Rheumatic Fever and Rheumatic Heart Disease For Nursing Students Subject: Child Health Nursing

1. Rheumatic
Fever

2. Rheumatic Fever
• It is an inflammatory disease that occurs after infection with
Group A β- hemolytic streptococcal (GABHS) pharyngitis.
• Most common in late school- age children or adolescent.
• RF is a self-limited illness that involves the joints, skin, brain,
serous surfaces and heart.
• Cardiac valve damage is referred to as Rheumatic Heart Disease

3. Etiology
• Relationship between URTI with
GABHS leading to RF within 2 to 6
weeks.
• Acute RF is the result of an
exaggerated immune response to
bacteria.

4. Risk
factors
Poor socio-economic status
Over- crowding
Age
Climate and season
Upper respiratory tract infection
Previous history of Rheumatic fever

5. Diagnostic
Evaluation
• Diagnosis is based on guidelines
recommended by the American Heart
Association.
• The guideline is known as Modified Jones
Criteria
• Suspected children are tested for
streptococcal antibodies: Anti-
streptolysin O titer

6. ASO Titre
• Procedure that demonstrates the presence of
antibodies generated by the body against infection by
group A Streptococcus
• Checked for Tonsillitis and Rheumatic Fever
• The micro-organism produces toxin streptolysin O which
destroys RBCs
• The toxin is immunogenic, that body produces
antibodies against it.

7. Modified Jones Criteria, 1992
Major Criteria Minor Criteria
 Carditis  Hyperpyrexia
 Arthritis  Arthralgia, without other signs
of inflammation
 Chorea  Lab indicators of acute phase
 Erythema marginatum  ESR, CRP
 Subcutaneous nodules  Prolonged PR interval in ECG
Probability of RF: A. Two Major criteria B. One major criteria + two minor criteria

8. Revised Jones Criteria, 2015
Major Criteria
Low risk Population High risk population
 Carditis  Carditis
 Arthritis- only polyarthritis  Arthritis- monoarthritis or
polyarthritis
 Polyarthralgia
 Chorea  Chorea
 Erythema marginatum  Erythema Marginatum
 Subcutaneous nodule  Subcutaneous nodule
Cont……

9. Minor Criteria
Low risk population High risk population
 Polyarthralgia  Monoarthralgia
 Hyperpyrexia (> 101.5°F or 38.5°C )  Hyperpyexia (> 100.4°F or 38°C )
 ESR > 60 mm/h or CRP > 3.0 mg/dl  ESR > 30 mm/h or CRP > 3.0 mg/dl
 Prolonged PR interval (after taking
into account the age and if there is
no carditis)
 Prolonged PR interval (after taking
into account the age and if there is
no carditis)
Revised Jones Criteria, 2015

10. Population Risk
•A low risk population is one in which cases of
acute RF occur in ≤ 2/100 000 school-age
children or rheumatic heart disease is diagnosed
in ≤ 1/1000 patients at any age during one year

11. • Polyarthritis : Swollen, hot, red joints
• Polyarthralgia: Painful joints
• Large joints affected more: Knees,
Elbows, hips, ankles, shoulders, wrists

12. •Chorea:
Sudden aimless, irregular movements of extremities,
involuntary facial grimaces, speech disturbances

13. • Erythema Marginatum
- A rare skin rash that spreads on
trunks and limbs.
- The rash is round, with a pale-
pink center, surrounded by a slightly
raised red outline.

14. •Subcutaneous nodes:
- Non- tender
swelling
- Located over bony
prominences.

15. Therapeutic management
Goal:
1. Eradication of haemolytic streptococci
2. Prevention of permanent cardiac damage and arthritis
3. Supportive management & management of complications
4. Prevention of recurrence of RF

16. 1. Eradication of streptococci
Drug of Choice
- Benzathine Penicillin G
or
- Penicillin V
For individuals allergic to penicillin
- Erythromycin
or
- Ethyl succinate

17. 2. Anti- inflammatory treatment
Arthritis :
- Aspirin: 75 – 100 mg/kg/day as 4 divided doses for 6 weeks
Carditis :
- Prednisolone: 2 – 2.5 mg/kg/day, given as two divided doses for
2 weeks.
- Tapered after two weeks and add aspirin 75 mg/kg/day for 2
weeks
- Continue aspirin for two more weeks at 100 mg/kg/day

18. 3. Supportive management and management of
complications
- Bed rest
- Treatment of cardiac failure: digitalis, diuretics
- Treatment of Chorea: Diazepam or haloperidol
- Rest to joints and supportive splinting

19. 4. Prevention of recurrence of RF
Benzathine penicillin G
OR
Penicillin V
OR
Sulfadiazine
Individuals allergic to penicillin
Erythromycin

20. • Drug of choice:
- Penicillin
- Erythromycin (for penicillin sensitive)
- Salicylates ( to control inflammation) e.g. Aspirin
- Anti- pyretics
- Steroids
• Bed rest during the acute febrile phase
• Prophylactic treatment against recurrence is started after acute therapy
- Inj Benzathine Penicillin
- Penicillin orally
- Sulfadiazine
Prophylaxis is given for 5 years from last episode or age 18, longer with cardiac
involvement

21. Rheumatic Heart Disease
• Rheumatic heart disease is
a condition in which the
heart valves have been
permanently damaged
due to Rheumatic fever.
• The heart valve damage
may start shortly after
untreated or under-
treated streptococcal
infection such as strep
throat.
• An immune response
causes an inflammatory
condition in the body
resulting in valvular
damage of heart.

22. Pathophysiology
Infection by Group A Beta- Hemolytic
Streptococci
Untreated URTI with GABHS (Sore throat)
Rheumatic Fever: damage and invade human
tissue
All layers of heart and mitral valve become
inflamed

23. Colonizing of GABHS in heart- Vegetation
Valvular regurgitation and stenosis
Heart failure
Immune reaction

24. Vegetations

25. Symptoms:
Depend on
degree of valve
damage
Shortness of breath: with
activity or lying down
Chest pain
Swelling

26. Diagnosis
• Echocardiogram
• Electrocardiogram
• Chest X-ray
• Blood test
• Throat culture

27. Treatment
• Depends on how much damage has been done to the heart
valves:
• Severe cases: Replacement or repair of valve
• The best treatment is to prevent Rhematic fever by
Antibiotics
• Anti- inflammatory drugs to reduce inflammation and lower
risk of heart damage.

29. Nursing care management
Objective :
1. Encourage compliance with drug regimens
2. Facilitate recovery from illness
3. Provide emotional support
4. Prevention of disease

30. Nursing Diagnosis
• Acute pain related to joint pain when extremities are touched or moved.
• Activity intolerance related to carditis or arthralgia
• Risk for injury related to chorea
• Risk for non-compliance with prophylactic drug therapy related to financial
or emotional burden of lifelong therapy
• Deficient knowledge of parent related to the condition, need for long term
therapy and risk factors.