Topic for BAMS

2. RHEUMATIC FEVER
•Definition And Overview
•Etiology
•Signs And Symptoms
•Epidemiology
•Pathogenesis
•Diagnosis
•Complications
•Investigations
•Management

3. Definition And Overview
Rheumatic fever is an inflammatory disease that can develop as a complication
of inadequately treated strep throat or scarlet fever. Strep throat and scarlet
fever are caused by an infection with streptococcus bacteria.
Rheumatic fever can cause permanent damage to the heart, including
damaged heart valves and heart failure. Treatments can reduce damage from
inflammation, lesion pain and other symptoms, and prevent the recurrence of
rheumatic fever.
Etiology
Rheumatic fever is a systemic disease affecting the connective tissue around
arterioles, and can occur after an untreated strep throat infection, specifically
due to group A streptococcus (GAS). It is believed to be caused by antibody
cross-reactivity.

4. Signs And Symptoms
The onset of rheumatic fever usually occurs about two to four
weeks after a strep throat infection which result from
inflammation in the heart, joints, skin or central nervous system
—can include:
•Fever
•Arthritis-Painful and tender joints most often in the knees,
ankles, elbows and wrists.
•Pain in one joint that migrates to another joint.
•Red, hot or swollen joints.
•Subcutaneous Nodules-Small, painless bumps (nodules)
beneath the skin.
•Carditis-Chest pain, heart murmur, fatigue, repiratory distress.
•Erythema Marginatum- Flat or slightly raised, painless rash
with a ragged edge.
•Sydenham’s Chorea-Jerky, uncontrollable body movement
most often in the hands, feet and face.

5. Rheumatic Fever
Repeated GAS infection
• Chronic Heart Valve damage
• Treatment = Surgery
Recurrent Acute Rheumatic
Fever
• Rheumatic Heart Disease
• Fatal if unrepaired.

6. Epidemiology
•15.6 million people affted worldwide.
•Among them, 2.4 million are children (age 5-15 years)
.
Risk Factors
•Overcrowding and poor housing standards.
•Reduced access to healthcare.
•Living in tropical climates.

7. Pathogenesis
Sequel of untreated/inadequately treated group A streptococcus(GAS)
infections. Streptococcus pyogenes.
↓
It is caused by antibody cross-reactivity. This cross-reactivity is a type II
hypersensitivity reaction and is termed molecular mimicry.
↓
During a streptococcal infection, mature antigen-presenting cells such as B cells
present the bacterial antigen to CD4+T cells which differentiate into helper T cells.
↓
Helper T cells subsequently activate the B cells to become plasma cells and induce
the production of antibodies against the cell wall of Streptococcus.
↓
However the antibodies may also react against the myocardium and
joints, producing the symptoms of rheumatic fever.
↓
Streptococcus pyogenes has a cell wall composed of branched polymers which
contain M protein, a virulence factor that is highly antigenic.
↓
The antibodies which the immune system generates against the M protein may
cross-react with heart muscle cell protein myosin, heart muscle glycogen and smooth
muscle cells of arteries, inducing cytokine release and tissue destruction.

8. Diagnosis
Jone’s Criteria
Major Criteria
• Joints(Arthritis)
• Carditis
• Subcutaneous Nodules
• Erythema Marginatum
• Sydenham’s Chorea
Minor Criteria
• Fever
• Arthralgia
• Prolonged PR Interval on
ECG
• Increased ESR or CRP

9. Arthritis

10. Subcutaneous Nodules

11. Erythema Marginatum

12. Sydenham’s Chorea

13. Complications
Inflammation caused by rheumatic fever can last a few weeks to several months. In some
cases, the inflammation causes long-term complications.
Rheumatic heart disease is permanent damage to the heart caused by rheumatic fever. It
usually occurs 10 to 20 years after the original illness. Problems are most common with
the valve between the two left chambers of the heart (mitral valve), but the other valves
can be affected. The damage can result in:
•Valve Stenosis- This narrowing of the valve decreases blood flow.
•Valve Regurgitation- This leak in the valve allows blood to flow in the wrong direction.
•Damage to heart muscle- The inflammation associated with rheumatic fever can weaken
the heart muscle, affecting its ability to pump.
Damage to the mitral valve, other heart valves or other heart tissues can cause problems
with the heart later in life. Resulting conditions can include:
•An irregular and chaotic beating of the upper chambers of the heart (Atrial Fibrillation).
•An inability of the heart to pump enough blood to the body (Heart Failure).

14. Investigations
Lab
Investigations
Diagnostic
Imaging
Other
 CBC
 ESR
 CRP
 Blood
Cultures
 ASO titer
 Anti-DNase B
 Throat Swab
 Chest X-Ray
 Echocardiogra
m
 ECG

15. Managements
•Inpatient admission.
• Education to prevent further episodes.
•Baseline echocardiogram to examine the heart valve status.
•Regular secondary medication prophylaxis.
•Routine medical checkups.
•Routine dental checkups.
•Echocardiogram following each episodes of ARF.

16. Lymph Node Examination
• The lymphatic system has two main functions: to return
extracellular fluid back to the venous circulation and to
expose antigenic substances to the immune system.
• As the collected fluid passes through lymphatic channels on
its way back to the systemic circulation, it encounters
multiple nodes consisting of highly concentrated clusters of
lymphocytes.
• Only nodes near the surface can be inspected or palpated.
Lymph nodes are normally invisible, and smaller nodes are
also non-palpable.
• However, larger nodes (>1 cm) in the neck, axillae , and
inguinal areas are often detectable as soft, smooth,
movable, non-tender, bean-shaped masses imbedded in
subcutaneous tissue.

17. Procedure
Because lymph nodes are distributed throughout the body,
their evaluation usually takes place as part of the regional
examinations of the head and neck, breast and axillae ,
upper extremities, external genitalia, and/or lower
extremities.
Lymph Nodes of the Head and Neck
With the patient's neck flexed slightly forward, inspect
for noticeably visible node enlargement.
For each of the following steps, plan to palpate the head
and neck nodes with both hands, one on each side. In
many cases, the nodes are not palpable.
Palpate the preauricular, posterior auricular, and
mastoid nodes in front of the ear, behind the ear, and
superficial to the mastoid process, respectively.
Palpate the occipital nodes posteriorly at the base of the
skull.

18. Palpate the tonsillar nodes located at the angle of
mandible, the submandibular nodes midway between the
angle and tip, and the submental nodes a few centimeters
from the tip. Note that submandibular nodes need to be
distinguished from the underlying submandibular gland,
which is larger and lobulated.
Palpate the anterior and superficial cervical nodes in
front of and overlying the sternomastoid muscle,
respectively. Deep cervical nodes, beneath the
sternomastoid muscle, are rarely palpable.
Palpate the posterior cervical nodes between the
anterior edge of the trapezius and posterior edge of the
sternomastoid.
Palpate the supraclavicular nodes deep within the angle
formed by the sternomastoid muscle and clavicle.
Palpate the infraclavicular nodes on the underside of the
clavicle.

19. Lymph Node Of Head and Neck

20. Axillary Lymph Nodes
Three groups of axillary nodes - brachial, subscapular, and pectoral -
drain their lymph into the central axillary nodes that lay deep within
axilla against the chest wall about midway between the anterior and
posterior axillary folds. These nodes, in turn, drain into the
infraclavicular (apical) and supraclavicular nodes. Of the four axillary
groups, only the central nodes are usually palpable.
To examine the left axillary nodes, stand in front and to the left of the
seated patient, supporting the patient's relaxed left arm at the wrist or
elbow.
Inform the patient that the exam may feel slightly uncomfortable.
Reach your right hand up high in the left axilla, just behind the
pectoralis muscle, with fingers pointing toward the mid-clavicle. Press
your fingers against the chest wall, and slide them downward to feel the
central nodes.
If not done yet, palpate the infraclavicular (apical) and supraclavicular
nodes.

21. While still supporting the patient's left arm, palpate the epitrochlear
nodes, which are located medially about 3 cm above the elbow.
Repeat steps 2.1 - 2.5 for the patient's right axilla and upper extremity
using your left hand.
Axillary Lymph Nodes

22. Superficial inguinal lymph nodes
These nodes are located high in the anterior thigh and drain various
regions of the legs, abdomen, and perineum. These nodes are often
large enough to palpate, even when normal.
Have the patient lay supine with hips fully extended or slightly
flexed.
Palpate a horizontal group of nodes along and just inferior to the
inguinal ligament. These nodes drain the superficial buttock and
lower abdomen, external genitalia (excluding the testes), lower
vagina, anal canal, and perianal area.
Palpate a vertical group of nodes medial to the horizontal group just
inferior to the femoral artery pulse. These nodes lie along the upper
saphenous vein and drain the same regions of the lower extremities.

23. Superficial Inguinal Lymph Nodes