Acute Rheumatic Fever

ACUTE RH EU MATIC FEVER
Acute rheumatic fever

• Usually affects children (most commonly between 5 and
15 years) or young adults
• Rheumatic fever is an autoimmune inflammatory

process that develops as a sequale of group A beta
hemolytic streptococcus infection.
• Antibodies produced against the streptococcal antigens

crossreact with cardiac myosin and sarcolemmal
protein.
• Inflammation in the endocardium, myocardium and
pericardium, as well as the joints and skin.
Clinical Features
• Multisystem disorder that usually presents with
- Fever
- Anorexia
- Lethargy
- Joint pain
• Latent period: 2-3 weeks after an episode of
streptococcal pharyngitis.
• Diagnosis is made using the revised Duckett Jones
criteria
- 2 or more major manifestations,
- Or 1 major and 2 or more minor manifestations,
- along with evidence of preceding streptococcal infection
Carditis
• Involves the endocardium,myocardium and
pericardium to varying degrees
• Incidence declines with increasing age - ranging from 90%
at 3 years to a round 30% in adolescence.
• It manifest as
- Breathlessness - heart failure or pericardial effusion
- Palpitations or chest pain - pericarditis or pancarditis
- Other features include tachycardia,cardiac enlargement
and new or changed cardiac murmurs.
- Systolic murmur- due to mitral mitral regurgitation
- Mid- diastolic murmur due to valvulitis (carey coombs)
- Aortic regurgitation - 50% of cases but the tricuspid and
pulmonary valves are rarely involved.
- Syncope: Conduction defects
• ECG changes:ST and T wave changes
Arthritis
• Most common and early

manifestation
J ,,,,,
• Acute painful asymmetric

and migratory inflammation of
the large joints
• Typically affects the knees,
ankles, elbows and wrists.
• Joints become red swollen
and tender
Skin lesions
• Erythema marginatum
- occurs in < 5% of patients
- lesions start as red macules (blotches)
that fade in the centre but remain red at
the edges
- occur mainly on the trunk and proximal
extremities but not the face
• Subcutaneous nodules
- occur in 5-7% of patients
- Small (0.5-2.0 c m), firm and painless
- Best felt over extensor surfaces of bone
or tendons
- typically appear more than 3 weeks after -
help to confirm rather than make the
diagnosis
SUBCUTA NEOUS
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SUBCUTA NEOUS
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ERYTH EMA MA RGINATUM
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Sydenha m's chorea
(St Vitus dance)
•Late neurological manifestation
•Appears at least 3 months after the
episode of ARF
•all the other signs may have
disappeared.
•Occurs in up to 1;3rd of cases and
is more common in females
•Emotional breakdown or changes
may be the first feature.
•Typically followed by purposeless
involuntary choreiform movements
of the hands, feet or face.
•Speech may be explosive and halt
ing.
•Spontaneous recovery in a few
months
Investigations
• ESR and CRP: monitoring progress of the
disease
• Positive throat swab cultures are obtained in only
10-25% of case.
• Echocardiography
- Mitral regurgitation with dilatation of the mitral
annulus
- Prolapse of the anterior mitral leaflet
- May also show aortic regurgitation and pericardial
effusion
Evidence of a systemic illness (non-
•specifec)
Leucocytosis ,raised ESR and CRP
Evidence of preceding streptococcal infection (specific)
• Throat swab culture: group A-haemolytic streptococci
(also from family members and contacts)
• Antistreptolysin O antibodies (ASO titres):rising
titres,or levels of > 200 U (adults) or > 300 U
(children)
Evidence of carditis
• Chest X-ray:cardiomegaly; pulmonary
congestion.
• ECG:first- and rarely second-degree AV
block;features of pericarditis;T-wave inversion; CXR: cardiomegaly due
reduction in QRS complex. to carditis
• Echocardiography:cardiac dilatation and valve

abnormalities.
Management
• Treatment strategies can be divided into management
- acute attack,
- management of the current infection
- prevention of further infection and attacks.
• Management of the acute attack
- Single dose of benzylpenicillin 1.2 million U i.m.
- Oral phenoxymethylpenicillin 250 mg 6-hourly for 10 days
- Penicillin-allergic : erythromycin or a cephalosporin
- Analgesia: optimally achieved with high doses of salicylates
• Treatment is then directed towards limiting cardiac
damage and relieving symptoms.
Management
• Bed rest and supportive therapy
- Reduces joint pain and cardiac workload.
- Duration should be guided by symptoms a long with
temperature,leucocyte count and ESR
- Should be continued until these have settled.
- Return to normal physical activity but strenuous
exercise should be avoided in those who have had
carditis
Management
• Protracted Sydenham chorea has responded to

haloperidol
• It requires long-term antimicrobial
prophylaxis, even if no other manifestations of
rheumatic fever evolve.
• Complete physical and mental rest is essential
because the manifestations of chorea may be
exaggerated by emotional trauma.
Management
• Aspirin
- Relieve the symptoms of arthritis rapidly and a response within
24 hours helps to confirm the diagnosis.
- Reasonable starting dose is 60 mg/kg body weight/day, divided
into six doses.
- In adults,100 mg/kg per day
- should be continued until the ESR has fallen and then
gradually tailed off.
• Corticosteroids
- more rapid symptomatic relief than aspirin and are indicated in
cases with carditis or severe arthritis.
- Prednisolone,1.0-2.0 mg/kg per day in divided doses, should
be continued until the ESR is normal then tailed off.
Primary prevention
• It involves eradication of Streptococcus from

the pharynx,
• Administering a single i.m.benzathine
benzylpenicillin
Secondary prevention
• Patients are susceptible to further attacks if another
streptococcal infection occurs.
• Long term prophylaxis with penicillin should be given
- Benzathine penicillin 1.2 million U i.m. monthly
- Oral phenoxymethylpenicillin 250 mg 12-hourly
• Long-term antibiotic prophylaxis prevents another attack
of ARF but does not protect against infective
endocarditis.
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ACUTE RH EU MATIC FEVER

Acute rheumatic fever

• Rheumatic fever is an autoimmune inflammatory

• Antibodies produced against the streptococcal antigens

• Most common and early

• Acute painful asymmetric

• Echocardiography:cardiac dilatation and valve

• Protracted Sydenham chorea has responded to

• It involves eradication of Streptococcus from

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