Rheumatic fever is an autoimmune condition that occurs after a Group A streptococcal infection, typically affecting the heart, joints, and brain. It causes inflammation of the heart valves, which can lead to scarring and deformity known as rheumatic heart disease. Symptoms of rheumatic heart disease include shortness of breath, palpitations, and swelling from fluid buildup. Treatment involves antibiotics to prevent initial and recurrent streptococcal infections, along with medications, surgery, and lifestyle changes to manage valve damage and heart failure. Complications can include arrhythmias, valve stenosis, heart failure, and endocarditis if left untreated.

1. Rheumatic Heart
Disease/Rheumatic fever

2. INTRODUCTION
• Rheumatic fever is an autoimmune collagen
disease which occurs as hypersensitivity
reaction to group-A beta hemolytic
streptococcal infection. Many organs are
involved through these rheumatic processes,
including the heart, the joints and the central
nervous system
• The illness typically develops 2 or 3 weeks
after streptococcal infection

3. • Rheumatic heart disease is a chronic
condition resulting from rheumatic fever that is
characterized by scarring and deformity of the
heart valves.
• Every part of the heart, including the outer sac
(the pericardium), the inner lining (the
endocardium) and the valves may be
damaged by inflammation caused by acute
rheumatic fever.

4. • RHD usually affects children, young adults
and has become very rare in Europe and
America
• However it remains endemic in parts of Asia,
Africa and South America
• RHD can be prevented and controlled.
• Rheumatic fever is caused by a preceding
group A streptococcal (strep) infection.
Treating strep throat with antibiotics can
prevent rheumatic fever.

5. • Rheuatic heart disease can be acute and
chronic
• Acute RHD:- It affects endocardium,
myocardium and pericardium causing
endocarditis, myocarditis, and pericarditis or
all 3 layers causing pancarditis
• Chronic RHD:-the valves are particularly
affected due to chronic inflammation but
involvement of the pericardium and myocardium
may contribute to heart failure and conduction
disorders. Mitral stenosis regurgitation, aortic
and tricuspid valve stenosis and regurgitation.

6. Incidence
• The global burden of disease caused by rheumatic fever
and RHD currently falls disproportionately on children
and young adults living in low-income countries and
about 233,000 deaths annually.
• At least 15.6 million people are estimated to be
currently affected by RHD
• It has declined in developed countries but remains
important public health issues in developing countries
• Up to 1 per cent of all schoolchildren in Africa, Asia,
the Eastern Mediterranean region, and Latin America
show signs of the disease.

7. • Ages between 5-15 yrs are most susceptible
• Girls> boys
• Incidence more during fall, winter and early
spring

9. Risk factors
• Infection with group A Beta streptococcal
infection
• Age group between 6-15 years are at high risk
• Poor hygiene
• People living in crowded conditions
• Malnutrition
• Lower socioeconomic status
• Poor environmental sanitation
• Occurs approximately 20 days after strep throat or
scarlet fever
• Girls> boys

10. Pathophysiology
Group A beta hemolytic streptococcus infection
Antigen- antibody reaction
Sore throat
Rheumatic fever

11. Attack heart, joint, subcutaneous tissue and CNS
In heart carditis ( swelling of all layers of heart)
Endocardia inflammation lead to swelling of valve
Exudation
Bacterial vegetation around valve leaflet

12. Platelet and fibrin deposit around valve leaflet
Valve stenosis, regurgitation
Heart failure

13. Sign and symptoms
Major signs:
1. Polyarthritis (80%of cases): a temporary
migrating inflammation of the large joints,
usually, usually starting in the legs and
migrating upwards
2. Carditis (40-50% of cases): Inflammation
of heart layers including pericarditis,
myocarditis, and endocarditis. Inflammation
of all three layers is called pancarditis.

14. 3. Subcutaneous nodules(10%): small(0.5-
2cm), painless, firm collection of collagen
fibers over bones or tendons. they commonly
appear on the back of the wrist, the outside of
elbow and the front of the knees
4. Erythema marginatum (<5%): it is a long
lasting rash that begins on the trunk or arms as
macules and spreads outward to form a snake
like ring while clearing in the middle. This
rash never starts on the face and it is made
worse with heat.

16. Erythema marginatum

17. 5.syndenham’s chorea (5-10%of cases) this is
emotional lability, muscular weakness, rapid,
purposeless, jerky, uncoordinated, involuntary
movement of extremities and face. This can occurs
very late in the disease
Minor signs and symptoms
• High fever(upto 101-102 degree)
• Arthralgia (joint pain without swelling)
• Pallor, fatigue
• Anorexia
• Weakness, malaise
• Chest pain, SOB

18. syndenham’s chorea

19. • Raised ESR and CRP
• Leucocytosis
• First- degree AV block
• Loss of weight
• Abdominal pain
• Valvular stenosis and regurgitation
Mitral stenosis(75-80% affected)
Aortic valve (30% affected)
Pulmonary and tricuspid valve(5% affected)

20. Jones Criteria for Rheumatic Fever
Major Criteria Minor Criteria
•Pancarditis (Pericarditis,
Endocarditis, Myocarditis)
•Polyarthritis
•Syndenham’s chorea
•Subcutaneous nodules
•Erythema marginatum
•High fever(upto 101-102
degree)
•Arthralgia
•Prolonged PR interval
•Increased ESR or CRP
•Leukocytosis

21. Diagnosis
• The rheumatic fever can be diagnosed by
presence of 2 major criteria or presence of 1
major criteria and 2 minor criteria along with
evidence of streptococcal infection
• History taking( usually sore throat or pharyngitis
within 5 days
• Physical examination
• Laboratory tests
Throat swab culture
Erythrocyte sedimentation rate( ↑ESR)

22. C reactive protein(elevated)
Antistreptomycin O titer-elevated
TCDC-elevated
Rheumatoid factors
Electrocardiogram
Echocardiography
Chest x-ray

23. Treatment/ management
Prevention
Early and adequate treatment of oropharyngeal
streptoccal infection
Medical management
The choice of drug for group-Beta haemolytic
streptococcus is penicillin
• Benzathine penicillin’G’ is commonly used
Dose: 600,000 units IM- less than 27kg
1200000 units IM-more than 27kg( every 3 weeks)

24. • Penicillin V (phenoxymethyl penicillin)
Dose: 250mg orally(BD or TID) children
500mg orally(BD or TID) adults and
adolescence
• For patients allergic to penicillin
erythromycin: 20-40mg/kg/day orally (2-4 times
daily
Ethyl succinate:40mg/kg/day orally (2-4 times
daily)

25. Other medications
• Aspirin/salicylates
• Corticosteroids
• Diazepam and phenobarbitone
• Digoxin, deuretics, beta blockers, salt and fluid
restriction in case of HF

26. Surgical management
• It include closed mitral commisurotomy,
valve repair and valve replacement
• Percutaneous tranluminal mitral
commisurotomy(PTMC)
• Valve repair technique and valve replacement
require open heart surgery using
cardiopulmonary Bypass

27. NURSING MANAGEMENT
• Teaching patients about the disease, treatment and
preventive steps needed to minimize reoccurance
and potential complication
• Keep patient in complete bed rest
• Advice to take medications regularly
• Always perform skin test before giving penicillin
• Always monitor the pt. for sign and symptoms of
valvular heart disease and heart failure
( shortness of breath, palpitation, pitting edema)

28. • Provide psychological support to the patient
• Help the patient to ventilate their feelings
• Advise patient to have regular medications in
correct time
• Have regular follow up
• Advise patient to have low salt and fluid if
heart failure had developed
• Care of bowel and urine is also important

29. NURSING DIAGNOSIS
1) Decreased Cardiac Output related to: a disturbance in
the closure of the mitral valve (valve stenosis).
2) Ineffective Peripheral Tissue Perfusion related to:
decreased metabolism primarily due to vasoconstriction of
peripheral blood vessels.
3) Acute Pain related to: inflammation of the synovial
membrane.
4) Hyperthermia related to: inflammation of the synovial
membrane, and inflammation of the heart valves.
5) Imbalanced Nutrition, Less Than Body Requirements
related to: an increase in stomach acid caused by the
sympathetic nervous system compensation.

30. 6) Activity intolerance related to: muscle weakness,
prolonged bed rest or immobilization.
7) Self-Care Deficit related to: Musculoskeletal
Disorders: polyarthritis / arthralgia and therapy bed rest.
8) Impaired Skin Integrity related to: inflammation of
the skin and subcutaneous tissue.
9) Risk for Impaired Gas Exchange related to: the
accumulation of blood in the lungs due to increased
atrial filling.
10) Risk for Injury related to: involuntary movements,
irregular, rapid and muscle weakness / Chorea.

31. Complications
• Arrhythmias
• Mitral stenosis
• Aortic stenosis
• Heart failure
• Ineffective endocarditis
• Pericardial effusion
• Pulmonary edema