lecture of 23 slides

1. Guidelines for prescriping of
long acting pencillin and
value of ASO Titer
By
Dr. Magdy Shafik
Ph. D of Pediatric
Pediatric Consulatant

2. Antibiotic Therapy for GABHS
 Goal is bacteriological cure.
 Antimicrobial therapy as early as before 9th
day of illness.
 Duration of therapy (10 days coverage).
– 10 days: oral penicillin (V)/Amoxacillin/1st
generation cephalosporin.
– Single IM, Benzathin penicillin.
– 10 days: erythromycin ethylsuccinate.
– 5 days: Azithromycin.
– 7 days: Clarithromycin,

3. The Requirements for the Development of RF
 Genetically Predisposed Host.
PLUS
 Presence of GABHS.
 Pharyngeal infection not
colonization.
 Persistence of the organism in the
pharynx for a sufficient period (delay
of therapy > 9th day or treatment <
10 days duration) or subclinical
infection.
 Streptococcal immune response
(anti-streptococcal antibodies).

4. What makes a link between the throat
and the heart ?

5. Major and Minor Manifestations of Rheumatic Fever
 Carditis
 Polyarthritis
 Chorea.
 Erythema Marginatum
 Subcutaneous nodules
 Fever
 Arthralgia
 Elevated acute phase reactants (ESR,
CRP)
 Prolonged P-R interval
PLUS
Evidence of preceding streptococcal infection (Culture, rapid antigen,
antibody rise / elevation)
Minor criteriaMajor criteria

6. Sequences of RF Manifestations
20 30 50 100 200
20 30 50 100 200
Subcut. Nodules
Erythema Marginatum
Chorea
Carditis
Arthritis
Abdominal pain
ASO titer
Days since strept. infection

7. Growing pains
Joint pains of subacute
rheumatic fever
Growing pains
Timing Durring entire day,
disappears on getting warm
in bed, worse on first getting
out of bed in the morning.
At end of day or
soon after falling
asleep, free of
pain in morrning
Location In joints. Pain on motion.
Cild points out pain in joints.
Involves joints in upper
extremities.
May cause limping.
In muscles of
thigh or legs. No
pain on motion.
Child vague in
pointing out site
of pain in upper
extremites
unusual.

8. Massage addressed by general pediatrician to parents
of children with growing pain
1-The pain is related to the muscle and has no relation
to the joint or the heart
2- The pain is very common, benign phenomenon in
children and usually related to increased day time
motor activity.
3- The child’s pain is completely unrelated to
streptococcal sore throat( you must repeat)
4-The child does not need any further special testing as
ESR or ASO or any sort of therapy apart from massage
or mild analgesic, if distressing or interfering with
sleep.
5-Any restrictions or precautions are not only
unnecessary but wrong.

9. 6-The pain may come and the pain may go, and is
self limiting by age but the child health is normal.
7-The child should keep physical active.

10. Myths that Should be Condemned in the
Diagnosis of RF X
 Any vague musculoskeletal pain during or following GABHS pharyngeal
infection supported by high ESR and elevated ASO titer is mostly related
to RF.
 The lack of migratory character of polyarthritis is a strong predictor against
RF
 Echocardiography is only confirmative to clinically evident carditis .
 Patients with Post-streptococcal reactive arthritis should not receive
prophylactic BPG, being a separate disease entity.
 Rheumatic fever is a primarily laboratory diagnosis ,so that a high
ESR/CRP plus elevated ASOT make the diagnosis of RF more likely.
 A markedly elevated titer of ASO is only seen in patients with ARF.
 ASO titer is a diagnosis by itself ,regardless the clinical setting of the
patient to whom the test is requested.

11. ASO Titer
 WHAT IS ASO Titer ?
IS A titer of antistreptolysin O which is one of the
streptococcal antibody
IS THERE IS ANY other streptococcal antibody ?
DNA se –B
NAD ase
Streptokinase
hyalourindase

12. The Pattern of ASA titer Following
GABHS Pharyngitis

13. III-The Diagnostic Utility of High ASO
Titer
 15% of normal children without clinical evidence of recent GAS infection
have a titer exceeding the ULN .
 About 20% of patents with the first attack of RF and many patients with
chorea, all have low ASO titer .
 In case of negative rising titer, other antibodies, such as anti-DNaseB and
anti-hyaluronidase, should be performed in order to improve the capacity
to confirm a previous infection.
 In most of developing countries, where the incidence of RF is high and
resources are limited, the only test available is ASO.
 It seems better to diagnose a suspected case with typical migratory
polyarthritis ,despite a normal ASO titer as RF, after exclusion of other
causes .
 A low or non rising ASO titer at the onset of isolated polyarthritis is not
necessary a negative predictor of RF .

14. Diagnostic Significance of Higher ASOT
More Than 400 in Different Clinical
Scenarios
All these scenarios are not indication for
ordering ASO titer in the daily clinical practice:
 A symptomatic child or with minor symptoms :
 a completely healthy child (15%) or subclinical GAS
infection in the preceding 3-6 month
 History suggestive of sore throat or clear evidence of
tonsillitis: GAS infection in the preceding 3-6 month
 Recurrent symptomatic or subclinical pharyngitis:
elevated titer is suggestive of GAS infection in the
preceding 3-6 month
 Acute tonsilopharngitis : not related to the current
infection

15. All these scenarios are indication for
ordering ASO titer in the daily practice:
1- Acute migratory polyarthritis or acute carditis:
support the diagnosis of initial attack of acute
rheumatic fever
2-Isolated chorea or indolent carditis:
support the diagnosis of rheumatic fever
3-Patient with polyarthalagia or Monoartheritis and
positive acute phase reactant :
support the diagnosis of initial attack of
probable rheumatic fever

16. 4-patient with past history of RF or RHD with fever or arthralgia
with positive acute phase reactant :
a rising titer support the diagnosis of recurrence.
5- A symptomatic patient with past history of RF, Chorea or
RHD on follow up:
support the diagnosis of GAS and so poor compliance and
hence prophylaxis failure
6-Patient with symptoms suggestive of AGN :
support the diagnosis of GAS

17. Guidelines for the prescriping of long
acting penicillin
1-Initial attack of acute rheumatic fever or recurrence :
to eradicate Group A B- Hemolytic strpt. Cocci. Prior to
prophylaxis. ONCE
2-Pasthistory of rheumatic fever, chorea, or established
RHD (secondary prevention) . / 2 WEEKES
3- Acute tonsilopharnigitis suggestive of Group A B-
Hemolytic strpt. Cocci infection: for a bacteriological cure
for the benefit of the patient and community . ONCE

18. 4- Acute Poststrptoccol GN
: for a bacteriological cure for the benefit of the community .
ONCE
5- Recurrent symptomatic tonsliopharnigitis suggestive of
Group A B- Hemolytic strpt. Cocci infection with a frequencies
not necessitating tonsillectomy:
to decrease the frequency of infections, antibiotic therapy,
school abestansism and superlative complication,
EVERY 2-3 WEEKS FOR HOW LONG??? And in what
season ?? INDVIDULAZED ….

19.  In cases of sensitivity to Lon acting penicillin use
erythromycin 250 mg once daily(↓ 27 year) if (↑ 27
year give 250 mg twice daily

20. Duration depends on clinical presentation and cardiac extent of
ARF.
1-Patients without rheumatic carditis require prophylaxis for 5
years or until age 21, whichever comes later.
2-Patients with a history of rheumatic carditis but with no
residual cardiac disease (clinical or echocardiographic) require
prophylaxis for at least 10 years and well into adulthood,
whichever is longer.
3-Patients with rheumatic heart disease should have prophylaxis
for at least 10 years and at least until 40 years of age.
Duration of secondary infection by LAP

21. 1- The most common cause of syncope in pediatric is Neuromediate
syncope .
2-The most common cause of chest pain in children is muscloskeletal or
pulmonary
3-The most common cause of palpitation in children is NON Cardiac,
Physiological.
4-The most common cause of exercise intolerance in children is NON
Cardiac : exercise induced asthma.
5-The most common cause of murmur in children is innocent murmur.
Remember the following 10 facts

22. 6-The most common cause of leg pain in children is
growing pain
7-The most common cause of tachycardia in children is
emotional
8-The most common cause of pseduhypertesion in
children is white coati HTN
9-The most common cause of CYNOSIS in the daily practice is
ACROCYNOSIS
10-The most common cause of Subjective Feeling of
Dyspnea in a previously healthy adolescent girl is
Sighing Breathing in response to stressor