Rheumatic heart Disease Flashcards
In what age groups does acute rheumatic fever occur in?
Between ages 5-15
What organism causes acute rheumatic fever?
Group A beta-hemolytic streptococci
When do the signs and symptoms occur in acute rheumatic fever?
Usually 2-3 weeks after a pharyngeal infection
What are the 5 major JONES criteria we use to diagnose acute rheumatic fever?
- Carditis
- Chorea
- Polyarthritis
- Subcutaneous nodules
- Erythema marginatum
How would we diagnose a patient with rheumatic fever?
- If there are 2 or more major criteria or if there is 1 major criteria with 2 minor criteria present with the history of a pharyngeal infection
What is chorea?
-a neurological disorder characterized by jerky involuntary movements affecting the shoulders, hips and face
What age is most affected by chorea?
-girls aged between 7-14 years
How long does it take before the symptoms of chorea start to develop after the streptococcal infection?
-weeks to months
How does a child with chorea usually present?
- clumsy and spilling drinks and dropping things
- they have involuntary grimacing, asymmetrical jerky movements which make writing, tying up shoe laces etc difficult to do
- they have alternating crying and laughing spells
- hippus when shining a light in their eye
What is hippus?
Hippus is the involuntary relaxation and constriction of the pupil
Where does the erythema marginatum usually occur?
- on the trunk and limbs and never on the face
- characterized by transient, serpentine erythematous rash
How do the subcutaneous nodules usually appear?
-They are small, mobile and non tender usually on the extensor surfaces like the elbows, wrists, knuckles and knees
How do we diagnose carditis?
- Cardiac murmurs
- cardiac enlargement
- friction rubs
- pancarditis
What cardiacs murmurs do we hear at the apex/mitral valve?
- high pitched pansystolic murmur due to mitral valve regurgitation
- sometimes low pitched mid-diastolic murmur at the apex is also heard but disappears after the acute process
What cardiac murmurs do we hear at the aortic area?
- high pitched early diastolic murmur heard at the aortic area
- it can be at the left sternal edge when the patient is sitting up and leaning forward
- if severe a wide pulse pressure + collapsing pulse is present
How do we observe the cardiac enlargement?
-we detect it on chest X-ray
What is a friction rub?
Also known as a pericardial rub, it is a way to diagnose pericarditis
What is tamponade?
Compression of the heart due to fluid accumulation
How does a large pericardial effusion present?
- it presents with tamponade
- distended neck veins
- hepatomegaly
- pulsus paradoxus
- ST elevation on electrocardiogram
- globular enlargement of cardiac shadows on X-ray
What are the 5 minor criteria used to diagnose rheumatic fever?
- Arthralgia
- Prolonged PR interval on ECG >0,18 seconds
- Increased CRP/ESR
- Previous history of rheumatic fever
- Fever >38 degrees
- Leucocytosis 12-15 x 10 to the power of 9/l
How do we test for streptococcus in a child?
-we do throat swabs
What is the management of rheumatic fever?
- Prevention
- Penicillin
- Rest in bed
- Anti-inflammatories for the arthritic pain
How do we prevent rheumatic fever?
-usually occurs in crowded areas, lack of primary care facilities and poor housing
When should we give the patient penicillin?
-we should give the patient penicillin a week after the onset of symptoms to try to prevent rheumatic fever from occurring
What can we give instead of penicillin?
We can give the child erythromycin (125-250mg)
What is important pertaining to rest with children?
The children must lie still and shouldn’t be allowed to walk until the joints have been treated, the cardiac enlargement decreased and the and the sleep rate pulse diminished
What would you give to treat the arthritis?
I would start by giving salicylates to alleviate the pain(40-60mg/kg/day) or give aspirin(80-120mg/kg/day)
What are the side effects of salicylates?
- Nausea
- Vomiting
- Tinnitus
- Dizziness
- Gastric irritation which can be buffered by milk
What do we use to treat the chorea?
Haloperidol (0,025mg-0,05mg/kg/day
What is chronic heart disease?
-heart valve damage caused by rheumatic fever
Which valves are usually affected in rheumatic heart disease?
-mitral and aortic valves
What special investigations would we do in rheumatic heart disease?
- Chest X-ray
- ECG
- Electrocardiogram
- Full blood count
- Electrolytes
What occurs more often between mitral regurgitation and mitral stenosis?
Mitral regurgitation
What type of murmur usually occurs with mitral regurgitation?
Pansystolic murmur radiating to the left axilla
What happens to the left ventricle in mitral regurgitation?
- left ventricle becomes enlarged and hypertophied
- causes left heart failure and pulmonary oedema
What happens if it is severe mitral regurgitation?
-displacement of the apex to the left axilla And back which is thrusting in nature
What should we consider if there’s a third heart sound before a diastolic murmur?
-there is critical overloading of the left ventricle
What do the patients with ventricular overloading present with?
Poor effort tolerance
- orthopnea
- paroxysmal nocturnal dyspnea
How would you treat the overloaded left ventricle?
Using digoxin
How does the mitral stenosis occur?
-takes a longer time to develop in children and must be more severe type of rheumatic disease
What happens as a result of the mitral stenosis?
- Increased atrial pressure
- Pulmonary arteriolar hypertension
- Pulmonary oedema
What murmur is associated with mitral stenosis?
-diastolic murmur with a tapping apex and opening snap if the valves are mobile
What would we find on chest X-ray for mitral stenosis?
-enlarged left atrium
