infection and also indolent carditis i.e. not acute, may be the only manifestation months after a strep infection.

Question 5

What are the 5 major Jones criteria for acute rheumatic fever?

Answer 5

1. An asymptomatic migratory polyarthritis of the large joints (ankles, knees, wrists)
2. Signs of carditis: Valves, myocardium, and pericardium can be affected so look for new murmurs, CHF, cardiomegaly, and pericarditis.
3. Painless, firm subcutaneous nodules (wrists, elbows, knees)
4. Erythema marginatum which is a transient, erythematous, macular and light-colored rash it is described as serpiginous or snake like and the margins seem to progress as the center clears.
5. Sydenhams chorea: Movements of the face and/or extremities without purpose also known as purposeless dancing

Question 6

How can the name J O N E S be used as a pneumonic to remember the major joints criteria?

Answer 6

J: Joints, asymmetric, migratory, polyarthritis of the large joints
O: Looks like a heart or carditis, new murmurs, CHF, cardiomegaly and pericarditis
N: Nodules, painless and firm subcutaneous nodules
E: Erythema MARGINatum
S: Sydenhams chorea

Question 7

What are the 4 minor Jones criteria for acute rheumatic fever?

Answer 7

1. Arthralgias refers to the pain without inflammation and cannot be used if the polyarteritis is present i.e. joint criteria can only be used once.
2. ESR or CRP elevation
3. fever
4. PR interval prolongation

Question 8

What findings are pathopneumonic for acute rheumatic fever?

Answer 8

Aschoff bodies or nodules on the heart or in the aorta. Biopsy reveals inflammatory cells arranged in a row set pattern around the fibrinoid core.

Question 9

What valvular dysfunction is common in rheumatic fever?

Answer 9

Mitral, tricuspid and or aortic valve defects are common. Lesions can be stenotic or due to regurgitation. Mitral stenosis and tricuspid stenosis are frequently due to rheumatic fever. Mitral regurg is the most common murmur of rheumatic fever.

Question 10

How is mitral regurg commonly described?

Answer 10

Might include a harsh, systolic and apical murmur

Question 11

How is aortic regurg described?

Answer 11

And apical diastolic murmur, also look for evidence of congestive heart failure.

Question 12

What other symptoms or conditions are associated with Sydenhams chorea?

Answer 12

Emotional lability, dysarthria, hypotonia, tics, OCD, ADD, and anxiety.

Question 13

With rheumatic fever how does endocarditis develop?

Answer 13

Endocarditis occurs due to destruction of the valves, not infection.