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Acute rheumatic fever

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Acute rheumatic fever

  1. 1. ACUTE RHEUMATIC FEVERDefinitionIntroductionPathogensisClinical featureDiagnosisInvestigationTreatment
  2. 2. • Definition: A multisystem disease resulting from an autoimmune rxn to infection with group A streptococcus.• RHD is the most common cause of heart disease in children in developing countries.
  3. 3. Epidemology• World wide 15-19million people affected.• Disease of children (5-14yrs)• Rare in adults especially >30yrs• Recurrence is more common in adults.• RHD peaks 25-40yrs
  4. 4. pathogenesis• Caused by infection of URTI with Group A streptococci .• Following this infection an autoimmune reaction results which lead to damage to human tissues as a result of cross reactivity between epitopes of the bacteria and host. (molecular mimicry)
  5. 5. Clinical features• Incubation period ~3 weeks (1-5 wks) after pharengitis• Fever• Migratory polyarthritis (60-75%)• Carditis (50-60%)• Chorea (2-30%)• Erythema marginatum rare <5%• Subcutaneous nodules
  6. 6. Carditis• 60% of patients with ARF progress to RHD• Endocardium,myocardium,pericardium• Valvular involvement is the hallmark.• Mitral valve is almost alwayes involved• MR>MR+AR>TR• Early in the course regurgitation is common then progresses to stenosis.
  7. 7. migratory polyarthritis• Must be – Arthritic( swollen,hot,red,tender) – Very painful – > one joint – Migratory over hours• Large joint (knee,ankle,hip,elbow)• Highly responsive to salicylates and NSAIDS
  8. 8. Chorea• AKA sydenhams chorea• Usually presents alone.• Choreiform movements could involve head (dart like movt of the tongue) upper limb.• Eventually resolves completely within 6wks.
  9. 9. Skin manifestations• Erythema marginatum• Subcutaneous nodules OTHER FEATURES-raised acute phase reactants (CRP,ESR)-prolonged PR interval.
  10. 10. diagnosis• No definitive test• Combination of typical clinical features and evidence of precipitating gp A steptococcal infection.• We use “JONES CRITERIA”• 2 major• 1 major+ 2minor
  11. 11. Major criteria• Carditis• Migratory polyarthritis• Sydenhams chorea• Subcutaneous nodules• Erythema marginatum
  12. 12. Minor• Fever > = 390c• Arthralgia• raised ESR/CRP• Prolonged PR (ECG)
  13. 13. OR ONLY• CHOREA• INDOLENT CARDITIS patients who come to medical attention months after the acute infection.
  14. 14. Evidence of preciding strept.infection–Raised ASO titer/anti DNase–Positive throat culture–Rapid Ag test–Recent scarlet fever
  15. 15. Investigation• WBC• ESR• CRP• BLOOD CULTURE• ECG,ECHO,CXR• SEROLOGY
  16. 16. TREATMENT• Nothing to prevent the development or severity of RHD.• Rx is symptomatic• Rx of heart failure• Penicillin G 1.2mill IM stat or pen V 500mg po BID for 10 days for all.• ASA or NSAIDS for arthritis• Steroids for sever carditis• Carbamazepin or valproate for chorea
  17. 17. prevention• Primary prevention – Reduction of major risk factors (over crowding,unhygenic conditions) – Complete and timely Rx of URTI single dose IM cry.pen or po for 10days Erythromycin for pen allergy.
  18. 18. Secondary prevention• To prevent rheumatic recurrence• Benz.pen 1.2 mill units IM every 4wks• Or pen V 250mg 2x /wk po• Erythromycin 2x/day• Duration of RX 1- no carditis -5yrs after 1st attack or upto 18yrs 2-with mild carditis-10yrs after 1st attack or upto 25yrs 3-severe valvular disease or valve surgery-lifelong
  19. 19. THANK YOU!

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