Post on 04-Jun-2018
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Acute rheumatic fever
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Introduction
Inflammatory diseases that involves heart, joint,CNS, skin and subcutaneous tissues
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Epidemiology
Most common cause of acquired heart disease inchildren
Mainly in under developed countries
First infection is usually btw 5-15 years old
More common in girl > boy
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Aetiology
Streptococcus pyogenes (Group A hemolyticStreptococcus) pharyngeal infection
This genetic susceptibility is inherited as an
autosomal recessive gene
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Pathogenesis
Streptococci trigger autoimmune reaction
inflammation
- Not direct infection of the bacteria to the heart
- Antibody produce by the infection showed to cross
react with host tissue in the valvular tissue,myocardium, joint, subthalamic & caudate nuclei
- Valvular damage in mitral and aortic, less in triscupid
and pulmonary
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Revised Jones criteria
Major criteria- Sydenhams chorea (10%)
- Subcutaneous nodules (rare)
- Migratory polyarthritis or polyathralgia(80%), or
aseptic monoarthritis
- Carditis (50%)
- Erythema marginatum (
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Erythema marginatum
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Minor criteria- Fever (temperature > 38 C)
- Raised actue phase reactants, ESR > 30 mm/h or
CRP > 30 mg/L
- Prolonged PR interval
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Recurrent attack of ARF
- 2 major criteriaOr
- 1 major criteria + 2 minor criteria
Or
- 3 minor criteria
PLUS
evidence of a preceding group A streptococcalinfection
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ECG CXR
Echo
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Management
Acute phase1. Bed rest
2. Anti-streptococcal therapy
IV C. Penicillin 50 000U/kg/dose 6H
or oral Penicillin V 250 mg 6H (30kg) for 10 days
oral Erythromycin for 10 days if allergic to penicillin.
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3. Anti-inflammatory therapy
Mild / no carditis:
- oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4
weeks, taper over 4 weeks
Pericarditis, or moderate to severe carditis:- oral Prednisolone 2 mg/kg/day in 2 divided doses for
2 - 4 weeks,
- taper with addition of aspirin as above.
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4. Anti-failure medications - diuretics, ACE inhibitors, digoxin (to be used with
caution).
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Secondary Prophylaxis
IM Benzathine Penicillin 0.6 mega units (30 kg) every 3 to 4 weeks
oral Penicillin V 250 mg twice daily
oral Erythromycin 250 mg twice daily if allergic to
Penicillin
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Duration of prophylaxis- until age 21 years or 5 years after last attack of ARF
whichever was longer
- lifelong for patients with carditis and valvular
involvement.
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Infective endocarditis
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Introduction
Microbacteria infection which cause exudative andproliferative inflammatory alteration of the
endocardium or vascular endothelium
An uncommon condition in children but has a high
morbidity and mortality if untreated
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Risk factors
congenital heart disease repaired congenital heart defects
congenital or acquired valvular heart diseases
immunocompromised patients with indwelling central
catheters
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Aetiology
1. Bacteria- Streptococcus viridans
- Staphylococcus aerues
- Community acquired enterococci
- HACEK group
Haemophilus spp
Actinobacillus actinomycetemcomitan
Cardiobacterium hominis Eikenella corrodens
Kingella kingae
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2. Fungus
- Candida
- Aspergillus- Histoplasma
3. Others
- Libman-Sacks endocarditis (SLE)
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Clinical features
Fever + new murmur is IE until proven otherwise
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Symptoms
Fever Lethargy
Loss of appetite
Loss of weight
Arthralgia
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Signs
Peripheral stigmata- Splinter haemorrhage
- Oslers node
- Janeway lesion
- Necrotic skin lesion
- Clubbing (late)
- pallor
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Oslers node
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Oslers node
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Janeway lesion
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Janeway lesion
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Rothss spot on funduscopy
Neurological signs from cerebral infaction
New/changing murmur
Splenomegaly
Haematuria (microscopic)
Arthritis
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Modified Duke Criteria
Major criteria
1. blood culture positive:
typical microorganisms from two separate blood
cultures:
- Viridans streptococci,- Streptococcus bovis,
- HACEK group,
- Staphylococcus aureus- community-acquired enterococci
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2. evidence of endocardial involvement on
echocardiogram
- vegetation, abscess or dehiscence of prosthetic valve
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Minor criteria
1. Predisposing heart condition, prior heart surgery,
indwelling catheter
2. Fever, temperature > 38C
3. Vascular phenomena:- major arterial emboli
- septic pulmonary infarcts
- mycotic aneurysm
- intracranial hemorrhage,
- conjunctival hemorrhages
- Janeways lesions
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4. immunologic phenomena:
- glomerulonephritis- Oslers nodes
- Roths spots
- rheumatoid factor
5. microbiological evidence:
- positive blood culture not meeting major criterion
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Diagnosis Definite IE
Pathological criteria1. microorganisms by
- Culture
- histological examination of vegetation or intracardiacabscess specimen
2. pathological lesions with active endocarditis
Clinical criteria:
2 major or1 major + 3 minor or
5 minor
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Possible IE
- 1 major + 1 minor criteria
or- 3 minor
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Investigation
Blood
- FBC
- ESR
- CRP
- BLOOD C&S
- LFT
- C3/C4
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UFEME
CXR
ECG
ECHO
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Management
Ensure 3 blood cultures taken before antibiotic
therapy.
Do not wait for echocardiography.
Use empirical antibiotics,until culture results
available
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Guidelines on prophylaxis of IE
Endocarditis prophylaxis recommended
High-risk category
- prosthetic cardiac valves
- previous bacterial endocarditis
- complex cyanotic congenital heart disease
- surgical systemic pulmonary shunts
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Moderate-risk category
- other congenital cardiac malformations (other thanabove and below)
- acquired valvar dysfunction (e.g rheumatic heart
disease)
- hypertrophic cardiomyopathy
- mitral valve prolapse with regurgitation
Endocarditis prophylaxis not
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Endocarditis prophylaxis not
recommended
Negligible-risk category
isolated secundum ASD
repaired ASD & VSD
patent ductus arteriosus (after 6 mths)
mitral valve prolapse without regurgitation
functional, or innocent heart murmurs
previous Kawasaki disease without valvular
dysfunction
previous rheumatic fever without valvular dysfunction
cardiac pacemakers and implanted defibrillators
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Common procedures that require IE prophylaxis
Oral, dental procedures
- extractions, periodontal procedures
- placement of orthodontic bands (but not brackets)
- intraligamentary local anaesthetic injections
- prophylactic cleaning of teeth
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Respiratory procedures
- tonsillectomy or adenoidectomy
- surgical operations involving respiratory mucosa
- rigid bronchoscopy
- flexible bronchoscopy with biopsy
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Gastrointestinal procedures
- sclerotherapy for esophageal varices
- oesophageal stricture dilatation
- endoscopic retrograde cholangiography
- biliary tract surgery
- surgical operations involving intestinal mucosa
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Genitourinary procedures
- Cystoscopy
- Urethral dilation
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Standard general prophylaxis
Oral Amoxicillin 50 mg/kg (max 2 Gm) one hour before
procedure
Or
IV/IM Ampicillin 50 mg/kg (max 2 Gm)
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Penicillin allergy
Oral Clindamycin 20 mg/kg (max 600 mg)
Or
Oral Cephalexin 50 mg/kg (max 2 Gm)
Or
Oral Azithromycin/clarithromycin 50 mg/kg (max 500 mg)
Or
Oral Erythromycin 20 mg/kg (max 3 Gm)
Or
IV Clindamycin 20 mg/kg (max 600 mg)
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Kawasaki disease
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Introduction
Also known as mucocutaneous lymph node
syndrome
Systemic febrile condition affecting children usually