| ID | 59 |
|---|---|
| Name | RHEUMATIC FEVER |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnostic criteria (the Duckett-Jones criteria): Diagnostic criteria first described by Jones are still employed- ‘2 major criteria plus 1 minor criterion or 1 major criterion plus 2 minor criteria (with evidence of recent streptococcal infection i.e. high ASO titre, positive throat culture)’- establishes the diagnosis. |
| Investigations | Investigations: 1. Blood count- polymorphonuclear leucocytosis; high E.S.R. 2. Serological test- a. ASO titre- above 300 Todd units/ml. It may be normal (<200 units/ml) in about 80% of adult patients, b. C-reactive protein- increased. 2. Throat swab- 25% positive for isolation of haemolytic streptococci. 3. Urine- proteniuria. 4. X-ray chest- enlarged heart and/or pericardial effusion. 5. E.C.G- prolonged P-R interval & evidence of carditis. 6. Echocardiography- may be suggestive for cardiac lesion |
| Management | Management:1'2 1. Bed rest: In acute rheumatic fever patient should be under strict bed rest till all the signs of active inflammation subside (such as, return of temperature to normal without medication, ESR less than 20, normal leucocyte count, normal pulse rate and return of ECG to baseline). In these patients bed rest also helps in reducing joint pain and cardiac workload. In carditis, it is advised to continue bed rest for 2-6 weeks after ESR and temperature have returned normal. 2. Salicylates: In adult, tablet aspirin, a starting dose of 0.6-0.9gm every 4 hours after meal, or 80-100mg/kg/day in 6 divided doses; in children, 60mg/kg/day in 6 divided doses. Aspirin should be continued until the ESR has fallen and then gradually tailed off. Aspirin causes symptomatic relief of arthritis, reduces fever & swelling. It has no effect on the natural course of the disease process. 3. Penicillin therapy: Benzathine penicillin 12 lac units deep i.m every 3-4 weekly in patients more than 27kg, if less than 27kg 6 lac units i.m, or phenoxymethyl penicillin 250mg 6-hourly for 10 days to eradicate streptococcal infection if present. Erythromycin (40mg/kg/day) may be given in case of penicillin hypersensitivity. Prevention of recurrence: To prevent recurrence benzathine penicillin 12 lac units i.m once monthly (or phenoxymethyl penicillin 250mg twice daily, but less reliable) to be continued until the patient reaches the age 21 or for 5 years after the last attack (which one is the longest). Recurrences are uncommon after 5 years of treatment and infrequent in patients over 21 years of age2 (in CMDT 25 years)1. 4. Corticosteroid: When there is active carditis with cardiomegaly, severe arthritis, or evidence of heart failure or in second attack- Prednisolone l-2mg/kg/day in divided doses until ESR is normal, then gradually tailed off and start Aspirin while tapering to prevent Re-bound. 5. Heart failure: Digoxin, diuretic is to be given according to the condition. 6. Diet: Normal, but plenty of fluid & salt restriction. 7. Prophylaxis Primary: Rheumatic fever can usually be prevented by early and complete treatment of streptococcal infections. Oral penicillin V 250mg three times daily for 10 days or benzathine penicillin 6 lac units i.m once for patients weighing less than 60 Ib; 12 lac units i.m for those weighing more than 60 Ib, should be given. Oral erythromycin 50mg/kg up to a maximum of Igm in two to four doses can be substituted in penicillin-allergic patients. N.B: Sodium containing salicylate should be avoided as it increases sodium load. |
| Introduction | Rheumatic fever is an acute recurrent systemic inflammatory disease of autoimmune origin, affecting mainly children (5 to 15 years) & young adults, often initiated as a sequela of group A GABH streptococcal infection of the pharynx. This specific strains of streptococci possess antigens that cross-react with cardiac myosin and sarcolemmal membrane proteins. As a result antibodies are produced that mediate inflammation in endocardium, myocardium and pericardium, as well as joints and skin. The mitral valve is affected in 75-80% cases, the aortic valve in 30% and the tricuspid and pulmonary valve in less than 5%. The Aschoff nodule is pathognomonic for heart involvement and is composed of multinucleated giant cells surrounded by macrophages and T lymphocytes. The clinical symdrome of rheumatic fever usually appears within 2-3 weeks following a pharyngeal infection |
| History | |
| Etiology | Etiology: Exact etiology is unknown. But, usually developed as an autoimmune disease secondary to pharyngitis or tonsillitis caused by GABHS infection streptococci. |
| Clinical Features | Clinical features: A. Maior criteria: 1. Carditis: It is the most important manifestation of rheumatic fever, & presents as palpitation, breathlessness. Cardiac involvement occurs in about 50% cases. It may be endocarditis, myocarditis and pericarditis. Endocarditis- usually involve mitral valve in 95& of patients. Myocarditis- undue tachycardia & diminished intensity of 1st heart sound, enlargement of heart & evidence of heart failure, signs of heart block & arrhythmia, changes in E.C.G e.g prolonged P-R interval & other grades of block. Pericarditis- malaise, restlessness, retro-sternal pain & pericardial rub. 2. Arthritis: Migratory polyarthritis, often asymmetrical, involving mainly larger joints like ankle, knee, elbow, wrists & occasionally temporomandibular or costoclavicular joints etc. There is pain, tenderness, redness, local temperature & sometimes joint swelling. Erythema marginatum: A painless, slightly elevated pinkish rashes appear in the trunk & proximal part of the limbs & last for about 24 hours. They may be either transient or persistant. 4. Subcutanaous nodules: Painless nodules on the elbows, knees, scapulae, occiput etc. 5. Sydenham’s chorea: It is the most diagnostic feature of rheumatic fever, and is the sign of CNS involvement. It apears as late as 3 months or more after initial infection. Sydenham’s chorea is characterized by- semipurposely involuntary, non-repeatative movement of the peripheral parts of the body & head; speech may be altered. Spontaneous recovery commonly occurs. B. Minor criteria: i. Fever (102-103°F)- which is remittent or intermittent in character & associated with sweating. ii. Arthralgia. iii. History of previous rheumatic fever or rheumatic vulvular disease. iv. High E.S.R & leucocytosis. v. First degree (prolonged P-R interval) or second degree AV block. vi. Increased C-reactive protein. |
| Preventions | |
| Treatment | |
| Complications | |
| Prognosis | |
| Types | |
| Classification | The common clinical presentations are- Major Criteria i. migratory polyarthritis, ii. carditis, iii. subcutaneous nodules, iv. erythema marginatum & v. sydenham’s chorea.1,2 Minor Criteria i. fever ii. arthalgia |
| Observation | |
| Pathology |
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