S2L5.1: Acute Rheumatic Fever

Question 1

The following describe ACUTE RHEUMATIC FEVER (ARF), except:

a. “Disease of the young” i.e. preschoolers
b. A multi-systemic disease
c. Results from an autoimmune
reaction to infection with Group B Beta Hemolytic Streptococci (GABHS) which usually affects the pharynx
d. Almost all of the manifestations resolve completely
except for valvular damage
e. NONE OF THE ABOVE

Answer 1

C. Results from an autoimmune
reaction to infection with GROUP A (not B) Beta Hemolytic Streptococci (GABHS) which usually affects the pharynx

Pharynx is the scientific word for throat (Source: Google)

Question 2

Which of the following is not true:
a. ARF is an inflammatory disease
b. ARF is autoimmune reaction to a bacterial infection which
you got when you were young and later on, damage will be manifested
c. It can affect the blood vessels, joints, skin, even the lungs
d. You cannot have ARF if you don’t have the suppurative pharyngitis
e. NONE OF THE ABOVE

Answer 2

C. It can affect the blood vessels, joints, skin, even the HEART

Question 3

Is the only well-established prequel (event before the ARF) to acute RF

Answer 3

Suppurative pharyngitis (strep pyogenes)

Question 4

Modified T/F: A young child (e.g. grade 5 or 6) will have a sore throat with suppurations (pus or nana) in suppurative pharyngitis. Pathomechanisms remains incompletely characterized in ARF.

Answer 4

TT

Question 5

Modified T/F: In ARF, valves are usually damage especially the mitral valve. Valvular damage doesn’t occur instantly instead, seen years after (10-15 years later)

Answer 5

TT

Question 6

Which of the following is not true about molecular mimicry:
a. The bacteria does not really cause the destruction of the tissues they will land on
b. Sequelae of carditis account for most of the morbidity
and virtually al the mortality associated with RF
c. Diagnosed on the basis of a composite of clinical criteria (Jones Criteria)
d. None of the above

Answer 6

D because all are true

Question 7

List of manifestations of signs and symptoms that would help physicians come up with the diagnosis of ARF

Answer 7

Jones Criteria

Question 8

Put the following mitems about molecular mimicry in order:

Heart receptors within the valves in the endocardium will be binding on the enzymes released by the bacteria

The bacteria (streptococci) will be releasing enzymes that some receptors in the body will react to

Epitopes on the bacterial surface that mimic cardiac myosin, as well as antigens found in valve, skin, joint, and tissue

The antigen coming from the bacteria will now cause inflammation by these heart receptors (other receptors can also be found in the joints, skin, or
brain); Higher concentration on the valves i.e. mitral

Answer 8

The bacteria (streptococci) will be releasing enzymes that some receptors in the body will react to

Heart receptors within the valves in the endocardium will be binding on the enzymes released by the bacteria

The antigen coming from the bacteria will now cause inflammation by these heart receptors (other receptors can also be found in the joints, skin, or
brain); Higher concentration on the valves i.e. mitral

Epitopes on the bacterial surface that mimic cardiac myosin, as well as antigens found in valve, skin, joint, and tissue

Question 9

Inflammation of the heart / endocardium
(endocarditis) or valves (valvulitis)

Answer 9

Carditis

Question 10

Select which of the items that are true about the epidemiology of ARF:

A. Mainly a disease of children aged 5-14 years
B. Happens when the chronic sequelae of autoimmune disease reaction occurs in the heart 10-15yrs later
C.Rare in persons aged >30 years
D. Recurrent episodes of ARF remain relatively common in adolescents and young adults
E.Peaks between 30 and 40 years.
F.Initial episodes become less common in older adolescents and young adults → but still possible

Answer 10

A, C, D, F

Question 11

T/F: RHD peaks between 20 and 40 years.

Answer 11

False. It peaks between 25 and 40 years

Question 12

Modified T/F: Chronic sequelae of endocarditis/valvulitis is seen
10-15 years after. If affectation occurs in pre-teen years, rheumatic heart disease (RHD)
manifestation would occur in the 20s-40s

Answer 12

TT

Question 13

Select which of the items that are true about the epidemiology of ARF:
A. No celar gender assocaition for ARF
B. No presdisoposition
C. ARF is in the acute phases of the bacteria, breaking havoc on the individual
D. RHD is when the chronic sequelae of autoimmune disease reation occurs in the heart 10-15 years later, and there’s evident myocardial/valvular damage

Answer 13

All are true

Question 14

T/F: RHD more commonly affects males

Answer 14

False. It commonly affects females

Question 15

GLOBAL CONSIDERATIONS
The following are true, except:
A. More of a tropical climate problem, rare in colder/more
temperate countries (Asia Pacific Region > US/Europe)
B. Asia Pacific Region doctors are more knowledgeable
in managing ARF/RHD
C. Application of the minor and major criteria will be dependent on the
prevalence of RF in the area
D. PH belongs to the low risk population
E. None of the above

Answer 15

D. PH belongs to a moderate/highrisk population

Question 16

Match the following items regarding criteria in a LOW RISK population:
1. Clinical* and/or
subclinical* carditis
2. Polyarthritis
3. Chorea
4. Erythema marginatum
5. Subcuatneous nodules
6. Prolonged PR interval in carditis
7. Polyarthralgia
6. ≥38.5 C
8. Peak ESR ≥60 mm
in 1 h and /or CRP
≥3.0 mg/dL

A. Major Criteria
B. Minor Criteria

*Clinical - something doctors may appreciate using
inspection/auscultation and even 2d echo

*Subclinical - not that seen, have to have a high index of
suspicion

Answer 16

1-5 A
6-8 B

Question 17

Match the following items regarding criteria in a MODERATE/HIGH RISK population:
1. Peak ESR ≥30 mm in
1 h and /or ≥3.0
mg/dL
2. Monoarthralgia
3. Polyarthritis and/or
polyarthralgia
4. Chorea
5. Erythema marginatum
6. Subcutaneous nodules
7. Prolonged PR interval
8.Mono arthritis
9. ≥38 Degrees
10. Clinical and/or subclinical carditis

A. Major Criteria
B. Minor Criteria

Answer 17

1.B
2.B
3 - 6 A
7 - 9 B
10. A

Question 18

The following are true, except:
A. Most of the time, patients with RF have high fever and
severe joint pain → they would look so sick
B. Already have RHD but if you look into the Hx, their mothers don’t even remember their children had RF
C. Parents disregarding the fever as just
something ordinary and would just subside in a few days (unknowing that complications would occur
10-15 yrs after)
D. None of the above

Answer 18

D

Question 19

Match the following items regarding criteria:
1. Myocarditis
2. CRP increase
3. Athralgia
4. Joint Pains
5. Fever
6. Elevated ESR
7. Prolonged PR interval
8. Anamnesis of Rheumatism
9. Leukocytosis

A. Major Criteria
B. Minor Criteria

Answer 19

1. A
   2-9 B

Question 20

Use to determine the level of severity of an infection

Answer 20

CRP increase

Question 21

Measure of inflammation

Answer 21

CRP increase

Question 22

Relationship between C-reactive protein and inflammation

Answer 22

Direct. If c-protein is high, patient is highly inflammatory

Question 23

Blood test that will tell the intensity of inflammation

Answer 23

Elevated ESR

Question 24

Found in CBC; dominance of WBC

Answer 24

Leukocytosis

Question 25

T/F: Does not rely on major and minor criteria

Answer 25

True

Question 26

The following are true regarding diagnosis of ARF, except:
A. Throat cultures growing GABHS
B. Should check the throat through swab; in checking the throat, swabs is sometimes not used
D. Culture media
and check for presence of Group
B Streptococci
E. None of the Above

Answer 26

D. Culture media
and check for presence of Group
A Streptococci

Question 27

DIAGNOSIS

Released when the streptococi releases their enzymes into the system; high levels

Answer 27

Antistreptolysin O-titers

Question 28

T/F regarding diagnosis: 2 major criteria or 1 major criterion and 2 minor criterion

Answer 28

True

Question 29

Associated with virtually all the major sequelae of RF,
including mortality; deadliest

Answer 29

CARDITIS

Question 30

Select the items that point to carditis:
A. Typically manifests as valvulitis, detected by the presence of mitral regurgitation (MR) or, less commonly,
aortic regurgitation
B. Autopsy findings are Beefy red and Vegetations (growth)
C. Can be detected by physical examination with the use of
stethoscope
D. May be the only clinically apparent manifestation in
30-50%
E. Responsible for acute and chronic myocardial
dysfunction and acute, although not chronic, pericardial
disease
F. Typically very painful, migratory, and limited to the major
joints of the arms and legs; tenderness out of proportion
to the other findings

Answer 30

A, B, C, E

D and F point to polyarthritis not carditis

Question 31

T/F: Approximately 40 - 60 percent of RF episodes result in
RHD

Answer 31

True

Question 32

Affects the heart, in particular the endocardium: the
valves (acute traumatic valvulitis)

Answer 32

Carditis

Question 33

Advanced progression of
traumatic heart disease; growing on margins of the
leaflets

Answer 33

Vegetations

Question 34

In the physical examination of carditis, it is observed because after the
mitral valve, the next valve that is most predisposed to develop neuromatic heart disease is the aortic valve. It usually attacks male population

Answer 34

Aortic regurgitation

Question 35

The most frequent manifestation of RF (75%) and is also the earliest sign

Answer 35

POLYARTHRITIS

Question 36

The following are true about polyarthritis, except:
A. Typically very painful, migratory, and limited to the major joints of the arms and legs; tenderness out of proportion
to the other findings
B. The earliest manifestation (within 3 to 4 weeks after onset of RF)
C. May be the only clinically apparent manifestation in 30-50%
D. Self-limited
E. None of the above

Answer 36

B. The earliest manifestation (within 2 to 3 weeks after onset of RF)

Question 37

T/F: In polyathritis, if you don’t give pain relievers, the arthritis will resolve on
its own but can be inhumane if not given by the doctors due to pain

Answer 37

True

Question 38

T/F: Polyathritis can be really debilitating; may affect more than 1 joint

Answer 38

True

Question 39

The following are true about polyarthritis, except:
A. Vary from minor arthralgias to severe arthritis with erythema, warmth, and swelling
B. It can be mild joint pains only; some mothers would not be so scared hence not bringing their child to the doctor
C. Polyarthritis and rheumatic fever is a form of reactive
arthritis
D. Reactive arthritis = colds + joint pain (e.g. viral infection)
E. None of the above

Answer 39

E because all are true

Question 40

The following are true about polyarthritis, except:
A. It is a viral infection which
coarses through your autoimmune disease pathway
causing inflammation via the molecular mimicry
B.Joint aspiration may reveal moderate leukocytosis
C. If joint gets swollen this may be done to relieve the pain = Arthrocentesis
D. Joint fluid would present a lot of WBCs after aspirtation
E. None of the above

Answer 40

A. It is NOT a viral infection but rather a BACTERIAL ONE which
coarses through your autoimmune disease pathway
causing inflammation via the molecular mimicry

Question 41

The following are true about polyarthritis, except:
A. Multiple joints can be involved in different phases of inception and resolution
B. Inflammation lasts 1 to 2 weeks
C. Polyarthritis as a whole resolves in <1 month
D. If the coarse of the disease is already there, the stage of the joint involvement would vary; they won’t be starting or resolving at the same time
E. None of the above

Answer 41

E. None of the above

Question 42

Modified T/F: In polyarhtritis, chronic sequelae and disability always appears to occur. In Jaccoud arthropathy, permanent joint
destruction/disability but this has very ew cases

Answer 42

FT. In polyarhtritis, chronic sequelae and disability do not appears to occur.

Question 43

Happens years after the resolution of rheumatic fever; permanent joint disability in the young

Answer 43

Jaccoud arthropathy

Question 44

In this condition, not much can be seen on x-ray except for misalignment; with the use of MRI, permanent joint destruction can be visible leading to this deformation

Answer 44

Jaccoud arthropathy

Question 45

The following are true about polyarthritis, except:
A. The arthritis phase frequently overlaps with the onset of
carditis
B. Athritis phase is directly related with the carditis in terms of severity
C. Severe athritis is preferred over sever carditis because there are no chronic
consequences or joint destruction in rheumatic fever
D. With carditis, you can expect in 50-60% of cases, you would have rheumatic heart disease 10-15yrs after
E. None of the above

Answer 45

B. The two manifestations appear to be inversely related in severity

Question 46

Describe the appearance of JACCOUD ARTHROPATHY

Answer 46

Jaccoud’s arthropathy (JA) is a condition characterised clinically by ‘reversible’ joint deformities such as swan neck, thumb subluxation, ulnar deviation, ‘boutonniere’ and hallux valgus, along with an absence of articular erosions on a plain radiograph.

(Source: Google) check transes too for the picture

Question 47

Involuntary, irregular movements, fibrillatory muscles
movements to the tongue, characteristics spooning with external rotation of the hands, and abolition of the movements with sleep

Answer 47

CHOREA

Question 48

The following are true about chorea , except:
A. May involve the tongue not just the muscles of upper and lower extremities
B. Incidence of 5-35%
C. Uniquely delayed manifestation of ARF (1-7 mos)
D. In some cases, you dont see chorea in the acute phases of acute rheumatic fever
E. None of the above

Answer 48

E

Question 49

The following are true about chorea , except:
A.1-7mos after ARF has resolved, you will get to see young patients dancing involuntarily
B. It may stand alone as a diagnosis for ARF
C. May last for months, occasionally years
D. No residual neurological deficits
E. None of the above

Answer 49

E

Question 50

Select the items that points to chorea:
A. Psychiatric disturbances may occur decades after
B. Recurrences are common in patients who have had ARF
C. Resolve completely
D. Occur several weeks after the onset of cardiac findings
E. Typically in pts with moderate to severe
rheumatic carditis

Answer 50

A and B; C - E are manifestations of subcutataneous noduels

Question 51

Other name for Sydenham’s chorea

Answer 51

St. Vitus Dance

Question 52

Match the following items regarding cutaneous manifestations:
1. Asymptomatic; typically in pts with moderate to severe rheumatic carditis
2. Typically occurs in conjunction with carditis; rashes
3. Resolve completely
4. May last for months or years
5. Occur several weeks after the onset of cardiac findings
6. Occur over the trunk or proximal extremities, early in the
course of RF; erythematous changes over cheek & nose
7. Firm nodules found over major joints and bony prominences
8. Sometimes evanescent, typically resolving within weeks
to 1-2 months → easily overlooked
9. Not specific for RF; occurs with sepsis and drug reactions, resembles the cutaneous findings seen in
juvenile RA and Lyme disease
10. Not diagnostic of RF; can be seen with other autoimmune disease

A.SUBCUTANEOUS NODULES
B. ERYTHEMA MARGINATUM

Answer 52

1. A
2. B
3. A
4. B
5. A

Question 53

Match the following items:
6. Occur over the trunk or proximal extremities, early in the
course of RF; erythematous changes over cheek & nose
7. Firm nodules found over major joints and bony prominences
8. Sometimes evanescent, typically resolving within weeks
to 1-2 months → easily overlooked
9. Not specific for RF; occurs with sepsis and drug reactions, resembles the cutaneous findings seen in
juvenile RA and Lyme disease
10. Not diagnostic of RF; can be seen with other autoimmune disease

A.SUBCUTANEOUS NODULES
B. ERYTHEMA MARGINATUM

Answer 53

6. B
7. A
8. A
9. B
10. A

Question 54

TREATMENT

What kind of prevention is this?

Acute antimicrobial therapy to
remove GABHS from the pharynx

Answer 54

Primary Prevention

Question 55

TREATMENT

What kind of prevention is this?

continuous antibiotics

Answer 55

Secondary Prevention

Question 56

Modified T/F: First line of symptomatic therapy has traditionally been
antiinflammatory agents, ranging from salicylates to
steroids → injections every 28 days. Given for a long period of time >10yrs and it may still be extended.

Answer 56

TF iven for a long period of time >5yrs and it may still be extended.