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Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
Rheumatic  fever clinical features and diagnosis
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Rheumatic fever clinical features and diagnosis

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rheumatic fever, aetiopathogenesis, clinical features and diagnosis

rheumatic fever, aetiopathogenesis, clinical features and diagnosis

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  • 1. RHEUMATIC FEVERClinical features and diagnosis DR . SUJIT SAHU http://cardiologysearch.blogspot.in/
  • 2.  INTRODUCTION HISTORICAL BACKROUND EPIDEMIOLOGY PATHOGENESIS PATHOLOGY CLINICAL FEATURES DIAGNOSIS http://cardiologysearch.blogspot.in/
  • 3. INTRODUCTION Clinical syndrome Acute , non-suppurative inflammatory disease following Group A Beta Hemolytic Streptococcal sore throat Classified as Connective tissue disease or collagen vascular disease affecting the Joints, heart , brain , skin and subcutaneous tissue http://cardiologysearch.blogspot.in/
  • 4. HISTORICAL BACKROUND 1604 – Guilleaume (France) Thomas Syndenham (Eng) -Polyarthritis 1605 - Sydenham - St. Vitus Dance 1761 - Morgani (Italy) – Heart valves 1813 - W.C.wells – Subcutaneous Nodules 1818 - Laennec - RHD (clinical) http://cardiologysearch.blogspot.in/
  • 5. HISTORICAL BACKROUND 1886 - Cheadle - Full syndrome 1904 - Aschoff - Aschoff Nodule 1931 - Coburn - Streptococcal assoc. 1944 - Jones - Criteria 1951 - Wannamaker (penicillin prophylaxis) http://cardiologysearch.blogspot.in/
  • 6. EPIDEMIOLOGYhttp://cardiologysearch.blogspot.in/
  • 7. EPIDEMIOLOGYhttp://cardiologysearch.blogspot.in/
  • 8. India S Padmavati Director, National Heart Institute, New Delhi, India In 2000, in a school survey involving 3963 children from the district of Kanpur, the prevalence of RHD was 4.54 per 1000 (Urban 2.56 and Rural 7.42). The prevalence of RF was 0.75 per 1000 (Rural 1.20, Urban 0.42) http://cardiologysearch.blogspot.in/
  • 9. EPIDEMIOLOGY 2000 - 2004HOSPITAL BASED SURVEYS : Agarwal et al (varanasi) : Decreasing (8.4% - RHD & 1.1% RF) Despande et al (Mumbai): No change Mishra et al (cuttack) : No change http://cardiologysearch.blogspot.in/
  • 10. EPIDEMIOLOGYPREVELANCE : 2 million at presentINCIDENCE : 50 000 new cases every year http://cardiologysearch.blogspot.in/
  • 11. PATHOGENESI S http://cardiologysearch.blogspot.in/
  • 12. STRUCTURE OF Group –ABeta Hemolytic Streptococcus http://cardiologysearch.blogspot.in/
  • 13. Group - A Streptococcus Two highly conserved epitopes within M protein divide GAS immunologically into Class I (throat) Class II (skin) strains. All RF strains fall clearly into Class I throat strains The site of infection must be pharyngeal . Regardless of how virulent an invasive strain may be, ARF does not result when it is introduced extra- pharyngeally, e.g. through skin lesions or wound infections http://cardiologysearch.blogspot.in/
  • 14. CROSS REACTIVITY http://cardiologysearch.blogspot.in/
  • 15. CO-PATHOGENS Burch et al & Pongpanich et al : (1970) (1976) Serological evidence of Cox B viruses in patients with rheumatic fever http://cardiologysearch.blogspot.in/
  • 16. GENETIC PREDISPOSITION Specific B - cell alloantigen HLA DR 3 - Indians Moari races in New Zealand & Samoans in Hawaii High concordance in twins Increased risk in families with H/O RF http://cardiologysearch.blogspot.in/
  • 17. ENVIRONMENT Low socio-economic group Urban slums Poor accesibility to health care Over crowding Unclean environmentMostly seen in developing countries http://cardiologysearch.blogspot.in/
  • 18. INTERACTIONhttp://cardiologysearch.blogspot.in/
  • 19. http://cardiologysearch.blogspot.in/
  • 20. PATHOLOGYhttp://cardiologysearch.blogspot.in/
  • 21. INFLAMMATORY RESPONSE Edematous change Cellular infiltrate Fibrinoid necrosis Aschoff body (seen only in heart)http://cardiologysearch.blogspot.in/
  • 22.  Joints : serositis Pericardium Skin (S/C nodule) : Fibrinoid Heart degeneration Erythema Marginatum : Vasculitis Chorea : Vasculitis http://cardiologysearch.blogspot.in/
  • 23. ASCHOFF BODY  Granuloma  Central fibrinoid necrosis  Surrounded by lymphocytes, Antischkow cells and Plasma cellshttp://cardiologysearch.blogspot.in/
  • 24. http://cardiologysearch.blogspot.in/
  • 25. http://cardiologysearch.blogspot.in/
  • 26. http://cardiologysearch.blogspot.in/
  • 27. http://cardiologysearch.blogspot.in/
  • 28. Initial edemaHyaline degenerationVerrucae formation at the edge of leafletsPrevents approximation RegurgitationFibrosis & calcification Stenosis
  • 29. http://cardiologysearch.blogspot.in/
  • 30. ORDER OF VALVE INVOLVEMENT Mitral Aortic Tricuspid Pulmonary http://cardiologysearch.blogspot.in/
  • 31. INTERNATIONAL SERIES BY BONOW  PURE MS : 25 %  PURE MR : 10 %  MS / MR : 25 %  AORTIC : 8%  ALL VALVES : 7% http://cardiologysearch.blogspot.in/
  • 32.  CLINICAL FEATURES http://cardiologysearch.blogspot.in/
  • 33. PERCENTAGE INVLOVEMENT (Indian Scenario) ARTHRITIS : 70 % ARTHALGIA : 90 % CARDITIS : 70 % CHOREA : 08 % S/C NODULE : 02 % ERYHTEMA MARGINATUM : 01 http://cardiologysearch.blogspot.in/
  • 34. LATENCY From onset of sore throat to onset of initial attack of rheumatic fever is 1 – 5 weeks for recurrent attacks Median of 19 days & shorter http://cardiologysearch.blogspot.in/
  • 35. LATENCY Joint manifestations are first to occur - heralding onset of disease Carditis occurs within 2 weeks - is apparent when patient is first seen Subcutaneous nodules appear 4 weeks or more after onset of symptoms Chorea may appear 2 to 6 months later Erythema marginatum occurs both early & later http://cardiologysearch.blogspot.in/
  • 36. MODE OF ONSET Variable Abrupt onset with fever & acute polyarthritis Insidious or sub clinical in mild indolent carditis May present with CCF May present atypically with acute abdomen due to peritoneal inflammation http://cardiologysearch.blogspot.in/
  • 37. POLYARTHRITIS Most common & Least specific severe in adults Large joints ; asymetrical Flitting- involves joints after joints Fleeting - Lasting for short time 3 days - 1 week No residual damage http://cardiologysearch.blogspot.in/
  • 38. POLYARTHRITIS Responds dramatically to aspirin Severity inversely related to carditis (Feinstein & Spagnuola et al – 1962) JACCOUDS ARTHRITIS :  Smalljoints  Produces residual damage  Seems to be related to RF http://cardiologysearch.blogspot.in/
  • 39. PANCARDITIS More severe in the young Sub clinical to fulminant ENDOCARDITIS :  AR : 20 %  MR : 75 % : due to - Valvulitis - MVP (anterior leaflet) - Annular dysfunction http://cardiologysearch.blogspot.in/
  • 40. ENDOCARDITISClinical Evidence of Endocaritis :  Apical holosystolic murmur  Carey coomb’s murmur  Early diastolic murmur http://cardiologysearch.blogspot.in/
  • 41. MYOCARDITIS Clinical evidence of Myocarditis : Cardiomegaly Clinical features of CHF Gallop rhythm http://cardiologysearch.blogspot.in/
  • 42. PERICARDITIS Clinical evidence of Pericarditis : Pericardial rub Associated with endocarditis Indicates severe carditis (High rheumatic activity) No residual constriction http://cardiologysearch.blogspot.in/
  • 43. CHOREA Occurs 3 months later than other RF features - spontaneous resolution Duration : variable ( upto 6 months) Often in prepuberal girls Neuropsychiatric disorder Seen in 5 - 15 % cases http://cardiologysearch.blogspot.in/
  • 44. CHOREA ST. VITUS DANCE 25 - 30 % develop RHD particularly MS (Bland et al – 20 years follow up) Multiple purposeless movements of legs and hands (also involves face) on exertion & absent during sleep http://cardiologysearch.blogspot.in/
  • 45. DD FOR CHOREA HABITUAL SPASMS WILSONS DISEASE POST ENCEPHALITIS HYSTERESIS http://cardiologysearch.blogspot.in/
  • 46. SUBCUTANEOUS NODULE FIRM PAINLESS 0.5 – 3 cm IN SIZE IN CROPS ( OVER EXTENSORS) DISAPPEAR IN 12 WEEKSALWAYS ASSOCIATED WITH CARDITIS http://cardiologysearch.blogspot.in/
  • 47. SUBCUTANEOUS NODULEhttp://cardiologysearch.blogspot.in/
  • 48. SUBCUTANEOUS NODULEhttp://cardiologysearch.blogspot.in/
  • 49. ERYTHEMA MARGINATUM Rare (< 1 %) Bikini distribution Evanescent vanishing Non pruritic
  • 50. OTHER MANIFESTATIONS EPISTAXIS ABDOMINAL PAIN- Occurs in 5% cases- Clinical importanceOften appear hours or days before major manifestationsAcute abdomen [ appendicitis ] to be excluded http://cardiologysearch.blogspot.in/
  • 51. FEVER Relatively common But nonspecific Low grade; subside without treatment in 1-2wk Associated with constitutional symptoms Lab indices are high even after fever subsides Remission does not exclude rheumatic activity http://cardiologysearch.blogspot.in/
  • 52. ECG CHANGES Seen in 2/5th patients [ Disciascio(1980)] PR interval ; QT interval ; AV blocks Does not correlate with organic murmurs, prognosis or residual heart disease Nonspecific & occur in many other infection http://cardiologysearch.blogspot.in/
  • 53. LAB INVESTIGATIONSMonitoring the Detecting the antecedentinflammatory activity infection with streptococcus There is no single diagnostic test http://cardiologysearch.blogspot.in/
  • 54. EVIDENCE OF STREPTOCOCAL INFECTIONTH ROAT SWAB CULTURE : Only in Minority of casesASO TITRE :  elevated from 7 - 10 days  rise and fall rapidly  >240 todd units (adults)  >330 todd units (children)  Antibiotics/steroids/liver disease affect the titre http://cardiologysearch.blogspot.in/
  • 55. EVIDENCE OF STREPTOCOCAL INFECTION ANTI-DNAase B TEST : # > 120 todd units (adults) # > 240 todd units (children) # used when ASO titre is not conclusive # remains elevated for long time STREPTOZYME TEST : Detects antibodies against streptococcal antigen http://cardiologysearch.blogspot.in/
  • 56. RHEUMATIC ACTIVITY DETECTION Activity considered ended only when both ESR & CRP become normal and remain so for 2 weeks after stopping drugs Fever & tachycardia subside long before lab reactants decline Joint symptoms & active carditis do not occur after ESR & CRP decline http://cardiologysearch.blogspot.in/
  • 57. RHEUMATIC ACTIVITY DETECTION CRP more specific than ESR Usually lasts for 3 months Longer in patients with valvular involvement In 5% cases rheumatic activity persist longer than 6 months termed CHRONIC RHEUMATIC FEVER http://cardiologysearch.blogspot.in/
  • 58. ECHOCARDIOGRAM Abernathy et al: echo allowed earlier diagnosis of carditis Veasy et al : echo increased the sensitivity of detecting carditis from 72% to 91% http://cardiologysearch.blogspot.in/
  • 59. ECHOCARDIOGRAM Differentiates between innocent murmur and Rheumatic MR Detects MVP due to Rheumatic fever (Wu et al – JACC 1994) - AML - Elongated chordae - No myxomatous thickening http://cardiologysearch.blogspot.in/
  • 60. ECHOCARDIOGRAM Cost effectiveness and the additional workload have to be validated Vasan et al (Circ . 1994 ): showed no additional detection of carditis by echo than by clinical detection http://cardiologysearch.blogspot.in/
  • 61. OTHER INVESTIGTIONSEndomyocardial biopsy – to establish the myocarditisnot likely to provide additional informationsRadionuclide imaging-- Gallium-67 imaging has better diagnostic characteristics than antimyosin scintigraphy - the results confirm that rheumatic carditis is infiltrative rather than degenerative in nature - not suitable for routine investigation http://cardiologysearch.blogspot.in/
  • 62. DUCKETT JONES CRITERIA ORIGINAL (JAMA 1944)MAJOR MINORCarditis erythema mariginatumChorea fever / epistaxis /Arthralgia abdominal painS/C Nodule WBC / ESR / CRPPreexisting RF http://cardiologysearch.blogspot.in/
  • 63. DUCKETT JONES MODIFIED CRITERIA :1956 - AHA Arthritis : Included as – major criteria Erythema marginatum: Included as – major criteria REVISED : 1965 /84 - AHA Recent streptococcal infection is included as essential criteria WHO : 1988 UPDATED : 1992 - AHA WHO CRITERIA : 2003 http://cardiologysearch.blogspot.in/
  • 64. DUCKETT JONES CRITERIA WHO CRITERIA FOR RF AND RHD- 2003 MAJOR MINOR Carditis Clinical Polyarthritis - Fever Chorea - Arthralgia S/C Nodules Laboratory Ery. Marginatum - Leucocytosis - Elevated : ESR /CRP ECG - IncreasedPR interval http://cardiologysearch.blogspot.in/
  • 65. DUCKETT JONES CRITERIASupporting evidence of antecedentstreptococcal infection Within the last 45days - positive Throat culture - Rapid streptococcal antigen test - Elevated or Rising ASO Titer - Recent scarlet fever http://cardiologysearch.blogspot.in/
  • 66. Diagnostic categories: WHO 2003 PRIMARY RF : 2 major or 1 major and 2 minor + evidence of preceding Gr-A streptococcal infection RECURRENT ATTACK OF RF WITHOUT ESTABLISHED RHD 2 major or 1 major and 2 minor + evidence of preceding Gr-A streptococcal infection RECURRENT ATTACK OF RF WITH ESTABLISHED RHD 2 minor + evidence of preceding Gr-A streptococcal infection http://cardiologysearch.blogspot.in/
  • 67. Diagnostic categories: WHO 2003 Rheumatic chorea Insidious onset rheumatic carditis Other major manifestations or evidence of Group-A streptococcal infection not required http://cardiologysearch.blogspot.in/
  • 68. Diagnostic categories: WHO 2003 Chronic valve lesions of RHD Patients presenting first time with pure MS or mixed mitral valve disease and /or aortic valve disease Do not require any other criteria for diagnosis as having RHD http://cardiologysearch.blogspot.in/
  • 69. DUCKETT JONES CRITERIA  Specificity – 97 %  Sensitivity – 77 %http://cardiologysearch.blogspot.in/
  • 70. BEYOND JONES CRITERIA Not a substitute for clinical judgment Not meant to predict course or severity Useful for initial diagnosis only Exceptions : - Chorea - Isolated indolent carditis - Recurrence with RHD http://cardiologysearch.blogspot.in/
  • 71. APPLYING JONES CRITERIA 2 major criteria is stronger than One major and 2 minor Arthalgia cannot be used as minor criteria when arthritis is present Prolonged PR cannot be used as a minor criteria when clinical carditis is present http://cardiologysearch.blogspot.in/
  • 72. APPLYING JONES CRITERIA Absence of evidence of an antecedent Group-A Beta-hemolyticus Streptococci is a warning that RF is unlikely Possibility of early suppression of full clinical manifestations by drugs should be sought during history taking http://cardiologysearch.blogspot.in/
  • 73. RECURRENCE Cardiac status deteriorates with each new attack Younger the patient - higher recurrence rate Recurrence decreases with passage of time – . - 50% within first year - only 10% after 5 years Recurrence more in those with valvular lesion Increase antibody response associated with high recurrence rate http://cardiologysearch.blogspot.in/
  • 74. RECURRENCE Clinical manifestations in recurrence tend to mimic those in preceding attack Recurrence distinguished from rebound or exacerbation if interval of 3 months freedom of rheumatic activity Valve stenosis at diagnosis indicates recurrence http://cardiologysearch.blogspot.in/
  • 75. RHEUMATIC FEVER Licks the Joint and Bites the Heart http://cardiologysearch.blogspot.in/
  • 76. http://cardiologysearch.blogspot.in / http://cardiologysearch.blogspot.in/
  • 77.  THANK YOU http://cardiologysearch.blogspot.in/
  • 78.  Kindly send your suggestions to improve this site Visit us regularly for updates Send your articles/ ppt/pdf to publish in this site . http://cardiologysearch.blogspot.in/ http://cardiologysearch.blogspot.in/

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