2. objective
At the end of the session
- Define rheumatic fever
- Explain the manifestation of rheumatic
fever
- discuss the management of rheumatic
fever
5/10/2023 By Tomas 2
3. Acute Rheumatic Fever
Indirect (non-suppurative)
complication of group A beta-hemolytic
streptococcal pharyngitis
Delayed immune response
Primarily affects the heart, CNS, joints
and the skin
Carditis is the only long-term
complication
All the others resolve
5/10/2023 By Tomas 3
4. Acute Rheumatic …
Acute rheumatic fever is the most
common cause of acquired heart
disease in children living in sub-
Saharan Africa and other 3rd world
countries.
Acute rheumatic fever is preventable
Prompt and proper treatment of
streptococcal pharyngitis can
eliminate the risk for acute rheumatic
fever.
Peak age for ARF is 5 – 15 years (rare
5/10/2023 By Tomas 4
5. Risk factors
Poverty, overcrowding and conditions
facilitating spread of gr.A streptococcal
pharyngitis.
Magnitude of the immune response to
the antecedent streptococcal pharyngitis.
Persistence of the organism during
convalescence.
Rheumatogenicity of gr.A strept strains.
Previous attack of rheumatic fever
5/10/2023 By Tomas 5
6. Major manifestations
1. Carditis (in 50 – 60% of patients)
Pancarditis (myocardium, endocardium and
pericardium).
The most specific manifestation of rheumatic
fever.
Cardiac murmur – most important manifestation.
Mitral and Aortic valvulitis and involvement of the
chordae of the mitral valve – most characteristic.
5/10/2023 By Tomas 6
7. Major manifestations
Mitral regurgitation – hallmark of
rheumatic carditis.
Involvement of the right side valves
(TV & PV) – less common.
2. Migratory polyarthritis (in about 75%
):
Most common major manifestation
but least specific.
Almost always asymmetrical and
migratory.
5/10/2023 By Tomas 7
8. Major manifestations
Larger joints (knees, ankles, elbows,
wrists).
Swelling, severe pain, redness, heat,
limitation and tenderness.
No permanent joint deformity.
Untreated – lasts 2 to 3weeks.
Dramatic response to salicylates
- hallmark
5/10/2023 By Tomas 8
9. Major manifestations
3. Sydenham's Chorea (involvement of
Basal ganglia & caudate nucleus)
In about 20% of patients with RF.
Delayed manifestation – usually 3mo
or longer.
Purposeless and involuntary
movements, muscle incoordination,
weakness and emotional liability.
May disappear with sleep.
5/10/2023 By Tomas 9
10. Major manifestations
4. Erythema marginatum:
In < 5% of cases.
Evanescent, erythematous, macular
nonpruritic rash with pale centers and
rounded or serpinginous margins.
Mostly trunk and proximal
extremities.
May be induced by application of
heat.
5/10/2023 By Tomas 10
11. Major manifestations
5. Subcutaneous nodules
In less than 3% of patients with RF.
Firm, painless, freely movable nodules (0.5 – 2cm in size).
Most often seen in patients with carditis.
Usually located over the extensor surfaces of the joints
(elbows, knees and wrists), in the occipital portion of the scalp,
or over the spinous processes.
5/10/2023 By Tomas 11
12. Diagnosis of acute rheumatic
fever
Modified Jones Criteria:
Major –
Carditis
Migratory polyarthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
5/10/2023 By Tomas 12
13. Modified Jones …
Minor criteria
Clinical findings
Arthralgia
Fever
Laboratory findings
Elevated acute phase reactants (ESR,
CRP).
Prolonged PR interval.
5/10/2023 By Tomas 13
14. Modified Jones …
Supporting evidence for antecedent
streptococcal pharyngitis:
Positive throat culture or rapid
streptococcal antigen test.
Elevated or rising streptococcal
antibody titer.
5/10/2023 By Tomas 14
15. Modified Jones …
Diagnosis made with:
2 major criteria or 1 major and 2
minor
+
Supporting evidence for antecedent
streptococcal pharyngitis (mandatory)
5/10/2023 By Tomas 15
16. Modified Jones …
Exceptions (strict adherence to Jones
criteria not needed):
1. Sydenham’s Chorea
2. Indolent Carditis
3. Rheumatic Fever recurrence
5/10/2023 By Tomas 16
17. Treatment of acute rheumatic
fever
General
Place on bed rest and monitor closely
for evidence of carditis.
Antibiotic treatment for 10 days with
oral penicillin or erythromycin or a
single IM dose of Benz. Penicillin.
Long-term antibiotic prophylaxis.
5/10/2023 By Tomas 17
18. Treatment of acute rheumatic
fever
Anti – rheumatic therapy:
Withheld anti-inflammatory treatment till full blown picture
of RF appears.
Pain relief – achieved by acetaminophen.
Migratory polyarthritis and carditis with out Cardiomegaly or
CHF → ASA 100mg/kg/24hr divided into 4 doses po for 3 – 5
days, then 75mg/kg/24hr for 4weeks.
5/10/2023 By Tomas 18
19. Treatment of acute rheumatic
fever
Carditis with cardiomegaly or CHF →
Prednisone 2mg/kg/24hr divided into
4 doses po for 2 – 3weeks. While
tapering prednisone start ASA
75mg/kg/24hr in 4 divided doses for
6weeks.
Supportive treatment.
5/10/2023 By Tomas 19
20. If Sydenham's chorea - Sedatives
phenobarbital (16-32 mg every 6-8 hr
PO) is the drug of choice. If
phenobarbital is ineffective, then
haloperidol (0.01-0.03 mg/kg/24 hr
divided bid PO) or chlorpromazine
(0.5 mg/kg every 4-6 hr PO) should be
initiated
5/10/2023 By Tomas 20
21. Prevention
I. Primary Prevention (prompt and proper
treatment of gr. A streptococcal pharyngitis)
after 9 days of pharyngitis episode.
Benz. Penicillin
weight ≤ 27kg→ 600,000IU IM stat.
weight > 27kg→ 1,200,000IU IM stat.
5/10/2023 By Tomas 21
