Acute Rheumatic Fever
Pediatric infectious disease
Definition
It is a consequence of a pharyngeal infection.
Commonly occurs 2-3 weeks after throat symptoms due to immune cross
reactivity between the bacteria and the connective tissue.
Rheumatic heart disease = most common cause of valvular heart disease.
Clinical Features
1. Large Joints
a. Effusions and synovitis
b. > 2 joints involved
2. Subcutaneous nodules
a. Over bony prominences
3. Rash erythema marginatum
a. Slightly raised pink/red rash blanches with pressure
b. Trunk and proximal limbs
4. Choreiform movements
a. Usually occur 3 months post throat infection
5. Cardiovascular Signs of pancarditis
a. Pericardial rub = pericarditis
b. CCF = myocarditis
c. Mitral or Aortic regurgitation = Acute endocarditis
6. Temperature
Investigations/Diagnosis/ Criteria
Diagnosis
Usually clinical and lab to confirm
Clinical Diagnosis JONES CRITERIA
Major Minor
Carditis Fever
Most serious manifestation,
Tachycardia, murmurs, cardiac failure,
pericarditis
Arthritis Arthralgia
Migratory polyarthritis usually of the large
joint
Chorea Previous RF or Rheumatic
Sydenham chorea- abrupt, purposeless, heart disease
nonrhythmic, involuntary movements
Subcutaneous nodules rare Acute phase proteins
Firm painless, non inflamed, variable in size,
symmetric when multiple and over boney
surfaces
Erythema marginatum Prolonged PR interval on ECG
Pink, evanescent, non itchy rash on trunk and
limbs, NOT OF FACE
Definitive2 major OR one major + 2minor AND evidence of a recent strep
infection
Lab Diagnosis
1. Elevated titres of anti-streptolysin O or Strep antibodies
2. Positive throat culture for Group A beta hemolytic strep
3. Recent scarlet fever
Treatment
1. Acute Treatment
a. Oral penicillin 500mg bd tds for 10 days OR
b. Pen G (Benzathine penicillin) 1.2 million IM once
c. Erythromycin 40mg/kg/day divided into 2-4 doses
2. Secondary Prophylaxis
a. Pen G 1.2 million units every 2-3 weeks for approx. 5 years
b. Lifelong prophylaxis is recommended for patients with carditis
and residual heart disease.
3. Anti-Inflammatory drugs
a. Suppress immune system
b. Aspirin 20-25mg/kg PO qds for 3-6 weeks if NO cardiac
involvement
c. Mild carditis 3 months
d. Sever carditis 6 months can also give prednisolone 0.5mg/kg
qds for 2 weeks
4. Heart failure
5. Chorea
a. Sodium valproate 10mg/kg po bd for 3 months
Rheumatic Heart Disease
Valvular heart disease
Definition
Occurs 10-20 years after original attack. Recurrent episodes of inflammation
lead to chronic fibrosis and calcification of the valves.
Pathophysiology
Tiny nodules gather on the valve leaflets in ARF (acute rheumatic fever). Over
time valves thicken or fuse. There is gradual loss of valve area.
Specific Symptoms
1. Mitral stenosis Most common
2. Aortic stenosis
Treatment
Symptoms drive the need for intervention.
Surgery Can do closed or open commisurotomy, percutaneous balloon
valvulotomy, or valve replacement.
Mitral valve replacement should occur in symptomatic patients (NYHA Class
III-IV) with severe mitral stenosis.
Complications
1. Heart failure
2. Atrial fibrillation occurs in 45% of MS patients
3. Pulmonary hypertension
4. Thromboembolic events
5. Bacterial endocarditis