brief idea about ARF, incidence and management

1. Acute Rheumatic Fever

2. Introduction
 Non-infectious, post-infection inflammatory disease
affecting primarily the heart, joints, subcutaneous
tissues, and CNS
 Occurs as a delayed complication of infection with
certain serotypes of Group A Streptococci

3. Epidemiology
 Burden: 10-50% of cardiac admission
 Incidence of rheumatic fever following streptococcal
sore throat: 0.3% in western
 Increased to 1-3% in crowded communities

4. Epidemiology
 Most common age group: 5-15 years
 Sex: nearly equally affected
 Role of
 Overcrowding
 Poverty

5. Etiopathogenesis
 Incompletely understood
 Strong association with β-hemolytic streptococci
 Post-infectious sequelae
 Autoimmune response
 Genetic susceptibility

6. Clinical features
 Pancarditis: [50-60% patients]
 Early manifestation
 Occur within first 2 weeks
 Pericarditis
 Precordial pain
 Friction rub
 Associated with mitral or aortic regurgitation murmurs
 Myocarditis
 Cardiomegaly
 Soft S1
 S3 gallop
 CCF
 Carey Coomb’s murmur

7. Clinical features
 Pancarditis (cont’d………..)
 Endocarditis
 Mitral valve: 100% patients with carditis
 Only Aortic valve: 5-8%
 Tricuspid valve: 10-30%
 Pulmonary valve: Not seen
 Results in regurgitation murmur
 Volume overload left ventricular failure

8. Clinical features
 Polyarthritis
 Migratory
 Large joints: knees, ankles, elbows
 Early feature
 30-50% of patients [70-75% in western countries]
 Transient
 Tenderness may be out of proportion to the objective findings
and severe enough to result in excruciating pain on touch
 Response to salicylates: very good
 No residual damage to joints
 “licks joints, but bites heart”

9. Clinical features
 Subcutaneous nodules
 Late manifestation: about 6 weeks
 Occurs in <1% patients
 Over bony prominences: elbows, shin, occiput, spine
 Pinhead to almond size
 Painless
 Lasts for few days to weeks
 Strong association with carditis

10. Clinical features
 Sydenham’s chorea
 Late manifestation
 10-15% patients
 Occurs after about 3 months
 Purposeless jerky movements, deranged speech, muscular
weakness, gait abnormality
 Emotional lability:
 More frequent in females
 Self-limiting

11. Clinical features
 Sydenham’s chorea
 Milkmaid’s grip
 Spooning and pronation of hands when extended
 Wormian movements of tongue when protruded

12. Clinical features
 Erythema marginatum
 Early
 Rare (<3%)
 Starts as red spot with pale center
 Increase in size to coalesce with
adjacents spots to form
serpentiginous outline
 Faint red, not raised above the skin,
non pruritic
 Predominantly seen over trunks
 Evanescent

13. Diagnosis
 Modified Jones criteria
 Major criteria
 Carditis
 Arthritis
 Subcutaneous nodules
 Erythema marginatum
 Minor criteria
 Clinical
 Fever
 Arthralgia [in absence of
arthritis]
 Laboratory
 Raised ESR, CRP
 Prolonged PR interval
 Essential criteria
 Evidence of recent
streptococcal infection
 Elevated ASO titre
 Positive throat
culture

14. Diagnosis
 2 major criteria
OR
 1 major criteria and 2 minor criteria
AND
 Presence of recent streptococcal infection
 Exceptions
 Chorea
 Indolent carditis

15. Treatment
 Supportive treatment
 Bed rest
 Penicillin
 Procaine penicillin daily for 10 days
 Single dose of Benzathine penicillin
 Suppressive therapy
 Aspirin
 Steroids
 Prophylaxis

16. Treatment
 Aspirin or Steroids?
 Presence of carditis: STEROID
 Caridits without CCF: Steroids preferred
 Absence of steroids: Aspirin preferable
 Duration of suppressive therapy: 12 weeks

17. Prevention
 Primary prevention
 Identification of streptococcal pharyngitis and effective
treatment

18. Prevention
 Secondary prevention
 Benzathine penicillin 12 lakh units IM once every 3 weeks
 Erythromycin
 Penicillin V

19. Prevention
 Secondary prevention
 Duration
 No carditis: 5 years/18yrs of age, whichever is longer
 Mild to moderate carditis and healed carditis: 10 yrs/25 yrs of age,
whichever is longer
 Severe disease or post intervention patients: Life long [One may
opt for secondary prophylaxis up to the age of 40 years]

20. Querries