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acute rheumatic fever

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  • 1. DIAGNOSIS OF ACUTE RHEUMATIC FEVER Gusti Ayu Riska Pertiwi 1002005069 Faculty of Medicine Udayana University
  • 2. INTRODUCTION
  • 3. INTRODUCTION • Acute Rheumatic fever (ARF) is a nonsuppurative, immune- mediated inflammatory disease, which occurs as a delay sequel to group A, β-hemolytic streptococcus (GABHS) pharyngitis 1-4. • Affects connective tissue of the heart, joints, skin and vessels1-4. • Rheumatic Heart Disease (RHD) as squale condition of ARF can leading to congestive heart failure, strokes, endocarditis, and death 1-41 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease Clinical Epidemiology 2011;3:67–84. 12 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heartdisease in Australia, An evidence-based review. 2006; Pp. 7-26.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrison’s rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29Oct – 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).
  • 4. INTRODUCTION cont. How does ARF develop? O GABHS “rheumatogenic” O Susceptible individual O Environmental risks small proportions of people in any population (3- 5%) have an inherent susceptibility to ARF 6,76 Lawrenson J. Rheumatic fever: New ideas in diagnosis and management. SAHeart 2010;7:252-257.7 Beggs S, Peterson G, Tompson A. Antibiotic use for the prevention and treatment of rheumatic fever and rheumaticheart disease in children. Report for the 2 nd Meeting of World Health Organization’s subcommittee of the ExpertCommittee of the Selection and Use of Essential Medicines. Geneva: 2008. Pp. 3
  • 5. INTRODUCTION cont. . An estimated 12 million people are affected by ARF and RHD globally4,9 Up to 150 cases per 100 000 population in developing countries versus 1 case per 100 000 population in developed countries such as the United States4,9 Predominantly affects children aged 5–14 years, rare affect children less than 3 years old or adults2,7 Recurrenct may occurs well into their fourties 40 y.o 2,72 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia, Anevidence-based review. 2006; pg7-26.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 Oct – 1 Nov 2001.Geneva: WHO 2004. (WHO Technical Report Series No. 923).7 Beggs S, Peterson G, Tompson A. Antibiotic use for the prevention and treatment of rheumatic fever and rheumatic heart disease in children. Report for the 2 nd Meeting of World HealthOrganization’s subcommittee of the Expert Committee of the Selection and Use of Essential Medicines. Geneva: 2008. Pp. 39 Miyake CY, Gauvreau K, Tani LY, Sundel RP. Newburger JW. Characteristics of Children Discharged From Hospitals in the United States in 2000 With the Diagnosis of Acute Rheumatic Fever.Pediatrics 2007;120:503-508.
  • 6. CONTENT
  • 7. CONTENT2.1 Diagnosis  Based on Jones’s Criteria  Jones’s criteria consist major and minor criteria  To fulfill Jones criteria: two major criteria OR one major criterion and two minor criterion, PLUS evidence of antecedent streptococcal infection 1-5,11
  • 8. Tabel 1. The Jones Criteria for Acute Rheumatic Fever, Update 1992 3 Major Criteria Minor Criteria Carditis Clinical Fever Polyarthritis Arthralgia Laboratory Chorea Acute-phase reactants—erythrocyte sedimentation rate, C-reactive protein Erythema marginatum Electrocardiogram—prolonged PR Subcutaneous nodules interval Plus supporting evidence of antecendent GABHS infection : •Increased antistreptolysin O (ASO) or other streptococcal antibodies (DNAse B) •Positive throat culture for GABHS •Positive rapid antigen detection test for GABHSKaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrison’s rheumatology. New York: McGraw-hill; 2006. Pp 105-108 .3
  • 9. Tabel 2. 2002–2003 WHO criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on the revised Jones criteria) 2,4,112 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever andrheumatic heart disease in Australia, An evidence-based review. 2006; Pp. 7-26.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO ExpertConsultation, Geneva, 29 Oct – 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).11 Cilliers AM. Clinical review: Rheumatic fever and its management. BMJ 2006;333:1153–1156.
  • 10. Jones’s Major CriteriaCarditis • 40% to 60% of patients with ARF have evidence of carditis • Carditis is typically valvulitis, and has been traditionaly diagnosed by a murmur suggestive of valvar regurgitation • There may be pericarditis and myocarditis • Echocardiography as supportive examination
  • 11. Jones’s Major Criteria Carditis cont. Clinical diagnosis of carditis is based on3,4: the presence of significant murmurs apical systolic murmur of mitral regurgitation and/or the basal diastolic murmur of aortic regurgitation tachycardia, pericardial friction rub  cardiomegaly3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrison’s rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heartdisease: report of a WHO Expert Consultation, Geneva, 29 Oct – 1 Nov 2001. Geneva: WHO 2004. (WHO TechnicalReport Series No. 923).
  • 12. Jones’s Major Criteria Polyarthritis  Asymmetrical redness, swelling, and intense pain of multiple joints, that can be migratory or additive 1-3  Affect large joint (ankles, knee, wrists, and elbow, seldom involve the hip joints); not the small joint3,4  It occurs at early course of the disease3,4  Shoud be differentiated from PSRA111 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease Clinical Epidemiology2011;3:67–84.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrison’s rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHOExpert Consultation, Geneva, 29 Oct – 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).11 Cilliers AM. Clinical review: Rheumatic fever and its management. BMJ 2006;333:1153–1156 .
  • 13. Jones’s Major CriteriaChorea  rapid, uncontrolled movements, especially affecting the hands, feet, tongue and face2-4  Bilateral or unilateral (hemichorea) 2-4  Latency period 1-7 months2-4  Females > male, and occur primarily in children and are rare after the age of 20 years2-4  milkmaid’s grip, spooning , pronator sign, inability to control protrusion of tongue2,3  emotional lability, changes in personality, moodiness, or a change in school performance12
  • 14. Jones’s Major Criteria Erythema marginatum2,4 non-pruritic bright pink macules or papules that blanch under pressure and spread outwards in a circular or serpiginous pattern (snake-like) commonly on the trunk and proximal extrimities; never on face difficult to detect in patients with dark skin found in 3% to 5%2 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management ofacute rheumatic fever and rheumatic heart disease in Australia, An evidence-based review. 2006; Pp. 7-264 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease:report of a WHO Expert Consultation, Geneva, 29 Oct – 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No.923).
  • 15. Jones’s Major Criteria Subcutaneous nodules 1-4  least common (1% of patients)  round, freely moveable, non painful, vary in size from 0.5 to 2 cms  usually found on the extensor surfaces of the arms and legs1 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever andrheumatic heart disease Clinical Epidemiology 2011;3:67–84. 12 National Heart Foundation of Australia and the Cardiac Society of Australia and NewZealand. Diagnosis and management of acute rheumatic fever and rheumatic heartdisease in Australia, An evidence-based review. 2006; Pp. 7-26.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrison’s rheumatology. New York:McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumaticfever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 Oct –1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).
  • 16. Minor Criteria Fever 4,11• 38°C or higher• occurs in almost all rheumatic attacksArthralgia1,3,4• arthritis and arthralgia do not occurs together• is pain usually involves large joints, may be mild or incapacitating, without associated redness or swelling,• may be present for days to weeks
  • 17. Minor CriteriaAcute-phase reactants2,10 erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and WBC count are increase as a sign of inflammatory Prolonged PR interval 1,2• suggests that there is a first degree of heart block• ECG should be repeated after 1–2 months to document a return to normal. If it has returned to normal, ARF becomes a more likely diagnosis.
  • 18. Evidence of antecedent GABHS infection Throat Culture 8,12 May fail to isolate the organism (60% to 70% of cases) because of the latency period between the primary infection and the development of ARF12 Streptococcal Antibody Tests8 antistreptolysin O (ASO) and antideoxyribonuclease B Antigen Detection Tests8 RADTs are vary in method and have high specificity but low sensitivity
  • 19. Table 3. Differential Diagnosis of ARF2 Polyarthritis and Carditis Chorea Fever Differential • Septic arthritis • Innocent murmur • Systemic lupus Diagnosis (including • Mitral valve erythematosus gonococcal) prolapse • Drug • Connective tissue • Congenital heart intoxication and other auto- disease • Wilson’s disease immune disease* • Infective • Tic disorder‡ • Viral arthropathy† endocarditis • Choreoathetoid • Reactive • Hypertrophic cerebral palsy arthropathy† cardio-myopathy • Encephalitis2 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia,An evidence-based review. 2006; Pp. 7-26.
  • 20. Table 3. Differential Diagnosis of ARF2 cont. Polyarthritis and Carditis Chorea Fever Differential • Reactive • Myocarditis — • Familial chorea arthropathy viral or idiopathic (including Diagnosis • Lyme disease • Pericarditis — Huntington’s) • Sickle-cell anemia viral or • Intracranial • Infective idiopathic tumor endocarditis • Lyme disease • Leukaemia or • Hormonal lymphoma • Gout and pseudogout2 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia,An evidence-based review. 2006; Pp. 7-26.
  • 21. SUMMARY
  • 22. ARF is a serious condition and due to physical,mental, and undue economic burden whichcaused by inappropriate diagnosis of ARF,accurate diagnosis of ARF is important. Jones’s criteria as guideline to diagnose ARF. To fulfill Jones’s criteria, either two major criteria or one major criterion and two minor criterion, plus evidence of antecedent streptococcal infection are required clinical findings are still the major consideration in making diagnosis. However many of the clinical features of ARF are non-specific, so a wide range of differential diagnoses should be considered.
  • 23. Thank you 

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