This document discusses rheumatic fever in children. It provides an overview of the incidence and prevalence of rheumatic fever worldwide and in Nepal. It describes the pathogenesis of rheumatic fever as an autoimmune response to Group A streptococcal infection. The document outlines the criteria for diagnosing rheumatic fever, including Jones criteria and WHO criteria. It also discusses treatment approaches such as aspirin to suppress inflammation.
Rheumatic fever is an autoimmune reaction that can occur following a streptococcal throat infection. It is characterized by inflammation of the heart, joints, skin, and brain. The document discusses the definition, etiology, epidemiology, pathogenesis, clinical features including carditis, arthritis, chorea and others, diagnosis, treatment and prognosis of rheumatic fever in detail across multiple pages. It provides diagrams and images to illustrate concepts like the structure of group A streptococcus and changes in heart valves that occur in rheumatic heart disease.
Myocarditis is an inflammation of the heart muscle that is most commonly caused by viral infections in children. Symptoms can range from mild to severe and include fatigue, chest pain, palpitations, and signs of heart failure like shortness of breath. Diagnosis is challenging as symptoms are often subtle, but can involve electrocardiograms, echocardiograms, cardiac MRI, and endomyocardial biopsy. Treatment is supportive with medications for heart failure, though immunoglobulin therapy may help in some cases of proven viral infection. Prognosis depends on age and severity of symptoms, with poorer outcomes more common in newborns and those with more severe heart failure.
This document discusses heart failure in children, including its definition, types, causes, symptoms, diagnosis, complications, and management. Heart failure occurs when the heart cannot pump enough blood to meet the body's needs. In children, common causes include congenital heart disease, rheumatic heart disease, and cardiomyopathy. Symptoms vary by age but may include feeding issues, sweating, poor growth, and edema. Diagnosis involves exams, chest x-rays, electrocardiograms, and echocardiograms. Complications can include arrhythmias, infections, and damage to other organs. Treatment focuses on supportive care, medications to improve heart function, and treating the underlying cause. Prognosis depends on the cause,
Rheumatic fever is an autoimmune disease that affects the heart, joints, skin, and brain. It occurs as a result of a streptococcal throat infection and abnormal immune response in genetically susceptible individuals. The disease is most common in children aged 5-15 years from developing countries. It can lead to long term heart complications such as rheumatic heart disease if untreated. Prevention involves proper treatment of streptococcal infections with antibiotics.
This document outlines a presidential action plan for infectious endocarditis in children. It begins with definitions of infective endocarditis and discusses the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prevention. Key points include that infective endocarditis is less common in children than adults but is increasing in those with cardiac surgery or conditions. Common causes are streptococcal and staphylococcal species. Clinical features may include fever, heart murmur and embolic phenomena. Echocardiography is important for diagnosis but blood cultures are also needed under the modified Duke criteria. Surgery may be indicated for complications such as heart failure or abscesses.
This document discusses myocarditis in children. It defines myocarditis and describes the epidemiology, etiology, pathophysiology, clinical presentation, diagnosis and treatment. Myocarditis has many potential causes including viruses like adenovirus and enterovirus. Clinically it presents variably depending on age from nonspecific symptoms to heart failure. Diagnosis involves blood tests, ECG, imaging like echocardiogram and cardiac MRI, and endomyocardial biopsy. Treatment is supportive with heart failure medications, antivirals may help, and immunosuppressants can reduce inflammation and improve function.
This document discusses the three main types of cardiomyopathy: dilated, hypertrophic, and restrictive. Dilated cardiomyopathy is the most common and is characterized by dilation of the heart chambers and reduced contractility. It has multiple potential etiologies like viruses, genetics, or toxins. Hypertrophic cardiomyopathy is usually genetic and causes abnormal thickening of the heart muscle. It can cause outflow obstruction and is a common cause of sudden death in young athletes. Restrictive cardiomyopathy is rare and causes stiff, non-compliant ventricles that impair filling. Diagnosis involves echocardiography and treatment focuses on symptoms like diuretics and transplantation.
Rheumatic fever is an inflammatory disease that can occur after a streptococcal throat infection. It involves the heart, joints, skin and connective tissue. The presentation includes fever, arthritis and heart complications like pancarditis. Diagnosis is based on clinical criteria after excluding other conditions. Prevention relies on prompt antibiotic treatment of streptococcal infections. For those with a history of rheumatic fever, long-term antibiotic prophylaxis is needed to prevent recurrences that can further damage the heart.
Rheumatic fever is an autoimmune reaction that can occur following a streptococcal throat infection. It is characterized by inflammation of the heart, joints, skin, and brain. The document discusses the definition, etiology, epidemiology, pathogenesis, clinical features including carditis, arthritis, chorea and others, diagnosis, treatment and prognosis of rheumatic fever in detail across multiple pages. It provides diagrams and images to illustrate concepts like the structure of group A streptococcus and changes in heart valves that occur in rheumatic heart disease.
Myocarditis is an inflammation of the heart muscle that is most commonly caused by viral infections in children. Symptoms can range from mild to severe and include fatigue, chest pain, palpitations, and signs of heart failure like shortness of breath. Diagnosis is challenging as symptoms are often subtle, but can involve electrocardiograms, echocardiograms, cardiac MRI, and endomyocardial biopsy. Treatment is supportive with medications for heart failure, though immunoglobulin therapy may help in some cases of proven viral infection. Prognosis depends on age and severity of symptoms, with poorer outcomes more common in newborns and those with more severe heart failure.
This document discusses heart failure in children, including its definition, types, causes, symptoms, diagnosis, complications, and management. Heart failure occurs when the heart cannot pump enough blood to meet the body's needs. In children, common causes include congenital heart disease, rheumatic heart disease, and cardiomyopathy. Symptoms vary by age but may include feeding issues, sweating, poor growth, and edema. Diagnosis involves exams, chest x-rays, electrocardiograms, and echocardiograms. Complications can include arrhythmias, infections, and damage to other organs. Treatment focuses on supportive care, medications to improve heart function, and treating the underlying cause. Prognosis depends on the cause,
Rheumatic fever is an autoimmune disease that affects the heart, joints, skin, and brain. It occurs as a result of a streptococcal throat infection and abnormal immune response in genetically susceptible individuals. The disease is most common in children aged 5-15 years from developing countries. It can lead to long term heart complications such as rheumatic heart disease if untreated. Prevention involves proper treatment of streptococcal infections with antibiotics.
This document outlines a presidential action plan for infectious endocarditis in children. It begins with definitions of infective endocarditis and discusses the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prevention. Key points include that infective endocarditis is less common in children than adults but is increasing in those with cardiac surgery or conditions. Common causes are streptococcal and staphylococcal species. Clinical features may include fever, heart murmur and embolic phenomena. Echocardiography is important for diagnosis but blood cultures are also needed under the modified Duke criteria. Surgery may be indicated for complications such as heart failure or abscesses.
This document discusses myocarditis in children. It defines myocarditis and describes the epidemiology, etiology, pathophysiology, clinical presentation, diagnosis and treatment. Myocarditis has many potential causes including viruses like adenovirus and enterovirus. Clinically it presents variably depending on age from nonspecific symptoms to heart failure. Diagnosis involves blood tests, ECG, imaging like echocardiogram and cardiac MRI, and endomyocardial biopsy. Treatment is supportive with heart failure medications, antivirals may help, and immunosuppressants can reduce inflammation and improve function.
This document discusses the three main types of cardiomyopathy: dilated, hypertrophic, and restrictive. Dilated cardiomyopathy is the most common and is characterized by dilation of the heart chambers and reduced contractility. It has multiple potential etiologies like viruses, genetics, or toxins. Hypertrophic cardiomyopathy is usually genetic and causes abnormal thickening of the heart muscle. It can cause outflow obstruction and is a common cause of sudden death in young athletes. Restrictive cardiomyopathy is rare and causes stiff, non-compliant ventricles that impair filling. Diagnosis involves echocardiography and treatment focuses on symptoms like diuretics and transplantation.
Rheumatic fever is an inflammatory disease that can occur after a streptococcal throat infection. It involves the heart, joints, skin and connective tissue. The presentation includes fever, arthritis and heart complications like pancarditis. Diagnosis is based on clinical criteria after excluding other conditions. Prevention relies on prompt antibiotic treatment of streptococcal infections. For those with a history of rheumatic fever, long-term antibiotic prophylaxis is needed to prevent recurrences that can further damage the heart.
Rheumatic fever and Rheumatic heart diseaseNahar Kamrun
Rheumatic fever is an inflammatory condition that can affect the heart, joints, brain and skin after a streptococcal throat infection. It is caused by an immune response triggered by group A streptococcal infection. Symptoms may include painful and migratory joint pain, heart inflammation known as carditis, neurological symptoms like chorea, and subcutaneous nodules under the skin. Treatment involves antibiotics to treat the initial strep infection along with anti-inflammatory drugs and bed rest. If not properly treated, it can lead to rheumatic heart disease.
This document provides an overview of acute rheumatic fever presented by Dr. Renesha Islam. Some key points:
- Acute rheumatic fever is an immune response to Group A streptococcus infection that causes inflammation of the heart, joints, brain and skin. It often damages the heart valves long term.
- Major symptoms include migratory polyarthritis in joints (75% of cases), carditis (50-60% of cases, involving the heart valves, myocardium and pericardium), Sydenham's chorea (10-15% of cases), erythema marginatum and subcutaneous nodules (rare).
- Diagnosis is based on the revised Jones criteria
Rheumatic fever (acute rheumatic fever) is a disease that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly. Early diagnosis of these infections and treatment with antibiotics are key to preventing rheumatic fever.
Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain.[1] The disease typically develops two to four weeks after a streptococcal throat infection.[2] Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum.[1] The heart is involved in about half of the cases.[1] Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. The damaged valves may result in heart failure, atrial fibrillation and infection of the valves.[1]
Case study- An 11 year old Polynesian male presents with fever up to 39 degrees (102 degrees F), joint pain and swelling, along with shortness of breath. The fever comes and goes at random times of the day. The symptoms have been present now for 4 days.
This document defines myocarditis as inflammation of the myocardium, outlines its main etiologies as viral and bacterial infections, and describes its pathogenesis. Signs and symptoms range from asymptomatic to cardiogenic shock. Diagnosis involves ECG, chest X-ray, echocardiogram, and endomyocardial biopsy. Treatment focuses on supportive care and conventional heart failure therapies. Prognosis depends on age, with higher mortality in newborns and potential recovery of function in children and adolescents.
Infective endocarditis is inflammation of the heart valves caused by bacterial infection. It is often a complication of congenital or rheumatic heart disease. Common causative organisms include streptococci and staphylococci. Risk factors include prior heart disease, dental/medical procedures, and intravenous drug use. Symptoms include fever, chills, weight loss and heart murmurs. Echocardiography and blood cultures help diagnose. Treatment involves antibiotics for 4-6 weeks. Surgery may be needed for severe valve damage or persistent infection. Prognosis remains serious despite treatment, with 20-25% mortality and high morbidity rates.
This document provides an overview of Kawasaki disease, including its history, definition, epidemiology, pathogenesis, clinical features, diagnosis, differential diagnosis, complications, and treatment. Kawasaki disease is an acute febrile illness that predominantly affects children under 5 years old and can lead to coronary artery aneurysms if left untreated. It is diagnosed based on the presence of fever for at least 5 days along with four of five principal clinical features. Intravenous immunoglobulin and aspirin are the primary treatments used to reduce the risk of coronary complications.
Rheumatic fever is a non-suppurative sequelae to group A streptococcal pharyngitis that causes inflammation in connective tissues like heart, blood vessels, joints, and brain. It is most common in children ages 5-15 from developing countries. The disease is caused by an abnormal immune response 1-3 weeks after streptococcal infection. Symptoms include migratory arthritis, heart valve damage, chorea, and subcutaneous nodules. Diagnosis is based on modified Jones criteria. Treatment involves antibiotics for streptococcal infection, aspirin or steroids for inflammation, and lifelong antibiotic prophylaxis to prevent recurrence, especially if carditis is present. Prognosis depends on age and whether
This document provides information on the approach and assessment of acyanotic congenital heart diseases in children. It discusses:
1. The typical presenting complaints which include feeding difficulties, respiratory distress, easy fatigability, recurrent infections, and failure to thrive.
2. The physical exam findings to assess including inspection, palpation of pulses, blood pressure, jugular venous pressure, auscultation of heart sounds and murmurs.
3. The classification of acyanotic heart diseases which include left-to-right shunts and outflow obstructions. The most common types are also listed.
1. The document discusses various acyanotic heart diseases seen in pediatrics including ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, aortic stenosis, and pulmonary stenosis. Clinical features, diagnosis using tools like echocardiography, and treatment approaches are described for each condition.
2. Complications of untreated defects include heart failure, infections, pulmonary hypertension, and Eisenmenger's syndrome. Critical cases may present in the neonatal period with shock, while milder cases cause symptoms like fatigue later in childhood.
3
Rheumatic fever is caused by a delayed immune response to group A beta-hemolytic streptococcal infection. It primarily affects the heart, joints, subcutaneous tissue, and brain. It is more common in developing countries and affects children between 5-15 years old. Symptoms include arthritis, carditis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum. Diagnosis is based on modified Jones criteria and treatment involves antibiotics, anti-inflammatories, and long-term prevention of recurrent infections.
1) The document discusses the history and latest developments in rheumatic fever, including the evolution of diagnostic criteria from Jones in 1944 to the 2015 AHA statement.
2) Key topics covered include subclinical carditis, the role of echocardiography in diagnosis, revisions to arthritis criteria, and implications of epidemiology for diagnostic approaches.
3) The 2015 AHA statement recommends echocardiography for all suspected rheumatic fever cases and considers monoarthritis a possible manifestation in high-risk populations.
Definition, classification, epidemiology, etiology, diagnosis, prognosis of DCM, HOCM, LVNC
Also review of acute myocarditis in children
R/v of heart failure management
Critical congenital heart disease (CCHD) refers to severe heart defects that require intervention, such as surgery or catheter procedures, in the first year of life. CCHD accounts for about 25% of all congenital heart disease cases. Common types include those dependent on ductal flow, such as hypoplastic left heart syndrome, as well as defects affecting the right ventricle outflow tract like pulmonary atresia. Diagnosis is based on symptoms like cyanosis and screening involves pulse oximetry of the right hand and foot in newborns. Treatment options include pharmacological therapy with prostaglandin E1 to keep the ductus arteriosus open, as well as surgical or catheter-based procedures.
This document discusses cyanosis in children. It defines cyanosis as a bluish discoloration of the skin caused by increased reduced hemoglobin. There are two types: peripheral cyanosis caused by slowed blood flow and central cyanosis caused by low oxygen saturation. Causes of central cyanosis include respiratory disorders like pneumonia, cardiac disorders like congenital heart diseases, and neurological disorders like seizures. Management involves diagnosis of the underlying cause through history, exams, oxygen testing, and imaging like echocardiograms. Treatment depends on the specific condition but may include oxygen, antibiotics for infection, or surgery for heart defects.
Rheumatic heart disease is caused by rheumatic fever, which is a sequela of strep throat infections. It is a major cause of mitral valve insufficiency and stenosis globally, with 15 million cases worldwide and over 200,000 deaths in 2008. In India, it commonly affects children aged 5-15, with a prevalence of 5-7 cases per 1,000 children. The severity of valve damage depends on factors like the number of previous rheumatic fever attacks, time between onset and treatment, and sex. Prevention involves treating strep throat infections aggressively with benzathine penicillin injections over multiple years.
This document discusses approaches to diagnosing and treating hypertension in children. It defines hypertension and outlines stages of severity. In infants and young children, hypertension is usually secondary to an underlying condition, while adolescents can develop primary or essential hypertension. Evaluation involves measuring blood pressure properly, considering causes of secondary hypertension, assessing for target organ damage like left ventricular hypertrophy, and determining if hypertension is primary or secondary. Treatment involves lifestyle changes, weight management if overweight, and potentially medications to lower blood pressure below guidelines.
This document discusses pediatric cardiac arrhythmias. Some key points:
- Arrhythmias are classified based on site of origin such as the sinus node, atria, AV node or ventricles. Common arrhythmias include sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia.
- Presentation of arrhythmias in children varies by age. Neonates may experience atrial flutter or ectopic atrial tachycardia. Older children may experience WPW syndrome or AV nodal re-entrant tachycardia.
- Diagnosis involves analyzing the ECG for heart rate, QRS width, and P wave relationship to the
Kawasaki disease is an acute febrile vasculitis that predominantly affects young children under 5 years old. It is characterized by inflammation of blood vessels and can lead to coronary artery abnormalities if left untreated. The cause is unknown but believed to be infectious. Treatment involves intravenous immunoglobulin in the acute phase along with aspirin to prevent coronary complications. Most patients recover completely but long-term aspirin therapy may be needed for those with coronary abnormalities.
An 8 year old female presented with signs of septic shock including a heart rate of 180, respiratory rate of 35, and hypotension. Initial assessments found a temperature of 39.9°F, respiratory rate of 32 breaths/min, blood pressure of 70/50 mmHg, and oxygen saturation of 90% on room air. The patient appeared tired and had delayed capillary refill of 4 seconds.
Paediatric septic shock remains a significant cause of morbidity and mortality worldwide. Early goal directed therapy is crucial and aims to achieve specific clinical targets within 6 hours such as a central venous pressure of 8-12 mmHg, mean arterial pressure over 65 mmHg, urine output over 0.5 ml/kg/
Kawasaki Disease is a self-limited vasculitis that predominantly affects children under 5 years old and can lead to coronary artery aneurysms if left untreated; it is characterized by fever for at least 5 days along with changes in extremities, rash, conjunctival injection, and cervical lymphadenopathy. Intravenous immunoglobulin and aspirin are the primary treatment to reduce the risk of coronary artery aneurysms developing.
Febrile seizures are seizures that occur in young children between 3 months and 6 years of age when they have a fever but no serious underlying condition. They are relatively common, affecting 3-4% of children under 5 years old. While the exact cause is unknown, there are likely genetic and environmental factors that make some children more susceptible. Most febrile seizures are brief and do not cause long-term problems, but recurrent or prolonged seizures may increase the risk of developing epilepsy later in life. Treatment focuses on managing the fever and preventing future febrile seizures.
This document summarizes key information about rheumatic fever, including its causes, symptoms, diagnosis, treatment and prevention. It is caused by a streptococcal throat infection which can trigger an autoimmune response attacking the heart, joints, brain and skin in genetically predisposed children. Symptoms include polyarthritis, carditis, chorea, subcutaneous nodules and erythema marginatum. Diagnosis is based on the Modified Jones Criteria. Treatment involves antibiotics for strep throat, anti-inflammatories like salicylates, and management of complications. Secondary prevention uses long-term antibiotics to prevent recurrent strep infections and further episodes of rheumatic fever.
Rheumatic fever and Rheumatic heart diseaseNahar Kamrun
Rheumatic fever is an inflammatory condition that can affect the heart, joints, brain and skin after a streptococcal throat infection. It is caused by an immune response triggered by group A streptococcal infection. Symptoms may include painful and migratory joint pain, heart inflammation known as carditis, neurological symptoms like chorea, and subcutaneous nodules under the skin. Treatment involves antibiotics to treat the initial strep infection along with anti-inflammatory drugs and bed rest. If not properly treated, it can lead to rheumatic heart disease.
This document provides an overview of acute rheumatic fever presented by Dr. Renesha Islam. Some key points:
- Acute rheumatic fever is an immune response to Group A streptococcus infection that causes inflammation of the heart, joints, brain and skin. It often damages the heart valves long term.
- Major symptoms include migratory polyarthritis in joints (75% of cases), carditis (50-60% of cases, involving the heart valves, myocardium and pericardium), Sydenham's chorea (10-15% of cases), erythema marginatum and subcutaneous nodules (rare).
- Diagnosis is based on the revised Jones criteria
Rheumatic fever (acute rheumatic fever) is a disease that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly. Early diagnosis of these infections and treatment with antibiotics are key to preventing rheumatic fever.
Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain.[1] The disease typically develops two to four weeks after a streptococcal throat infection.[2] Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum.[1] The heart is involved in about half of the cases.[1] Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. The damaged valves may result in heart failure, atrial fibrillation and infection of the valves.[1]
Case study- An 11 year old Polynesian male presents with fever up to 39 degrees (102 degrees F), joint pain and swelling, along with shortness of breath. The fever comes and goes at random times of the day. The symptoms have been present now for 4 days.
This document defines myocarditis as inflammation of the myocardium, outlines its main etiologies as viral and bacterial infections, and describes its pathogenesis. Signs and symptoms range from asymptomatic to cardiogenic shock. Diagnosis involves ECG, chest X-ray, echocardiogram, and endomyocardial biopsy. Treatment focuses on supportive care and conventional heart failure therapies. Prognosis depends on age, with higher mortality in newborns and potential recovery of function in children and adolescents.
Infective endocarditis is inflammation of the heart valves caused by bacterial infection. It is often a complication of congenital or rheumatic heart disease. Common causative organisms include streptococci and staphylococci. Risk factors include prior heart disease, dental/medical procedures, and intravenous drug use. Symptoms include fever, chills, weight loss and heart murmurs. Echocardiography and blood cultures help diagnose. Treatment involves antibiotics for 4-6 weeks. Surgery may be needed for severe valve damage or persistent infection. Prognosis remains serious despite treatment, with 20-25% mortality and high morbidity rates.
This document provides an overview of Kawasaki disease, including its history, definition, epidemiology, pathogenesis, clinical features, diagnosis, differential diagnosis, complications, and treatment. Kawasaki disease is an acute febrile illness that predominantly affects children under 5 years old and can lead to coronary artery aneurysms if left untreated. It is diagnosed based on the presence of fever for at least 5 days along with four of five principal clinical features. Intravenous immunoglobulin and aspirin are the primary treatments used to reduce the risk of coronary complications.
Rheumatic fever is a non-suppurative sequelae to group A streptococcal pharyngitis that causes inflammation in connective tissues like heart, blood vessels, joints, and brain. It is most common in children ages 5-15 from developing countries. The disease is caused by an abnormal immune response 1-3 weeks after streptococcal infection. Symptoms include migratory arthritis, heart valve damage, chorea, and subcutaneous nodules. Diagnosis is based on modified Jones criteria. Treatment involves antibiotics for streptococcal infection, aspirin or steroids for inflammation, and lifelong antibiotic prophylaxis to prevent recurrence, especially if carditis is present. Prognosis depends on age and whether
This document provides information on the approach and assessment of acyanotic congenital heart diseases in children. It discusses:
1. The typical presenting complaints which include feeding difficulties, respiratory distress, easy fatigability, recurrent infections, and failure to thrive.
2. The physical exam findings to assess including inspection, palpation of pulses, blood pressure, jugular venous pressure, auscultation of heart sounds and murmurs.
3. The classification of acyanotic heart diseases which include left-to-right shunts and outflow obstructions. The most common types are also listed.
1. The document discusses various acyanotic heart diseases seen in pediatrics including ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, aortic stenosis, and pulmonary stenosis. Clinical features, diagnosis using tools like echocardiography, and treatment approaches are described for each condition.
2. Complications of untreated defects include heart failure, infections, pulmonary hypertension, and Eisenmenger's syndrome. Critical cases may present in the neonatal period with shock, while milder cases cause symptoms like fatigue later in childhood.
3
Rheumatic fever is caused by a delayed immune response to group A beta-hemolytic streptococcal infection. It primarily affects the heart, joints, subcutaneous tissue, and brain. It is more common in developing countries and affects children between 5-15 years old. Symptoms include arthritis, carditis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum. Diagnosis is based on modified Jones criteria and treatment involves antibiotics, anti-inflammatories, and long-term prevention of recurrent infections.
1) The document discusses the history and latest developments in rheumatic fever, including the evolution of diagnostic criteria from Jones in 1944 to the 2015 AHA statement.
2) Key topics covered include subclinical carditis, the role of echocardiography in diagnosis, revisions to arthritis criteria, and implications of epidemiology for diagnostic approaches.
3) The 2015 AHA statement recommends echocardiography for all suspected rheumatic fever cases and considers monoarthritis a possible manifestation in high-risk populations.
Definition, classification, epidemiology, etiology, diagnosis, prognosis of DCM, HOCM, LVNC
Also review of acute myocarditis in children
R/v of heart failure management
Critical congenital heart disease (CCHD) refers to severe heart defects that require intervention, such as surgery or catheter procedures, in the first year of life. CCHD accounts for about 25% of all congenital heart disease cases. Common types include those dependent on ductal flow, such as hypoplastic left heart syndrome, as well as defects affecting the right ventricle outflow tract like pulmonary atresia. Diagnosis is based on symptoms like cyanosis and screening involves pulse oximetry of the right hand and foot in newborns. Treatment options include pharmacological therapy with prostaglandin E1 to keep the ductus arteriosus open, as well as surgical or catheter-based procedures.
This document discusses cyanosis in children. It defines cyanosis as a bluish discoloration of the skin caused by increased reduced hemoglobin. There are two types: peripheral cyanosis caused by slowed blood flow and central cyanosis caused by low oxygen saturation. Causes of central cyanosis include respiratory disorders like pneumonia, cardiac disorders like congenital heart diseases, and neurological disorders like seizures. Management involves diagnosis of the underlying cause through history, exams, oxygen testing, and imaging like echocardiograms. Treatment depends on the specific condition but may include oxygen, antibiotics for infection, or surgery for heart defects.
Rheumatic heart disease is caused by rheumatic fever, which is a sequela of strep throat infections. It is a major cause of mitral valve insufficiency and stenosis globally, with 15 million cases worldwide and over 200,000 deaths in 2008. In India, it commonly affects children aged 5-15, with a prevalence of 5-7 cases per 1,000 children. The severity of valve damage depends on factors like the number of previous rheumatic fever attacks, time between onset and treatment, and sex. Prevention involves treating strep throat infections aggressively with benzathine penicillin injections over multiple years.
This document discusses approaches to diagnosing and treating hypertension in children. It defines hypertension and outlines stages of severity. In infants and young children, hypertension is usually secondary to an underlying condition, while adolescents can develop primary or essential hypertension. Evaluation involves measuring blood pressure properly, considering causes of secondary hypertension, assessing for target organ damage like left ventricular hypertrophy, and determining if hypertension is primary or secondary. Treatment involves lifestyle changes, weight management if overweight, and potentially medications to lower blood pressure below guidelines.
This document discusses pediatric cardiac arrhythmias. Some key points:
- Arrhythmias are classified based on site of origin such as the sinus node, atria, AV node or ventricles. Common arrhythmias include sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia.
- Presentation of arrhythmias in children varies by age. Neonates may experience atrial flutter or ectopic atrial tachycardia. Older children may experience WPW syndrome or AV nodal re-entrant tachycardia.
- Diagnosis involves analyzing the ECG for heart rate, QRS width, and P wave relationship to the
Kawasaki disease is an acute febrile vasculitis that predominantly affects young children under 5 years old. It is characterized by inflammation of blood vessels and can lead to coronary artery abnormalities if left untreated. The cause is unknown but believed to be infectious. Treatment involves intravenous immunoglobulin in the acute phase along with aspirin to prevent coronary complications. Most patients recover completely but long-term aspirin therapy may be needed for those with coronary abnormalities.
An 8 year old female presented with signs of septic shock including a heart rate of 180, respiratory rate of 35, and hypotension. Initial assessments found a temperature of 39.9°F, respiratory rate of 32 breaths/min, blood pressure of 70/50 mmHg, and oxygen saturation of 90% on room air. The patient appeared tired and had delayed capillary refill of 4 seconds.
Paediatric septic shock remains a significant cause of morbidity and mortality worldwide. Early goal directed therapy is crucial and aims to achieve specific clinical targets within 6 hours such as a central venous pressure of 8-12 mmHg, mean arterial pressure over 65 mmHg, urine output over 0.5 ml/kg/
Kawasaki Disease is a self-limited vasculitis that predominantly affects children under 5 years old and can lead to coronary artery aneurysms if left untreated; it is characterized by fever for at least 5 days along with changes in extremities, rash, conjunctival injection, and cervical lymphadenopathy. Intravenous immunoglobulin and aspirin are the primary treatment to reduce the risk of coronary artery aneurysms developing.
Febrile seizures are seizures that occur in young children between 3 months and 6 years of age when they have a fever but no serious underlying condition. They are relatively common, affecting 3-4% of children under 5 years old. While the exact cause is unknown, there are likely genetic and environmental factors that make some children more susceptible. Most febrile seizures are brief and do not cause long-term problems, but recurrent or prolonged seizures may increase the risk of developing epilepsy later in life. Treatment focuses on managing the fever and preventing future febrile seizures.
This document summarizes key information about rheumatic fever, including its causes, symptoms, diagnosis, treatment and prevention. It is caused by a streptococcal throat infection which can trigger an autoimmune response attacking the heart, joints, brain and skin in genetically predisposed children. Symptoms include polyarthritis, carditis, chorea, subcutaneous nodules and erythema marginatum. Diagnosis is based on the Modified Jones Criteria. Treatment involves antibiotics for strep throat, anti-inflammatories like salicylates, and management of complications. Secondary prevention uses long-term antibiotics to prevent recurrent strep infections and further episodes of rheumatic fever.
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children characterized by inattention, hyperactivity, and impulsivity. It is diagnosed based on symptoms that cause impairment in multiple settings according to the DSM-IV criteria. Treatment involves psychosocial interventions, behavior management training, and stimulant medication which effectively treat the core symptoms of ADHD.
Bronchiolitis is caused by viral infections, most commonly respiratory syncytial virus (RSV). It involves inflammation of the small airways (bronchioles) and is most common in children under 1 year old. Symptoms include cough, wheezing, difficulty breathing and feeding. While most cases are mild and self-limiting, some children require hospitalization for severe respiratory distress. Treatment is supportive with oxygen supplementation as needed. Antibiotics and other medications are not effective as bronchiolitis is a viral illness.
Upper airway obstruction can occur from the nose to the larynx. Croup is most common in children ages 3 months to 5 years and is usually caused by a viral infection like parainfluenza. Epiglottitis is a medical emergency typically caused by bacterial infections and can lead to sudden airway obstruction. Foreign body aspiration is also common in young children and requires prompt diagnosis and removal to prevent complications.
Pediatric urinary tract infections (UTIs) are common in children, especially girls under the age of 1. Left untreated, UTIs can cause renal scarring and long-term kidney damage. Diagnosis involves urine tests to check for white blood cells and bacteria. Treatment depends on symptoms and severity but often involves antibiotics and hydration. Follow up is important to monitor for recurrent UTIs and issues like vesicoureteral reflux, as both increase risk of permanent kidney damage if not addressed.
Myocarditis is an inflammatory disease of the heart muscle that can be caused by infectious or non-infectious triggers. It has a variable clinical presentation ranging from mild symptoms to life-threatening cardiogenic shock. Diagnosis is challenging but can involve elevated cardiac biomarkers, ECG abnormalities, echocardiogram findings of ventricular dysfunction, and cardiovascular MRI or endomyocardial biopsy showing inflammatory infiltrates. Treatment focuses on managing heart failure symptoms and arrhythmias with medications like diuretics, ACE inhibitors, beta-blockers, and avoiding digoxin in acute heart failure. The prognosis varies from complete recovery to chronic dilated cardiomyopathy or sudden death.
This document discusses urinary lithiasis (kidney stones) in children. It covers the causes, types, and treatment of stones. The most common types are calcium oxalate and calcium phosphate stones, caused by hypercalciuria in 30-60% of cases. Other causes include cystinuria, struvite stones related to urinary tract infections, and uric acid stones. Treatment depends on the stone location and composition but may involve removal procedures like lithotripsy or addressing the underlying metabolic condition through diet, medication, or surgery. The goal is to dissolve or pass existing stones and prevent new stone formation.
The document provides 67 tips for creating an effective presentation. Some key tips include planning the presentation on paper first, avoiding full sentences in bullet points, making ideas stick through imagery and stories, engaging the audience, practicing extensively, and focusing on the audience's needs rather than what you want to present. The overall message is that an effective presentation conveys clear and concise messages in a way that involves and resonates with the audience.
This document discusses true or false statements about asthma and provides clarification. It states that asthma is not psychological, cannot be cured though can be controlled, is hereditary, not contagious, and requires medical treatment. Exercise may trigger attacks for some. Asthma medications are not addictive and attacks cannot be faked. Achieving control requires a partnership between patients and healthcare providers.
This document describes a case of croup in a 20-month-old male who presented to the emergency department with a cough. He developed rhinorrhea, fever, hoarse cry, and worsening barking cough over the past two days. On examination, he had inspiratory stridor, clear mucus, injected pharynx, and subcostal retractions. He was treated with nebulized racemic epinephrine and dexamethasone, which resolved his symptoms. The document then provides an overview of croup including definitions, etiology, pathophysiology, epidemiology, clinical presentation, diagnosis, and differential diagnosis.
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2. It was first described in the 1500s and the link between strep throat and heart damage was established in the 1800s. Diagnostic criteria were developed in 1944.
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2. INDEX
1. Introduction
2. Problem statement
3. Incidence and prevalence (worldwide & Nepal)
4. Pathogenesis
5. Diagnosis
6. Treatment
7. Rheumatic heart disease
8. Vaccine status
2
3. Introduction
• Rheumatic fever and rheumatic heart disease
are the non suppuartive complications of
Group-A Streptococcal infection due to a
delayed immune response.
• Most children developed at least one episode
of pharygitis per year
• 15-20% of which are cause by group-A
streptococci
3
4. • Group –A has been linked to the
etiopathogenesis of rheumatic fever and
rheumatic heart disease.
• Group C and D ,can produce extra cellular
antigens ( streptolysin-O)
• Group E & G may also cause rheumatic fever
4
5. Problem statement
• 20 million cases of rheumatic heart disease
world wide
• 500000 deaths each year due to acute
rheumatic fever and rheumatic heart disease
• Mainly in adolescents and young adults
( Carapetis JR, Steer AC, Mullholand EK et al, The global burden of group –A
strepptococcal disease, Lancet Infect Dis 2005)
• Disability adjusted life years ( DALYs) for south
east Asia region is 173.4 /100000 population
5
6. • Congestive heart failure- 3 millions
• Valve surgery required- 1 million
• Annual incidence of rheumatic fever- 0.5/
million
• Number of RHD cases added- 300000/year
• Estimated deaths from RHD- 200000/year
(WHO tech series923;2004)
6
7. • Rheumatic heart disease is a major cause of
morbidity and mortality in low and middle
income countries and among underprivileged
communities in high income countries
(Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group
A streptococcal diseases. Lancet Infect Dis. 2005;5:685–694)
• 15 million cases of RHD worldwide, with
282,000 new cases and 233,000 deaths
annually.
(Review article by Michael D seckeler, Tracy R hoke,dept.of pediatrics,
university of Viginia,US
Clinical epidemiology 2011)
7
8. Incidence worldwide( First attack)
• Review of ten prospective studies
• Five of them were using active surveillance while
other five were using passive surveillance
• Overall mean incidence rate 19/ 100000
population
• India (51/100000)
• Maori community of New Zealand
( >80/100000)
( K B Tibazarwa ,J A Wolmink, BM Mayosi, Heart 2008:94)
8
9. • Highest incidence among the indigenous
population of Australia and New Zealand.
• Annual number of cases in aged 5-14 years is
374/100000 population.
• 60% of these developed rheumatic heart
disease
• Rheumatic heart disease in school children
,sub Sahran Africa 5.7/1000, Indigenous
population of Australia and New Zealand
3.5/1000 while south central Asia is 2.2/1000.
9
10. Acute rheumatic fever in Nepal
• 9420 school students ,4466 male & 4956 females
between 4-14 years.
• 83 children suspected to have heart disease
• 23 were confirmed cases on clinical examination
• 11 rheumatic heart disease & 12 congenital heart
disease were found
• Prevalence 1.2 &1.3 respectively, Mitral
regurgitation and ASD most common lesion
identified
(Bahadur KC, Sharma D, Shrestha MP, Gurung S, Rajbhandari S, Malla
R, Rajbhandari R, Limbu YR,
Regmi SR, Koirala B,Department of Cardiology, Shahid Gangalal
National Heart Center, Bansbari, Kathmandu
Indian Heart Journal 2003, nov:dec) 10
11. Rural community-Hill region
• 5-16 years, 20-25 km outside Kathmandu valley
• 4816 school children were interviewed
• WHO expert committee criteria (1966) was used
• Chest X-ray ,ECG, Echocardiography, Doppler
study was done in all suspected cases
• 1 mitral stenosis, 3 mitral regurgitation and 2
combined MS & MR
• Prevalence 1.35/1000 children
(Shrestha UK, Bhattarai TN, Pandey MR,Department of Medicine, Bir
Hospital, Kathmandu, Nepal,
Indian heart journal 1991,jan:fab)
11
12. Acute rheumatic fever -Nepal
• Prevalence of rheumatic heart disease in
school children is 1.2/1000 population
(Prakash RR et al, Prevalence of rheumatic fever and rheumatic
heart disease in school children of Kathmandu city, Indian
Heart journal 1997,49:518-520)
12
13. Acute Rheumatic fever-TUTH
• Total admitted case between 10/67 to 09/68
1106
• Rheumatic fever / rheumatic heart disease
17
• Prevalence= 1.53
13
14. Acute rheumatic fever- Kanti children
hospital
• Total number of case = 6334
• Rheumatic fever/ rheumatic heart disease =
26
• Prevalence= 0.7
14
15. Etiology
• Group –A streptococcus
• 66% Patients have history of upper respiratory
tract infection
• Closed communities like boarding schools and
military bases
• M strain (type-1,3,5,6,18.24) is commonly
associated with ARF
• Type-4 , not associated with recurrence
• Mucoid strain are commonly isolated during
outbreaks
15
16. • Almost, always have raised ASO titre
• N-acetyl glucosamine ,cell wall carbohydrate
also present in human tissue
• Streptolysin hylauronidase,erythrogenic toxin,
streptokinase and deoxyribonuclease
• M1,M5,M6 & M19 share epitopes with human
myosin and tropomyosin
16
17. Pathogenesis of rheumatic fever
IMMUNOLOGICAL THEORY
• HLA molecules process antigen within a host cell
and present them on the cell surface to T-cells
• T-cells either attack the antigen or activate B-cells
to produce antibodies.
• If HLA molecule present antigen resembles both
streptococcus and human tissue ,host cells can be
attacked.
• No universal association between HLA allele &
ARF
• HLA-DR7 most frequently associated
• HLA-DR3 in south east Asia
17
18. • IN ARF & RHD ,foreign antigen is M-protein,
cross reacts with cardiac myosin
• T-cells mediated attack on heart tissue and
valve
• In Saydenham chorea ,carbohydrate
component of streptococcal cell wall cross
reacts with gangliosides in the cell
membrane of neurons in basal ganglion
• Damage neuron ,hampered cell signaling
,unable to stop motor impulses
18
19. Streptococcal M-Protein
• Two region
Hypervariable N terminal
Conserved C-terminal ( A,B & C
repeat)
• Class- I (1,3,5,6,14,18,19 & 24)
• ( 2,49,57,60 & 61 )
• Class-II Non reacting M protein
19
21. • TUMOR NECROSIS FACTOR-α
Also located on chromosome-6 ,near HLA
allele
TNF- α is upregulated in patients with
increase susceptibility to ARF
Increased inflammatory response & ARF
• MANNOSE BINDING LACTIN-
MBL helps to mark foreign cells to eliminate
High level of MBL in mitral valve damage
Low level in aortic valve involvement
21
22. Cytotoxic theory
• Gas toxin directly involved
• Anti steptolysin –O has direct effect on
mammalian cells in tissue culture
• Can not explain latent period
22
23. Risk factors
• Age- 5-15 years, high risk of developing GAS
pharyngitis
• Previous attack of rheumatic fever is risk factor
• Seasonal variation- winter and autumn months
• Closed communities- boarding schools
• Heredity- mataanalysis of six studies,435 twin
pair were included .concordance risk in
monozygotic twins is 44% while in dizygotic twin
is 12%,with 60% heritability in all studies
( Mark E Engel, Raphaella Stander,Jonathan Vogel,Adebowale
A,Bongani Mayosi, Deparment of medicine,Groot Schuur
hospital,Univery of capetown ,RSA,2011)
23
24. Jones’s criteria
• Major criteria
Carditis
Migratory polyarthritis
Sydenham chorea
Erythema marginatum
Subcutaneous nodule
• Minor criteria
Fever
Arthralgia
Previous rheumatic fever
or rheumatic heart
disease
Leukocytosis, raised ESR
or elevated CRP
Prolonged PR interval
Essential criteria
Recent staph. Infection with
culture positivity or Rapid testing,
DNAase-B, ASO title or
streptokinase, recent scarlet fever 24
25. WHO criteria (2002-03)
• Chorea and indolent carditis do not require
evidence of antecedent group –A streptococcus
infection
• First episode should be diagnose as per Jones
criteria
Recurrent episode
• In a patient without established RHD- as per first
episode
• In a patient with established RHD- two minor
manifestation plus evidence of antecedent group-
A streptococcal infection with addition of recent
scarlet fever 25
26. Changes in New Zealand Guidelines
2010
• Acceptance of echo-cardigraphic finding as a
major criteria
• When carditis is present as a major criteria,
prolonged P-R interval can not be considered
as minor criteria in the same patient.
• If polyarthritis is present as a major criteria ,
arthralgia can not be taken as minor criteria in
same patient
26
27. Carditis
• First layer to involve is endocardium
• Presence of pericardium and myocardium is
variable
• Isolated mitral valve involvement or mixed mitral
and aortic disease
• Valvular insufficiency
• Stenosis appear later
• Tachycardia /murmurs
• Present in 50-60% cases
• Carey coomb’s murmur
27
28. Arthritis
• 75% of patients
• Migratory in nature
• Involve larger joints
• NSAIDS
• Dramatic response to salicylates
• Non deforming
• Earliest manifestation
• Inverse relationship with cardiac involvement
• Synovial fluid aspiration
28
29. Chorea
• 10-15%
• Occasionally unilateral (16%)
• Latent period can be in months
• Milkmaid’s grip
• Pronation sign
• Handwriting
29
30. Erythema marginatum
• < 3%
• Serpiginous ,macular lesions with pale centers
• Non pruritic
• Trunk and extremities
30
31. Subcutneous nodule
• <1%
• firm nodule
• 1 cm in diameter
• extensor surface of tendon near bony
prominence
• Directly proportional to cardiac involvement
31
32. Lab parameters
• Anti streptolysin O titre > 480
• Anti DNAase-B > 680
• Lower level in very young and those who are
above 15 years.
• Two fold rise in level within 10-14 days is
diagnostic
• Leukocytes count-10000-15000/cu.mm
• ESR- 4-10 weeks, upto 12 weeks
32
33. Role of echocardiography
• Controversial- 80% of murmurs can be
ausculatated ,remaining 20% likely to heal
without permanent squealae.
• Silent MR has good prognosis
33
34. Role of echocardiography
• Early detection of milder lesion in
asymptomatic children can prevent severe
valvular lesion by instituting secondary
prophylaxis
( Narijon E et al, New England jour .of med 2007,357;470-6)
• Prevalence of rheumatic heart disease by
echo doppler is 20/1000 children
(Anita saxena, S.ramakrisnan, A roy, A krishnan,All India
institute of medical sciences ,New Delhi & India –U.K.
education reserch initiative,2010)
34
35. Echocardiography
• Prospective cross sectional study over 2years in KCH,
under 14 years of age with the diagnosis of RF as per
jones criteria( carditis 92%,arthritis33%, Chorea8%,
subcutaneous nodule 4%, fever 51%, raised ASO titre
94%, raised CRP 78%,Prolonged PR interval 45% ,
pericardial effusion 22% & cardiac failure 28%)
• Total 51 patients with male :female ratio was 1.6:1
• murmer was audible in 78.4% patients while diseased
valve on echocardiography seen in 88.2 %)
• Mitral regurgitation 24% is most common lesion
(Rayamajhi A, Sharma D, Shakya U.Cardiology Unit, Department
of Paediatrics, National Academy of Medical Sciences, Kanti
Children's Hospital, Kathmandu, Nepal
Ann Trop Paediatr. 2007 Sep;27(3):169-77) 35
36. Echocardiography
• In 51 patients ( 25 first episode ,26 recurrent
rheumatic fever),arthritis occur in higher number in
first episode( p= 0.047) while cardiac symptoms viz
SOB (p= 0.003), palpitation (p=0.034),aortic
regurgitation (p =0.001)
• Audible murmur with corresponding echo finding were
present in all cases of recurrent rheumatic fever
• In first episode audible murmur in 61.5% while echo
shows 81% regurgitation
(Rayamajhi A, Sharma D, Shakya U.
Department of Pediatrics, Cardiology Unit, National Academy of
Medical Sciences, Kanti Children's Hospital, Kathmandu, Nepal
Pediatr Int. 2009 Apr;51(2):269-75)
36
37. Right ventricular endomyocardial
biopsy
• Diagnostic sensitivity is only 27%
• Can be beneficial in pts when unexplained
heart failure in pre existing RHD with high ASO
titre
• No role in chronic heart disease
37
43. Suppression of the inflammatory
process
• Aspirin -100-125 mg/kg/day ,in 4-5 equal
doses
• 60-70 mg/kg/day after two weeks (3-4 weeks)
• Naproxen 10-20 mg/kg/day
• Steroids
prednisone
methyl-prednisolone
43
44. • Salicylates-
Rapid resolution of fever, arthritis & arthralgia
Should not be used in treatment of carditis
Do not decrease the incident of residual RHD
• Steroids-
Decreases fever and acute phase reactants
No superiority over salicylates in reducing
incidence of residual RHD and vice versa
44
48. Antibiotics
• Benzathine penicillin (i.m./single)
• Oral penicillin/erythromycin (10 days)
( Nelson’s text book of pediatrics)
• Procaine penicillin-400000 units,I.m., twice
daily for 10 days
• Followed by Benzathine penicillin 1.2 million
units every 21 days OR 0.6 million units every
15 days
48
50. Secondary prevention
Benzathine
penicillin
1.2 million units,
every 4 weekly
intramuscular
Penicillin V 250 mg, twice a day oral
Sulfadiazine or
sulfasoxazole
0.5 mg once a day
for <27kg
1.0 mg once a day
for >27kg
oral
Erythromycin 250 mg ,twice daily oral
50
51. Duration of prophylaxis
Rheumatic fever without
carditis
5 yr or untill age of
21yrs,whichever is longer
Rheumatic fever with carditis
without residual valve disease
10yr or well into adulthood
,whichever is longer
Rheumatic fever with carditis
with residual heart disease
At least 10 yrs since last
episode ,atleast 40 yr of age,
consider prophylaxis
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52. Mitral regurgitation
• Most common lesion
• Fatigue is most common symptom
• Systolic thrill is present in <10 % of patients
• Third heart sound may be present
• Diastolic murmur/thrill (more common, no
attenuation)
• Sinus tachycardia
• Left ventricular hypertrophy
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53. Treatment of Mitral regurgitation
• Mile to moderate- medical management
• Severe regurgitation- surgical repair
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54. Mitral stenosis & Tricuspid
Regurgitation
• 10 % off all rheumatic mitral stenosis
• Dyspnea –most common symptom
• Dyspnea on exertion, Paroxysmal nocturnal
dyspnea, atypical angina
• Small volume pulse , engorged neck veins,
tender liver
• Diastolic thrill(late attenuation)
• Opening snap
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55. Aortic regurgitation
• Pure aortic regurgitation in 5-8% patients
• Main symptom- Palpitation
• Corrigan’s sign
• Dancing peripheral arteries
• Visible pulsation of abdominal aorta
• de Musset’s sign
• Hill’s sign
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56. Prognosis
• Clinical manifestation at the time of initial
episode
• Severity of initial episode
• Recurrence of the disease
• Presence of Carditis
• Presence of Chorea
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57. Streptococcal vaccine
• Multiplicity of M protein serotypes
• Toxicity of M protein preparation
• Cross reaction with human tissue
• Antibodies against synthetic agent are
opsonic but does not cross react with human
tissue
• Phase -1 trial are in progress for this synthetic
vaccine
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59. References
• Nelson’s text book of pediatrics 19th edition
• WHO guideline for diagnosis & treatment of
ARF 2004
• Essential pediatrics- OP Ghai 7th edition
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