Acute Rheumatic Fever 2003

7/30/2019 Acute Rheumatic Fever 2003

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Acute rheumatic fever


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Acute rheumatic fever Non-suppurative sequel to Group A

hemolytic streptococcal infection of throat

Latent priod 2-3 weeks following streptococcal

pharyngitis

Peak incidence 5-15 years of age


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Diagnosis

2 major or 1 major and 2 minor

evidence of preceding group A streptococcalinfection


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Carditis Valvulitis: new murmur, most= MR, AR

Cardiomegaly

Congestive heart failure: from myocarditis Pericarditis: chest pain, pericardial friction rub


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Migratory polyarthritis Typically involves larger joints, particularly the

knees, ankles, wrists, and elbows

Generally hot, red, swollen, and exquisitely

tender

A severely inflamed joint can become normal

within 1-3 days without treatment


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Sydenham chorea milkmaid's grip: irregular contractions of the

muscles of the hands while squeezing theexaminer's fingers

spooning and pronation of the hands whenthe patient's arms are extended

wormian darting movements of the tongue

upon protrusion examination of handwriting to evaluate fine

motor movements


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Erythema Marginatum erythematous, serpiginous, macular lesions

with pale centers that are not pruritic

It occurs primarily on the trunk andextremities


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Subcutaneous Nodules 1% of patients

firm nodules approximately 1 cm in diameter

along the extensor surfaces of tendons nearbony prominences


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Minor Manifestations Fever(typically temperature 102F and

occurring early in the course of illness)

Arthralgia(in the absence of polyarthritis as amajor criterion)


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Investigation Evidence of Group A hemolytic streptococcal

infection

serum antistreptococcal antibody titers: increase

in 80-85%

anti-DNase B

Antihyaluronidase

If 3 different Ab: 95-100%


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Investigation Except

Sydenham Chorea

Insidious onset rheumatic carditis


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Investigation Serum ESR: increase

Serum CRP: positive

EKG: prolonged P-R interval CXR: cardiomegaly

Echocardiogram: subclinical valvulitis


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Treatment Antibiotics

Symptomatic treatment


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Antibiotics Appropriate antibiotic therapy before the 9th

day :highly effective in preventing 1st attacksof acute rheumatic fever from that episode.

10 days of orally administered penicillin orerythromycin or a single intramuscularinjection ofbenzathine penicillin

After this initial course of antibiotic therapy,the patient should be started on long-termantibiotic prophylaxis


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Anti-inflammatory therapy

Acetaminophen :

patient is being observed for more definite signs of

acute rheumatic fever or for evidence of anotherdisease.

Aspirin:

typical migratory polyarthritis and those with carditiswithout cardiomegaly or congestive heart failure

100 mg/kg/day in 4 divided doses PO for 3-5 days,

followed by 75 mg/kg/day in 4 divided doses PO for4 wk.


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Anti-inflammatory therapy Prednisone:

carditis and cardiomegaly or congestive heart failure

2 mg/kg/day in 4 divided doses for 2-3 wk

followed by a tapering of the dose that reduces the dose by5 mg/24 hr every 2-3 days

At the beginning of the tapering of the prednisone dose,aspirin should be started at 75 mg/kg/day in 4 divided dosesfor 6 wk

Supportive therapies for patients with moderate to severecarditis include digoxin, fluid and salt restriction, diuretics,and oxygen

The cardiac toxicity of digoxin is enhanced with myocarditis.


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Supportive therapy

bed rest: allowed to ambulate as soon as the signsof acute inflammation have subsided

patients with carditis require longer periods ofbed rest

Chorea:

phenobarbital (16-32 mg every 6-8 hr PO) is the drug of

choice. haloperidol (0.01-0.03 mg/kg/24 hr divided bid PO)

chlorpromazine (0.5 mg/kg every 4-6 hr PO)


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Secondary PreventionDRUG DOSE ROUTE

Penicillin G benzathine

600,000 U for children, 60 lb

1.2 million U for children >60 lb,

every 4 wk*

Intramuscular

OR

Penicillin V 250 mg, twice a day Oral

OR

Sulfadiazine or sulfisoxazole0.5 g, once a day for patients 60 lb

Oral

1.0 g, once a day for patients >60 lbFOR PEOPLE WHO ARE ALLERGIC TO PENICILLIN AND SULFONAMIDE DRUGS

Macrolide or azalide Variable Oral
http://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0015&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0015&appID=MDC


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Secondary PreventionCATEGORY DURATION

Rheumatic fever without carditis5 yr or until 21 yr of age, whichever is

longer

Rheumatic fever with carditis but withoutresidual heart disease (no valvular

disease*)

10 yr or until 21 yr of age, whichever is

longer

Rheumatic fever with carditis and residual

heart disease (persistent valvular

disease*)

10 yr or until 40 yr of age, whichever is

longer, sometimes lifelong prophylaxis
http://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDC


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Acute Rheumatic Fever 2003

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