Rheumatic fever
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Transcript of Rheumatic fever
1Rheumatic fever
2 Content
Disease overall view Precipitating factors Diagnosis Management
3 Disease overall view
Rheumatic fever is a systemic autoimmune disorder related to prior streptococcal infection
The development of rheumatic fever is preceded by the upper respiratory tract infection (tonsillitis or pharyngitis) with Group A β-hemolytic streptococci.
4 Disease overall view
Autoimmune mediated by: Antigenic similarity: Abs formed against streptococcal Ags react with native human tissue antigens(autoimmune tissue damage)
The latent period between streptococcal infection & onset of RF is 1-5 wks.
5 Precipitating factors
Age: between 5-15 yrs.
Sex: equal except for rheumatic chorea (common in females).
Socio-economic factors: common in developing countries &low social classes (overcrowding &bad hygiene).
Recurrent and severe recent strept. infections
6 Diagnosis
Jone’s criteria Polyarthritis: w/ low grade fever, large
joints, migratory - often 1 at a time, No permanent dysfunction. (>75%)
Carditis, pericarditis, cardiomegaly, or valvulitis (the most serious manifestation & often results in permanent damage). (~50%)
Major
criteri
a
plus Evidence of a recent group A Strep infection
7 Diagnosis
Jone’s criteria Chorea: late occurrence, 1- 6 months
after the infection, self-limiting, resolves in 1- 3 months. (~30%)
plus Evidence of a recent group A Strep infection
Major
criteri
a
8 Diagnosis
Jone’s criteria Erythema Marginatum:
“classic” truncal rash, migratory - appears & disappears within hours.
(pink rash – irregular red edges serpiginous borders– clear center) (~10%)
plus Evidence of a recent group A Strep infection
Major
criteri
a
9 Diagnosis
Jone’s criteria Subcutaneous Nodules:
Late occurrence ( months after infection) Painless small nodules over bony prominences:ElbowsKneesspine. (1- 2%) plus
Evidence of a recent group A Strep infection
Major
criteri
a
10 Diagnosis
Jone’s criteria Fever Arthralgia (mild pain without objective
findings): Can only be considered without finding of arthritis
Elevated acute-phase reactants: ESR, C-reactive protein.
plus Evidence of a recent group A Strep infection
Minor
criteri
a
11 Diagnosis
Anti streptococcal Abs are investigated:ASOAnti-deoxy-ribonuclease (DNAse) BAnti-hyaluronidase
Heart reactive antibodiesTropomyosin is elevated in acute rheumatic
fever.plus Evidence of a recent group A Strep infection
Work
ups
12 Diagnosis
Diagnosis with rheumatic fever if you meet two major criteria, or one major and two minor criteria, and have signs that you've
had a previous strep infection.
Work ups
Minor
criteri
a
Major criteria
13 Complications
Early complications:( Heart failure, Arrhythmias)
Late complications:(Rheumatic valvular lesions, rheumatic
activity)
14
Management
Acute state
Prevent further attacks
2ry 1ry
15 Management
Prevention 1ry prevention by treating Strep.
Pharyngitis:The penicillin is the drug of choice because:
Narrow spectrum of activityLong standing efficacyLow cost
16 Management
Prevention IM benzathine penicillin:
1. 0.6 Millions Unit IM 1 Time (< 27 Kg)2. 1.2 Millions units IM 1 Time (>27 Kg)
1ry preventio
n
17 Management
Prevention PO - Phenoxymethyl Penicillin
(Penicillin V)1. Children (50mg/kg/day) 250 mg (2-3
times/day) x10 days2. Adolescent /Adult 500 mg TID x10
days10 days course therapy
(++time & --
compliance)
1ry preventio
n
18 Management
Adverse effect of penicillins Allergic reaction:
Anaphylaxis, UrticariaAngioedema, rash.
GIT: Diarrhea, vomiting & oral thrush
1ry preventio
n
19 Management
Adverse effect of penicillins Renal:
Acute interstitial nephritisCNS:
Convulsion & fever
1ry preventio
n
20 Management
Adverse effect of penicillins Site of injection:
Pain with IM route, inflammation at IV-site
Blood:Hemolytic anemia, thrombocytopenia, neutropenia
1ry preventio
n
21 Management
In case of penicillin allergy use:Oral erythromycin:(20-40 mg/kg/day)(2-4 times/day)(up to 1gm/day) for 10 days.Newer macrolidesOral cephalosporins
10 days course therapy
(++time & --
compliance)1ry preventio
n
22 Management 1ry preventio
n
23 Management
Antibiotics “NOT” Recommended for Strep. Pharyngitis:Sulfonamides, Trimethoprim,
Sulfamethoxazole (not eradicate GAS).Tetracyclines / Doxycycline / Minocycline.(High prevalence of resistant strain)
1ry preventio
n
24 Management
2ry prevention starts after diagnosis of RF: Rheumatic Fever requires “continuous”
prophylactic antibiotics due to:
1. Increased “susceptibility” to recurrences2. Increased “severity” of recurrences3. “Asymptomatic nature” of Strep. Infections.
2ry preventio
n
25 Management 2ry preventio
n
Or Whichever is longer
26 Management Acute phase
Treatment of:ArthritisCarditisChorea
27 Management Acute phase
Treatment of:Arthritis
Relieves by aspirin within 24-48 hrs of pain
The diagnosis is questionable if aspirin isn’t effective
Mild arthritis may respond to paracetamol alone
28 Management Acute phase
Treatment of:Arthritis
Aspirin dose for pediatrics:90-130 mg/kg/day in equally divided doses every 4-6 hrs, up to 5.5 gm/day.
29 Management Acute phase
Treatment of:Arthritis
Salicylate serum levels (20-25 mg/mL)After 1-2 wks, the dosage is decreased to 60-70 mg/kg/day and given for 1-6 wks or longer if necessary, then gradually withdrawn over 1-2 wks.
30 Management Acute phase
Treatment of:Arthritis
Naproxen/ Ibuprofen/ paracetamol are potential alternative
31 Management Acute phase
Treatment of:Carditis
Avoid strenuous exercise Treat symptoms of heart failureSteroids are preferred over salicylates Treatment is guided according to clinical status of the patient
32 Management Acute phase
Treatment of:Carditis === severe case< use prednisolone
2 mg/kg /day 2-4 divided doses (max 60mgm /day ) 2-3 wks [ ESR < 30mm / 1hr ] Taper off 5 mg / 3 days Add - Aspirin 75 mgm / kg / day x 8 -10 weeks
33 Management Acute phase
Clinical Severity Arthralgia or mild
arthritis; no carditis
Mod./severe arthritis; no carditis OR carditis without failure
Treatment Analgesics only
Aspirin 100 mg/kg/d with meals for 3 wk (or longer up to 6 wk); then taper gradually over 6 wk
34 Management Acute phase
Clinical Severity Carditis with
failure; with or without joint manifestation
Treatment Prednisone 40-60
mg/d, if necessary; after 3 wk, slow tapering over 3 wk, continue aspirin for 4 wk after d/c of prednisone.
35 Management Acute phase
Treatment of:Rheumatic chorea
Haloperidol : initial dose 0.5 to 1 mg and 0.5 is added every 3 days for Maximal effect or until a maximal dose of 5 mg/ day
Sodium valproate: (15 to 20 mg/kg per day) is also effective.
36 Management Acute phase
Treatment of:Rheumatic chorea
Diazipam 0.25-0.5 mg/Kg/day
37 Management Acute phase
Treatment of:Rheumatic chorea
In resistant cases, plasmaphersis iv Immunoglubulins.
Steroid therapy is generally not effective in Sydenham’s chorea.
38
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