Differentiating two closely named different entity.

1. Rheumatic arthritis and
PSRA
Speaker: Dr. Arnab Nandy
1st year PGT
Dept. of Paediatrics, NBMC&H
Moderator: Dr. (Prof) Rakesh Kumar Mondal
Dept. of Paediatrics, NBMC&H

2. Introduction
 Rheumatic fever - ‘licks the joint and bites the heart’
 ARF & PSRA – Part of single clinical spectrum
Or
Different clinical entity
 Epidemiology- 1. Developing countries
2. Low-socioeconomic strata
3. Over-crowding
4. Winter-spring season
5. 5-15 years of age

3. Pathogenesis
 Molecular mimicry - GABHS
 Genetic predisposition – DR4 & DR7 allele
Clinical Spectrum
Prodrome:
Fever, Sore throat, Arthralgia, Malaise
Manifestation:
 Pan-carditis (50-70%) – young age group
 Poly-arthritis (35-66%)
 Chorea (10-30%) – latency of 6months
 Rheumatic nodules (0-10%) – latency of 6weeks
 Erythema marginatum (<6%)

4. Pathology
1. Exudative phase
2. Proliferative or granulomatous phase
Non-communicable but high recurrence rate
Diagnosis
Revised Jones criteria 2015 – AHA
(T Duckett Jones 1944)
a) 5 major criteria
b) 4 minor criteria
c) Evidence of recent strep. infection

5. Rheumatic arthritis in ARF:
 Immunologic
 Poly-arthritis( >1 joints)
 Migratory and fleeting
 Major large joints
 Swollen , warm and tender
 Short duration (avg. – 2weeks)
 Excellent response to salicylates
 No residual defect ( Exception – Jaccoud arthritis)
Post-streptococcal Rheumatic Arthritis:
o Arthritis - ≥1 joints
o Reactive or immunologic
o Recent group A streptococcal infection
o Condition not fulfill - the Jones criteria - ARF

6. Similarity and dis-similarity between rheumatic arthritis in ARF and PSRA:
• Preceding gr A beta hemolytic streptococcal infection
• Reactive or immunologic pathogenesis
• Non-erosive or non deforming
Differential diagnosis of rheumatic arthritis:
 SLE
 Serum sickness
 Rheumatoid arthritis
 Post infective reactive arthritis(shigella, salmonella, Yersinia)
 Sickle cell disease

7. Rheumatic arthritis in
ARF
PSRA
Age predilection Young Adult
Time of onset <2-3weeks <10days
Joint involvement Poly-articular
Large joints>>>small joints
More symmetrical
Poly or Mono- articular
Large joints>Small joints
Less symmetrical
Migratory nature
of arthritis
Classical Non migratory and
additive
Duration and
relapse
2-3weeks Prolonged and recurrent
Response to
salicylate
Excellent Partial
Laboratory
finding
ESR – high
CRP - high
ESR – low
CRP - low
Similarity and dis-similarity between rheumatic arthritis in ARF and PSRA:

8. Rheumatic arthritis in
ARF
PSRA
Genetics HLA DRB1*16 HLA DRB1*01
Carditis Common Uncommon and late
Cont.
Variables to look for:
 ESR
 CRP
 Duration of symptoms after starting salicylate
 Relapse after discontinuation of therapy

9. Implication
Antibiotic prophylaxis
 ARF – Long term prophylaxis
 PSRA - For 1 year if echocardiogram is normal (no carditis)

10. THANKYOU