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  • 1.DIAGNOSIS OF ACUTE RHEUMATICFEVER Gusti Ayu Riska Pertiwi1002005069 Faculty of Medicine Udayana University

2. INTRODUCTION 3. INTRODUCTION Acute Rheumatic fever (ARF) is a nonsuppurative, immune- mediated inflammatory disease, which occurs as a delay sequel to group A, -hemolytic streptococcus (GABHS) pharyngitis 1-4. Affects connective tissue of the heart, joints, skin and vessels1-4. Rheumatic Heart Disease (RHD) as squale condition of ARF can leading to congestive heart failure, strokes, endocarditis, and death 1-41 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease Clinical Epidemiology 2011;3:6784. 12National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heartdisease in Australia, An evidence-based review. 2006; Pp. 7-26.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrisons rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29Oct 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923). 4. INTRODUCTION cont.How does ARF develop?O GABHS rheumatogenicO Susceptible individualO Environmental risks small proportions of people in any population (3-5%) have an inherent susceptibility to ARF 6,76Lawrenson J. Rheumatic fever: New ideas in diagnosis and management. SAHeart 2010;7:252-257.7Beggs S, Peterson G, Tompson A. Antibiotic use for the prevention and treatment of rheumatic fever and rheumaticheart disease in children. Report for the 2 nd Meeting of World Health Organizations subcommittee of the ExpertCommittee of the Selection and Use of Essential Medicines. Geneva: 2008. Pp. 3 5. INTRODUCTION cont. .An estimated 12 million people are affected by ARFand RHD globally4,9Up to 150 cases per 100 000 population in developingcountries versus 1 case per 100 000 population indeveloped countries such as the United States4,9Predominantly affects children aged 514 years, rareaffect children less than 3 years old or adults2,7Recurrenct may occurs well into their fourties 40 y.o 2,72National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia, Anevidence-based review. 2006; pg7-26.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 Oct 1 Nov 2001.Geneva: WHO 2004. (WHO Technical Report Series No. 923).7 Beggs S, Peterson G, Tompson A. Antibiotic use for the prevention and treatment of rheumatic fever and rheumatic heart disease in children. Report for the 2 nd Meeting of World HealthOrganizations subcommittee of the Expert Committee of the Selection and Use of Essential Medicines. Geneva: 2008. Pp. 39 Miyake CY, Gauvreau K, Tani LY, Sundel RP. Newburger JW. Characteristics of Children Discharged From Hospitals in the United States in 2000 With the Diagnosis of Acute Rheumatic Fever.Pediatrics 2007;120:503-508. 6. CONTENT 7. CONTENT2.1 Diagnosis Basedon Joness Criteria Joness criteria consist major and minor criteria To fulfill Jones criteria: two major criteria OR one major criterion and two minorcriterion, PLUS evidence of antecedent streptococcal infection 1-5,11 8. Tabel 1. The Jones Criteria for Acute Rheumatic Fever, Update 1992 3 Major CriteriaMinor Criteria CarditisClinicalFeverPolyarthritis ArthralgiaLaboratory ChoreaAcute-phase reactantserythrocyte sedimentation rate, C-reactive proteinErythema marginatumElectrocardiogramprolonged PR Subcutaneous nodulesinterval Plus supporting evidence of antecendent GABHS infection :Increased antistreptolysin O (ASO) or other streptococcal antibodies(DNAse B)Positive throat culture for GABHSPositive rapid antigen detection test for GABHSKaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrisons rheumatology. New York: McGraw-hill; 2006. Pp 105-108 .3 9. Tabel 2. 20022003 WHO criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on the revised Jones criteria) 2,4,112 National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever andrheumatic heart disease in Australia, An evidence-based review. 2006; Pp. 7-26.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHO ExpertConsultation, Geneva, 29 Oct 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).11 Cilliers AM. Clinical review: Rheumatic fever and its management. BMJ 2006;333:11531156. 10. Joness Major CriteriaCarditis 40% to 60% of patients with ARF haveevidence of carditis Carditis is typically valvulitis, and has beentraditionaly diagnosed by a murmur suggestiveof valvar regurgitation There may be pericarditis and myocarditis Echocardiography as supportive examination 11. Joness Major CriteriaCarditis cont.Clinical diagnosis of carditis is based on3,4:the presence of signicant murmursapical systolic murmur of mitral regurgitationand/or the basal diastolic murmur of aorticregurgitationtachycardia,pericardial friction rub cardiomegaly3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrisons rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heartdisease: report of a WHO Expert Consultation, Geneva, 29 Oct 1 Nov 2001. Geneva: WHO 2004. (WHO TechnicalReport Series No. 923). 12. Joness Major CriteriaPolyarthritis Asymmetricalredness, swelling, and intensepain of multiple joints, that can be migratory oradditive 1-3 Affect large joint (ankles, knee, wrists, andelbow, seldom involve the hip joints); not thesmall joint3,4 It occurs at early course of the disease3,4 Shoud be differentiated from PSRA111 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease Clinical Epidemiology2011;3:6784.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrisons rheumatology. New York: McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease: report of a WHOExpert Consultation, Geneva, 29 Oct 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923).11 Cilliers AM. Clinical review: Rheumatic fever and its management. BMJ 2006;333:11531156 . 13. Joness Major CriteriaChorea rapid, uncontrolled movements, especially aecting the hands, feet, tongue and face2-4 Bilateral or unilateral (hemichorea) 2-4 Latency period 1-7 months2-4 Females > male, and occur primarily in children and are rare after the age of 20 years2-4 milkmaids grip, spooning , pronator sign, inability to control protrusion of tongue2,3 emotional lability, changes in personality, moodiness, or a change in school performance12 14. Joness Major CriteriaErythema marginatum2,4non-pruriticbright pink macules or papules thatblanch under pressure and spread outwards in acircular or serpiginous pattern (snake-like)commonly on the trunk and proximal extrimities;never on facedifficult to detect in patients with dark skinfound in 3% to 5%2National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Diagnosis and management ofacute rheumatic fever and rheumatic heart disease in Australia, An evidence-based review. 2006; Pp. 7-264 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumatic fever and rheumatic heart disease:report of a WHO Expert Consultation, Geneva, 29 Oct 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No.923). 15. Joness Major Criteria Subcutaneous nodules 1-4 least common (1% of patients) round, freely moveable, non painful, vary insize from 0.5 to 2 cms usually found on the extensor surfaces of thearms and legs1 Seckeler MD and Hoke TR. The worldwide epidemiology of acute rheumatic fever andrheumatic heart disease Clinical Epidemiology 2011;3:6784. 12National Heart Foundation of Australia and the Cardiac Society of Australia and NewZealand. Diagnosis and management of acute rheumatic fever and rheumatic heartdisease in Australia, An evidence-based review. 2006; Pp. 7-26.3 Kaplan EL. Rheumatic Fever. In: Fauci AS (eds). Harrisons rheumatology. New York:McGraw-hill; 2006. Pp 105-108.4 WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease. Rheumaticfever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 Oct 1 Nov 2001. Geneva: WHO 2004. (WHO Technical Report Series No. 923). 16. Minor CriteriaFever 4,11 38C or higher occurs in almost all rheumatic attacksArthralgia1,3,4 arthritis and arthralgia do not occurs together is pain usually involves large joints, may be mild orincapacitating, without associated redness or swelling, may be present for days to weeks 17. Minor CriteriaAcute-phase reactants2,10 erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and WBC count are increase as a sign of inflammatory Prolonged PR interval 1,2 suggests that there is a first degree of heart block ECG should be repeated after 12 months to document a return tonormal. If it has returned to normal, ARF becomes a more likelydiagnosis. 18. Evidence of antecedent GABHS infection Throat Culture 8,12 May fail to isolate the organism (60% to 70% of cases) because of the latency period between the primary infection and the development of ARF12 Streptococcal Antibody Tests8 antistreptolysin O (ASO) and antideoxyribonuclease B Antigen Detection Tests8 RADTs are vary in method and have high specificity but low sensitivity 19. Table 3. Differential Diagnosis of ARF2 Polyarthritis and CarditisChoreaFeverDifferential Septic