Rheumatology - Rheumatic Fever

Question 1

What is rheumatic fever?

Answer 1

Multisystemic autoimmune condition triggered by streptococci

It is caused by antibodies in response to strep that target tissues in the body

Question 2

What does rheumatic fever target?

Answer 2

Multi-systemic

• Joints
• Heart
• Skin
• Nervous system

Question 3

Why is rheumatic fever not common in the UK?

Answer 3

Early treatment of strep with antibiotics

Question 4

What is the pathophysiology of rheumatic fever?

Answer 4

Immune system creates antibodies in response to group A beta-haemolytic streptococcal infection (typically strep pyo)

Antibodies target bacteria but also match antigens on cells such as myocardium in the heart

Results in a type 2 hypersensitivity reaction where immune system attacks cells throughout the body

Question 5

How long does rheumatic fever occur after strep infection?

Answer 5

2-4 weeks

Question 6

How does rheumatic fever present?

Answer 6

2-4 weeks post strep infection e.g. tonsillitis
- Fever
- Joint pain
- Rash
- Shortness of breath
- Chorea
- Nodules

Question 7

What joint involvement occurs in rheumatic fever?

Answer 7

Migratory arthritis affecting large joints

Hot, swollen, painful joints

Migratory as different joints are affected and improve at different times

Question 8

What happens to the heart in rheumatic fever?

Answer 8

Carditis throughout the heart with pericarditis, myocarditis or endocarditis leading to :
- Tachycardia or bradycardia
- Murmurs due to valvular heart disease
- Pericardial rub on auscultation
- Heart failure

Question 9

What valve is typically affected in rheumatic fever?

Answer 9

Mitral valve

Question 10

What are the two key skin findings in rheumatic fever?

Answer 10

Subcutaneous nodules
Erythema marginatum rash

Firm painless nodules over extensor surfaces of joints

Question 11

What happens to the nervous system in rheumatic fever?

Answer 11

Chorea
Rapid, irregular and uncontrolled movements of the limbs

AKA Sydenham chorea

Question 12

What investigations are used to diagnose rheumatic fever?

Answer 12

Throat swab- bacterial culture

ASO antibody titre

Echocardiogram, ECG and CXR - heart involvement

Question 13

What criteria is used to diagnose rheumatic fever?

Answer 13

Jones criteria

Question 14

What are anti-streptococcal antibody titres?

Answer 14

Antibodies against streptococcus

Indicates recent strep infection and helpful to support rheumatic fever diagnosis

• Rise over 2 – 4 weeks
• Peak around 3 – 6 weeks
  -Gradually falls over 3 – 12 months

Question 15

When are ASO levels repeated?

Answer 15

After 2 weeks

• Confirm negative test
• Assess whether levels are rising or falling

Question 16

Using Jones criteria how is rheumatic fever diagnosed?

Answer 16

Two major criteria OR
One major + 2 minor criteria

JONES - FEAR

Major criteria
Joint arthritis
Organ inflammation, carditis
Nodules
Erythema marginatum rash
Sydenham chorea

Minor criteria
Fever
ECG changes without carditis
Arthralgia without arthritis
Raised inflammatory markers

Question 17

What ECG changes are present in the Jones minor criteria?

Answer 17

Prolonged PR interval

Question 18

How is rheumatic fever managed?

Answer 18

Treatment of strep infections with antibiotics to prevent development of rheumatic fever

Penicillin V

Patients with clinical features of rheumatic fever should be referred immediately for specialist management
- NSAIDs for joint pain
- Aspirin and steroids for carditis
- Prophylactic antibiotics
- Monitoring and complication management

Question 19

What are prophylactic antibiotics used for in rheumatic fever?

Answer 19

Prevent further strep infection and recurrence of rheumatic fever

Continued into adulthood

Question 20

What are the complications of rheumatic fever?

Answer 20

• Recurrence
• Valvular heart disease especially mitral stenosis
• Chronic HF