Acute Rheumatic Fever

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It is a non–suppurative sequela of a group A ß haemolytic streptococcal (GABHS) pharyngeal infection.

Diagnostic Criteria Jones

See table 20.7 below

Definitive Diagnosis

  • Two major criteria or
  • One major criterion with two minor criteria, with evidence of antecedent streptococcal infection

Table 20.7: Criteria for Acute Rheumatic Fever Diagnosis

Major Criteria 

Minor Criteria 

Carditis 

Migratory polyarthritis  Sydenham’s chorea  Erythema Marginatum 

 Clinical
Fever
Arthralgia
Laboratory
Elevated Acute Phase Reactants eg CRP
Prolonged PR interval

Plus 

Supporting evidence of recent group A streptococcal infection e.g. positive throat culture or antigen detection and/or elevated streptococcal antibody tests* 

*anti –streptolysin O, anti –deoxyribonuclease B

Non–pharmacological Treatment Acute stage:

  • Bed rest and supportive care until all evidence of active carditis has resolved
  • Patient education
  • Intensive health education for prevention of sore throats

Pharmacological Treatment Treatment  of  acute  attack  for  eradication  of  streptococci  in  throat:  Regardless  of  the presence  or  absence of pharyngitis at the time of diagnosis. 

A: benzathine penicillin (IM) 1.2MU stat  

Paediatric> 5 years 0.3MU, 5–10 years 0.6 MU > 10 years 1.2 MU stat 

OR 

A: penicillin V (PO) 500mg 8-12 hourly 24 hourly for 10days 

Children > 10years 500mg, 5–10 years 250mg, < 5years 125mg (PO) 8-12 hourly for 10  days 

Patients allergic to penicillin 

A: erythromycin (PO) 500mg or 40mg/kg 6hourly for 10days. 

Treatment of Acute Arthritis and Carditis: 

A: acetylsalicyclic acid (PO) 25mg/kg 6hourly 24hourly as required. 

Acetylsalicyclic acid should be continued until fever, all signs of joint inflammation and  the ESR have returned to normal and then tapered gradually over 2 weeks. If symptoms recur, full doses should be restarted. *Dose should be reduced if tinnitus or other toxic  symptoms develop 

In severe carditis with development of increasing heart failure or failure of response to aspirin, add

A: prednisolone (PO) 1–2mg/kg 24hourly for 3–4weeks 

Then  review  and  gradual  reduction  and  discontinuation  of  prednisolone  may  be  started  after  3–4  weeks when there has been a substantial reduction in clinical disease. 

Heart failure should be managed in the usual way (see Heart Failure Section). 

Treatment of Sydenham’s chorea: 

B: haloperidol (PO) 1.5–3mg 8hourly for 24 hours as required (Adult)

Paediatrics 50µg/kg for 24 hours in 2 divided doses

Referral:  Ideally  all  patients  should  be  referred  to  high  level  of  care  a  specialized  hospital  care,  where surgery is contemplated 

Antibiotic prophylaxis after rheumatic fever 

Prophylaxis should be given to all patients with a history of acute rheumatic fever and to those with rheumatic heart valve lesions. The optimum duration of prophylaxis should be up to at least 21years of age. 

Note: Specific situations requiring prophylaxis for longer periods (up to 30years as a guide): 

  • definitive carditis in previous attacks
  • high risk of exposure to streptococcal infection at home or work (crowded conditions, high exposure to children)

Medicine of choice 

A: benzathine penicillin (IM) 2.4MU monthly or every three weeks*  

Paediatrics <12yrs 1.2MU every 4 weeks or 3 weeks* up to 21–30yrs 

OR 

A: phenoxymethylpenicillin (PO) 250mg 12hourly Adult  

Paediatric <12yr 125–250mg 12hourly for 24hours up to 21–30years 

OR 

A: erythromycin (PO) 250mg 12hourly for 24hours Adult 

Paediatric <12yr 125–250mg 12hourly for 24hours up to 21–30yrs

*every 3week regimen is more effective 

Valvular Heart Disease and Congenital Structural Heart Disease 

Valvular Heart Disease are chronic acquired sequelae of Acute Rheumatic Fever or Acute Sequelae of Infective Endocarditis or Ischaemic Heart Disease, consisting of valvular damage, usually left heart valves, with varied progression of severity and complications. 

Congenital Heart Disease is a congenital chamber defects or vessel wall anomalies.   

Valvular Heart Disease and Congenital Structural Heart Disease may be complicated by: 

  • Heart failure
  • Infective endocarditis
  • Atrial fibrillation
  • Systemic embolism eg Stroke

General measures 

  • Advise all patients with a heart murmur regarding the need for prophylaxis treatment prior to undergoing certain medical and dental procedures
  • Advise patients to inform health care providers of the presence of the heart murmur when reporting for medical or dental treatment

Referral:  Should  be  considered  from  low  level  of  care  to  high  level  of  care  where  specialized  (physician's care) or super–specialized care (cardiologist's care) can be offered.