Rheumatic Fever

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This is an inflammatory disease that occurs in children and young adults (5 - 15 years) as a result of infection with group A streptococcus. It affects the heart, skin, joints and central nervous system. Pharyngeal infection with group A streptococcus may be followed by the clinical syndrome of rheumatic fever. This is thought to develop because of an autoimmune reaction triggered by the infective streptococcus and not due to direct infection of the heart or the production of a toxin.

Clinical features Revised Jones criteria for the diagnosis of rheumatic fever

Major

  • Carditis
  • Polyarthritis
  • Sydenham’s chorea
  • Erythema marginatum
  • Subcutaneous nodules


Minor

  • Arthralgia
  • History of rheumatic fever
  • Fever
  • Increased P-R interval on ECG
  • Raised ESR
  • Increased C-reactive protein

Evidence of streptococcal infection
Raised ASO titre (or increased titre of other specific antistreptococcal antibodies) Positive throat culture

Diagnosis Investigations

  • Throat swab
  • Serology
  • ESR
  • ECG
  • Echocardiography

Diagnosis is made based on two or more major criteria or one major plus two or more minor criteria plus evidence of antecedent streptococcal infection.

Treatment Drugs

  • Benzathine penicillin 0.6–1.2 mega units IM stat
    OR
  • Phenoxymethylpenicillin 500mg orally 4 times daily for 7 days. For recurrences, 250mg daily until the age of twenty or for 5 years after the latest attack
    OR
  • Erythromycin, 250 – 500mg orally 4 times daily for 7 days. For recurrences, 125 – 250mg once daily until the age of twenty or for 5 years after the latest attack
  • Prednisolone 1 – 2mg/kg per day divided into 4 equal doses for 10 days (in severe carditis)

Chronic rheumatic heart disease

More than 50% of those who suffer acute rheumatic fever with carditis will later develop chronic rheumatic valvular disease predominantly affecting the mitral and aortic valves.

Complications

  • Congestive cardiac failure
  • Pulmonary oedema

Management

Investigations

  • Chest X-Ray
  • ECG
  • Echocardiography

Treatment

  • Treat underlying complications
  • Give prophylaxis against recurrent rheumatic fever with Benzathine Penicillin 1.2 – 2.4 MU monthly for life
  • Give prophylaxis against infective endocarditis

Refer

  • For further evaluation, if the patient has significant heart murmurs
  • All patients with increasing cardiac symptoms.