Acute rheumatic fever is a multisystem disease caused by an autoimmune reaction to a Group A streptococcal infection. It commonly affects children between 5-14 years old in developing countries. Symptoms include migratory polyarthritis, carditis, chorea, and skin manifestations. Diagnosis is based on clinical features and evidence of a preceding streptococcal infection. Treatment involves antibiotics to prevent recurrence and symptom relief. Ongoing antibiotic prophylaxis is also needed long-term to prevent recurrence, especially in those who develop cardiac involvement.

1. ACUTE RHEUMATIC FEVER
Definition
Introduction
Pathogensis
Clinical feature
Diagnosis
Investigation
Treatment

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. 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. 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. 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. 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. 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. 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. Skin manifestations
• Erythema marginatum
• Subcutaneous nodules
OTHER FEATURES
-raised acute phase reactants
(CRP,ESR)
-prolonged PR interval.

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. Major criteria
• Carditis
• Migratory polyarthritis
• Sydenhams chorea
• Subcutaneous nodules
• Erythema marginatum

12. Minor
• Fever > = 390c
• Arthralgia
• raised ESR/CRP
• Prolonged PR (ECG)

13. OR ONLY
• CHOREA
• INDOLENT CARDITIS
patients who come to medical attention
months after the acute infection.

14. Evidence of preciding strept.infection
–Raised ASO titer/anti DNase
–Positive throat culture
–Rapid Ag test
–Recent scarlet fever

15. Investigation
• WBC
• ESR
• CRP
• BLOOD CULTURE
• ECG,ECHO,CXR
• SEROLOGY

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. 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. 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. THANK YOU
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