Rheumatic Fever

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Rheumatic Fever

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Rheumatic Fever

  1. 1. DEPARTMENT OF PEDIATRICS SACRED HEART HOSPITAL CEBU CITY
  2. 2. <ul><li>A case of C.K., 4 y.o , male, child, Filipino, Roman Catholic , from Tisa, Cebu City, admitted for the first time at SHH due to fever and joint pain. </li></ul>
  3. 3. Prenatal History <ul><ul><li>Prenatal check up at 4 months AOG </li></ul></ul><ul><ul><li>Regular , by OB Gyne , no maternal illness noted at time of pregnancy </li></ul></ul><ul><ul><li>Multivitamins and Ferrous Sulfate was taken with good compliance </li></ul></ul><ul><ul><li>Delivered via NSD , good cry , no complications </li></ul></ul>
  4. 4. Nutritional History <ul><ul><li>Breastfeeding from birth until 3 months </li></ul></ul><ul><ul><li>Formula Feeding: (Nestogen) 3 months to 1y.o. and 2 months (1:1 dilution) </li></ul></ul><ul><ul><li>semi solid foods at 4 months </li></ul></ul><ul><ul><li>Solid foods at 6 months </li></ul></ul>
  5. 5. Immunizations <ul><ul><li>BCG </li></ul></ul><ul><ul><li>DPT/OPV 3 doses </li></ul></ul><ul><ul><li>Hep B 3 doses </li></ul></ul><ul><ul><li>Measles </li></ul></ul>
  6. 6. <ul><li>Developmental History </li></ul><ul><ul><li>2months: social smile </li></ul></ul><ul><ul><li>4 months : roll over </li></ul></ul><ul><ul><li>7 months: sit with support , recognize familiar faces </li></ul></ul><ul><ul><li>1 y.o.: stands alone </li></ul></ul><ul><ul><li>2 y.o.: runs well </li></ul></ul>
  7. 7. Past Medical History / Family History <ul><ul><li>No previous hospitalization </li></ul></ul><ul><ul><li>No surgical procedure done </li></ul></ul><ul><ul><li>( - ) DM </li></ul></ul><ul><ul><li>( - ) HPN </li></ul></ul><ul><ul><li>( - ) Cancer </li></ul></ul><ul><ul><li>( -) Asthma </li></ul></ul>
  8. 8. Personal & Social History <ul><ul><li>Kindergarten-2 pupil </li></ul></ul><ul><ul><li>Lives with his parents </li></ul></ul><ul><ul><li>Playful , cooperative </li></ul></ul><ul><ul><li>No other member of the family noted to have the same health problem </li></ul></ul>
  9. 9. HPI: <ul><li>2 weeks PTA , fever ( 38 – 39c ). </li></ul><ul><li>Relieved by Paracetamol (AD:14.2 MKd). </li></ul><ul><li>Associated with pain on swallowing </li></ul><ul><li>No consult done. Condition was tolerated. </li></ul><ul><li>Fever subsided after 3 days. </li></ul>
  10. 10. <ul><li>1 week PTA , fever recurred, associated with minimal swelling of the ankle then on the next day on the knee. </li></ul><ul><li>Limitation of movement of the area was noted </li></ul><ul><li>Consult to a private physician, Ibuprofen P.O. (AD:11.3) was given with relief. </li></ul>
  11. 11. <ul><li>Recurrence of swelling and pain of the joint prompted consult at CCMC </li></ul><ul><li>CBC showed leukocytosis </li></ul><ul><li>Urinalysis showed unremarkable result </li></ul><ul><li>ASO showed elevated result </li></ul><ul><li>advised admission but opted to transfer here </li></ul>
  12. 12. <ul><li>Physical Exam </li></ul><ul><ul><li>Conscious , coherent , cooperative , NIRD </li></ul></ul><ul><ul><li>Vital signs: </li></ul></ul><ul><ul><li>BP: 90/60 HR: 98 bpm </li></ul></ul><ul><ul><li>RR: 28 cpm Temp: 37.1 c </li></ul></ul><ul><ul><li>Wt: 17.6 kgs </li></ul></ul>
  13. 13. <ul><li>Skin : warm , good turgor , no rashes </li></ul><ul><li>HEENT : anicteric sclera , pinkish palpebral conjunctiva , no discharges, moist lips and tongue , no tonsillopharyngeal congestion , no lymph node enlargement </li></ul>
  14. 14. <ul><li>Chest and Lungs : Equal chest expansion, no retractions , clear breath sounds </li></ul><ul><li>Heart : Normal rate , regular rhythm , apex beat at 5 th intercostal space midclavicular line , distinct heart sound, no murmur </li></ul><ul><li>Abdomen : flat , normoactive bowel sounds , soft , non tender , no organomegaly </li></ul>
  15. 15. <ul><li>Genitalia : grossly male , no lesions , no discharges </li></ul><ul><li>Rectal : patent , no lesions, no mass </li></ul><ul><li>Extremities : swelling of both ankles noted, with redness of the swollen area, with slight limitation of movement, strong pulses, CRT < 2 sec </li></ul>
  16. 16. Neurologic Exam : <ul><li>Conscious , coherent , cooperative , not irritable </li></ul><ul><li>Motor : 5/5 , full resistance with gravity </li></ul><ul><li>no atrophy , non spastic , non flaccid , with spontaneous movement </li></ul><ul><li>Sensory : intact , ( + ) response to pain and touch </li></ul>
  17. 17. Cranial Nerves <ul><li>CN 1 intact </li></ul><ul><li>CN 2 PERL </li></ul><ul><li>CN 3,4,6 EOM no limitation </li></ul><ul><li>CN 5 + corneal reflex </li></ul><ul><li>CN 7 no facial asymmetry </li></ul>
  18. 18. <ul><ul><ul><ul><li> CN 8 able to hear spoken words </li></ul></ul></ul></ul><ul><ul><ul><ul><li> CN 9 , 10 uvula at midline , + gag reflex </li></ul></ul></ul></ul><ul><ul><ul><ul><li> CN 11 able to shrug shoulders , turns head from side to side </li></ul></ul></ul></ul><ul><ul><ul><ul><li> CN 12 tongue at midline </li></ul></ul></ul></ul>
  19. 19. <ul><ul><li>DTR : 2 + </li></ul></ul><ul><ul><li> ( - ) Babinski reflex </li></ul></ul><ul><ul><li> ( - ) nystagmus </li></ul></ul><ul><ul><li> no ankle clonus </li></ul></ul><ul><ul><li>Meningeals : ( - ) nuchal rigidity </li></ul></ul>
  20. 20. <ul><li>Impression : Rheumatic Fever vs. JRA </li></ul>
  21. 21. Salient Features <ul><li>4 years old </li></ul><ul><li>Fever 2 weeks PTA </li></ul><ul><li>swelling of the joints at ankle and knee </li></ul><ul><li>Redness of the swollen joints </li></ul><ul><li>slight limitation of movement of joints </li></ul><ul><li>Leukocytosis(CBC) </li></ul><ul><li>ASO showed elevated result </li></ul><ul><li>ESR was also elevated </li></ul>
  22. 22. <ul><li>Differential Diagnosis </li></ul>
  23. 23. 1) Rheumatic fever <ul><li>RULE IN: </li></ul><ul><li>Joint tenderness </li></ul><ul><li>Fever 2 weeks PTA </li></ul><ul><li>Migratory polyarthritis </li></ul><ul><li>Rash was noted near the swollen joints </li></ul><ul><li>Leukocytosis(CBC) </li></ul><ul><li>ASO showed elevated result </li></ul><ul><li>Elevated ESR </li></ul>
  24. 24. 1) Rheumatic fever <ul><li>RULE OUT: cannot be totally ruled out </li></ul>
  25. 25. 2) Post-streptococcal Reactive Arthritis <ul><li>RULE IN: </li></ul><ul><li>Had history of fever </li></ul><ul><li>May follow infection with either group A or group G Streptococcus </li></ul><ul><li>arthralgia and joint swelling are transient, usually lasting less than 6 wk . </li></ul><ul><li>Leukocytosis(CBC) </li></ul><ul><li>ASO showed elevated result </li></ul>
  26. 26. 2) Post-streptococcal Reactive Arthritis <ul><li>RULE OUT: </li></ul><ul><li>Patient had migrating polyarthritis </li></ul><ul><li>diagnosis of reactive postinfectious arthritis is usually established by exclusion only after the arthritis has resolved </li></ul><ul><li>No urethritis and conjunctivitis noted </li></ul>
  27. 27. 3) JUVENILE RHEUMATOID ARTHRITIS <ul><li>RULE IN: </li></ul><ul><li>Age at onset <16 yr (4yo) </li></ul><ul><li>Arthritis in one or more joints </li></ul><ul><li>predominantly affects the joints of the lower extremities, such as the knees and ankle </li></ul><ul><li>Had history of fever </li></ul><ul><li>Elevated (ESR) </li></ul>
  28. 28. 3) JUVENILE RHEUMATOID ARTHRITIS <ul><li>RULE OUT: </li></ul><ul><li>Duration of disease 6 wk or longer (2 weeks duration only) </li></ul><ul><li>Arthritis of JRA is not migratory </li></ul><ul><li>No evanescent erythematous, macular rash most commonly over the trunk and proximal extremities noted </li></ul>
  29. 29. 4) Henoch-Schönlein Purpura <ul><li>RULE IN: </li></ul><ul><li>follows an upper respiratory tract infection </li></ul><ul><li>more frequent in children than adults ( 2–8 yo.) </li></ul><ul><li>had elevated (ASO) antibodies , - group A Streptococcus </li></ul><ul><li>Low-grade fever </li></ul><ul><li>Arthritis localized to the knees and ankles and appears to be concomitant with edema </li></ul><ul><li>Elevated (ESR) </li></ul>
  30. 30. 4) Henoch-Schönlein Purpura <ul><li>RULE OUT: </li></ul><ul><li>No pinkish maculopapular rash that initially blanch on pressure and progress to petechiae or palpable purpura noted </li></ul><ul><li>No intermittent abdominal pain that is often colicky in nature noted </li></ul><ul><li>Arthritis is not migratory </li></ul>
  31. 31. Course in the Ward <ul><li>On Admission </li></ul><ul><ul><li>IVF at Maintenance rate </li></ul></ul><ul><ul><li>Ibuprofen q 6 hours ( AD 9 MKd ) </li></ul></ul><ul><ul><li>Labs </li></ul></ul><ul><ul><li>CBC : Wbc 10 </li></ul></ul><ul><ul><li>Neu 61.4 % </li></ul></ul><ul><ul><li> Lym 28.9 % </li></ul></ul><ul><ul><li> Hgb 9.85 (11.5 – 15.5) </li></ul></ul><ul><ul><li>Hct 29.1 (35 – 45%) </li></ul></ul><ul><ul><li>Plt 327 </li></ul></ul><ul><ul><li> </li></ul></ul>
  32. 32. <ul><ul><ul><li>Urinalysis : </li></ul></ul></ul><ul><ul><ul><li> Sp gr: 1.005 </li></ul></ul></ul><ul><ul><ul><li>Ph 6.0 </li></ul></ul></ul><ul><ul><ul><li>WBC 0-1 </li></ul></ul></ul><ul><ul><ul><li>RBC 0-1 </li></ul></ul></ul><ul><ul><ul><li>Epithelial cells – rare </li></ul></ul></ul><ul><ul><ul><li>Bacteria – few </li></ul></ul></ul><ul><ul><ul><li>Mucus threads – few </li></ul></ul></ul><ul><ul><ul><li>Amorphous urates - few </li></ul></ul></ul>
  33. 33. <ul><li>ESR : Result 125 mm </li></ul><ul><li>reference range : 0 -15 </li></ul><ul><li>ASO : Result 400 IU/ml </li></ul><ul><li>reference range :< 200 </li></ul><ul><li>CXR: later revealed Right Basal Pneumonitis </li></ul>
  34. 34. 1 St Hospital Day <ul><ul><li>BP 90/60 HR 94 RR 28 Temp 37.8 – 38c </li></ul></ul><ul><ul><li>Referred to Pedia Cardiologist: </li></ul></ul><ul><ul><li>Impression : Post – streptococcal reactive arthritis </li></ul></ul><ul><ul><li>Suggested: anti inflammatory dose of aspirin </li></ul></ul><ul><ul><li>Aspirin 80 mg q 8hrs ( AD 54.5 mkd ) </li></ul></ul>
  35. 35. 2 Nd Hospital Day <ul><li> BP: 90/60 HR: 96 </li></ul><ul><li> RR: 26 Temp: 38 - 39c </li></ul><ul><li>- no swelling of joints (ankle) noted </li></ul><ul><li>- Phenoxymethylpenicillin ( AD 50 mkd ) </li></ul><ul><li>- Referred to Rheumatologist </li></ul>
  36. 36. 3 RD Hospital Day <ul><li>BP 90/60 HR 96 </li></ul><ul><li>RR 26 temp 36.5 - 38c </li></ul><ul><li>Pedia Cardio out of service </li></ul>
  37. 37. 4 TH Hospital Day <ul><li>BP 90/ 60 HR 98 RR 28 Temp:36.4 – 38.1 </li></ul><ul><li>Seen by an Adult Rheumatologist: </li></ul><ul><li>Impression : Post – streptococcal arthritis </li></ul><ul><li>Suggested: continue phenoxymethylpenicillin </li></ul><ul><li>Aspirin at 50 – 100 mkd for 2 weeks </li></ul><ul><li>Repeat CBC , ESR and ASO after 2 weeks </li></ul>
  38. 38. 5 TH Hospital Day <ul><li>Discharged Improved </li></ul><ul><li>THM : Phenoxymethylpenicillin </li></ul><ul><li> Aspirin ( 54.5 mkd ) for 13 days more </li></ul><ul><li>Follow up at AP’s clinic after 2 weeks (CBC, ESR, ASOT ) </li></ul>
  39. 39. Final Diagnosis: <ul><li>Rheumatic Fever: </li></ul><ul><li>Is a multisystem inflammatory disease that occurs as a delayed sequel to a group A streptococcal infection : </li></ul><ul><li>• Throat </li></ul><ul><li>• Skin </li></ul><ul><li>• Results in inflammation of: </li></ul><ul><li>• Heart - Carditis </li></ul><ul><li>• Skin - Erythema marginatum </li></ul><ul><li>• Brain - Chorea </li></ul><ul><li>• Joints - Polyarthritis / arthralgia </li></ul>
  40. 40. <ul><li>most often occurs in children between 5 and 15 years. </li></ul><ul><li>Epidemiologic risk factors include: </li></ul><ul><li>Lower standards of living (crowding) </li></ul><ul><li>More common among socially and economically disadvantaged populations. </li></ul>
  41. 41. Pathogenesis: <ul><li>cytotoxicity theory </li></ul><ul><li>GAS produces several enzymes that are cytotoxic for mammalian cardiac cells. For example, streptolysin O has a direct cytotoxic effect on mammalian cells in tissue culture. </li></ul>
  42. 42. <ul><li>immunologic theory </li></ul><ul><li>clinical similarity of acute rheumatic fever to other illnesses produced by immunopathogenic processes and by the latent period between the group A streptococcal infection and the acute rheumatic fever. </li></ul>
  43. 43. Diagnosis <ul><li>Revised Jones Criteria for Acute Rheumatic Fever: </li></ul><ul><li>Major Criteria: </li></ul><ul><li>Polyarthritis </li></ul><ul><li>Minor Criteria: </li></ul><ul><li>Arthralgia </li></ul><ul><li>Fever </li></ul><ul><li>Leukocytosis/ elevated ESR </li></ul>
  44. 44. Treatment <ul><li>two necessary therapeutic approaches to patients with acute rheumatic fever: </li></ul><ul><li>anti-streptococcal antibiotic therapy </li></ul><ul><li>therapy for the clinical manifestations of the disease </li></ul>
  45. 45. <ul><li>Bedrest </li></ul><ul><li>Close monitoring for evidence of carditis </li></ul><ul><li>Antibiotic Therapy: </li></ul><ul><li>10 days Oral Penicillin/ Erythromycin </li></ul><ul><li>Single Dose IM Benzathine Penicillin </li></ul>
  46. 46. Anti-inflammatory Therapy <ul><li>Migratory polyarthritis + carditis ( w/o cardiomegaly or CHF): </li></ul><ul><li>- Aspirin (100 mg/kg/day) QID PO for 3-5 days, followed by 75mg/kg/day QID PO for 4 weeks </li></ul>
  47. 47. <ul><li>Carditis + cardiomegaly/ CHF: </li></ul><ul><li>Prednisone 2 mg/kg/day QID for 2-3 weeks followed by a tapering of the dose that reduces the dose by 5 mg/24 hrs every 2-3 days </li></ul><ul><li>At the beginning of tapering of prednisone dose, Aspirin should be started at 75mg/kg/day QID for 6 weeks </li></ul>
  48. 48. <ul><li>Sydenham’s Chorea – not seen in our patient </li></ul><ul><li>- Phenobarbital 16-32 mg/kg, q6 – 8 hrs PO </li></ul><ul><li>- Haloperidol > if Phenobarbital is not effective </li></ul><ul><li>> 0.01 - 0.03 mg/kg/24hrs BID PO </li></ul><ul><li>- Chlorpromazine > 0.5 mg/kg q 4 -6 hrs PO </li></ul>
  49. 49. Complications: <ul><li>Arthritis and chorea of resolve completely without sequelae. </li></ul><ul><li>Long-term sequelae are usually limited to the heart </li></ul><ul><li>Infective Endocarditis : those w/ cardiac valvular disease due to RF are at increased risk during episodes of transient bacteremia. </li></ul>
  50. 50. Prevention <ul><li>PRIMARY PREVENTION. </li></ul><ul><li>Antibiotic therapy instituted before the 9th day of symptoms of acute group A streptococcal pharyngitis - highly effective in preventing first attacks of acute rheumatic fever from that episode. </li></ul>
  51. 51. Secondary prevention <ul><li>To prevent acute GAS pharyngitis in patients at substantial risk of recurrent acute rheumatic fever </li></ul><ul><li>No carditis in initial episode of acute rheumatic fever have low risk of carditis with recurrences. </li></ul><ul><li>Antibiotic prophylaxis may be discontinued when they reach their early 20s and after at least 5 yr have elapsed since their last episode of acute rheumatic fever </li></ul>
  52. 52. Secondary Prevention <ul><li>Regimen of choice: </li></ul><ul><li>Single IM of Benzathine penicillin G (1.2 million IU) every 4 wk </li></ul><ul><li>Compliant Pt: Penicillin V BID PO and Sulfadiazine OD PO </li></ul><ul><li>Pt allergic to penicillin and sulfonamides: erythromycin BID may be used </li></ul>
  53. 53. Thank You

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