2. • Rheumatic fever is an acute immunologically
mediated multi system inflammatory disease
that occur 1-4 weeks after an episode of sore
throat or pharyngitis by the rheumatogenic
strains 3,5,18,19,24 of group A beta hemolytic
streptococcus.
• It affects heart, joints and skin.
3. Aetio-pathogenesis
• After pharyngeal infection with group A beta
haemolytic streptococcus,an antibody is
produced against the M protien of the
streptococcus,which has a antigens similar to
those in heart and other tissues so,the
antibody produced against bacterial
antigen(M protien)cross reacts with heart and
other tissues.
4. Clinical features
• Children usually between 5-15yrs having a
history of sore throat 2 to3 weeks back
present with :
-fever,anorexia,lethargy and joint pain.
5. Dr. T. Duckett Jones Criteria
• Major criteria
• Polyarthritis: A temporary migrating inflammation of the large joints, usually
starting in the legs and migrating upwards.
• Carditis: Inflammation of the heart muscle (myocarditis) which can manifest
as congestive heart failure with shortness of breath, pericarditis with a rub, or a
new heart murmur.
• Subcutaneous nodules: Painless, firm collections of collagen fibers over bones
or tendons. They commonly appear on the back of the wrist, the outside elbow,
and the front of the knees.
• Erythema marginatum: A long-lasting reddish rash that begins on the trunk or
arms as macules, which spread outward and clear in the middle to form rings,
which continue to spread and coalesce with other rings, ultimately taking on a
snake-like appearance. This rash typically spares the face and is made worse with
heat.
• Sydenham's chorea (St. Vitus' dance): A characteristic series of rapid movements
without purpose of the face and arms. This can occur very late in the disease for at
least three months from onset of infection.
7. • Minor criteria
• Fever of 38.2–38.9 °C (100.8–102.0 °F)
• Arthralgia: Joint pain without swelling (Cannot be
included if polyarthritis is present as a major symptom)
• Raised erythrocyte sedimentation rate or C reactive
protein
• Leukocytosis
• ECG showing features of heart block, such as a
prolonged PR interval
• Previous episode of rheumatic fever or inactive heart
disease
8. • Essential criteria:
a. Evidence of recent streptococcal infection as
indicated by:
-recent scarlet fever
-raised antistreptolysin O or other streptococcal
Ab.
-positive throat culture.
9. • For diagnosis of rheumatic fever:
-2 or more major criteria or
- 1 major criteria and 2 or more minor criteria
+
evidence of preceding streptococcal
infection……….
10. Management of acute rheumatic fever
Investigation in acute rheumatic fever
a) Evidence of a systemic infections:
-leucocytosis
-raised C-reactive protien
-raised ESR
b)Evidence of preceding streptococcal infections:
-throat swab culture : Group A beta haemolytic
streptococci
-antistreptolysin “O “ antibodies (ASO titers)rising titers
or level of > 200 units(adult) or >300 units(children)
11. c) Evidence carditis:
Chest Xray: cardiomegaly,pulmonary congestion
ECG : PR interval prolonged
T wave inversion
reduction in QRS voltage
Echocardiography: cardiac dilatation and valve
abnormalities.
12. Treatment
A) Symptomatic and supportive treatment:
I. Bed rest : till acute phase subsides(ESR,CRP
become normal).
II. Arthritis : aspirin 100 mg/kg/day for 2 weeks
and 75mg/kg/day for 4-6 weeks or till the
activity of disease subsides(ESR becomes
normal ) in 6 divided doses.
III. Carditis or arthritis if not responds to Aspirin:
13. • Prednisolone 1-2 mg/kg/day in 4 divided doses
for 2 weeks and gradually taper by another 2
weeks.
• Aspirin 75 mg/kg/day in 6 divided dose when
prednisolone is started or taper.
iv) Chorea : diazepam for mild chorea & haloperidol
(0.5-2mg every 8 hr) for severe chorea.
v) Treatment of heart failure and other
complication.
14. B) Antistreptococcal therapy :
Penicillin:
penicillin V 250 mg 6hrly for 10 days, or single IM inj.
Benzathinepenicillin G(6 lakhsfor children <60 lb & 12 lakhs
for children >60 lb).
- Erythromycin 40mg/kg/day or 1st generation
cephalosporin's may be used for 10 days in patientswho are
allergic to penicillin.
15. C. Preventionof rheumaticfever :
I. Primary prevention : prevention before occurrence of
rheumaticfever by early identificationand treatmentof
streptococcal throat infectionwith penicillin.
16. ii)Secondary prevention: preventionofrecurrenceofrheumatic feverafterthe
patienthad manifestation ofrheumatic feveronce. Itis done mainly toprevent
cardiac involvementand furthervalve destruction than before.
Inj.benzathine peniciilin 12 lack unit i.m every 3 weeks for
5 years or upto the age of 18 yrs whichever is longer
according to WHO criteria.If the weight is less than 30
kg,Benzathine peniciliin 6 lack unit should be given.
oral penicillin v 125-250 mg
Alternative to penicillin
Sulfadizine 1 gm daily
erythromycin 250 mg PO BD
