acute rheumatic fever (arf) & rheumatic

8/12/2019 Acute Rheumatic Fever (Arf) & Rheumatic

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ACUTE RHEUMATIC FEVER (ARF) &

RHEUMATIC HEART DISEASE (RHD)

SYARIF HIDAYAT

RSUD SERANG



INTRODUCTION, DEFINITION,

PATHOPHYSIOLOGY

Streptococcusgroup A β

haemolyticusARF RHD



An immune-mediated, multisystem inflammatorydisease that follows group a streptococcal

infection.

Characterized by tissue inflammation that givesrise to typical clinical characteristics, includingcarditis, valvulitis, arthritis, chorea, erythemamarginatum, and subcutaneous nodules.

Carditis occurs in 30 –80% of patients with ARF, andat least 60% of untreated patients develop chronicRHD.

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Inflammation leads to neo vascularization, which enables furtherrecruitment of t cells, leading to granulomatous inflammation

Molecular mimicry between group a streptococcal antigens and human hosttissue is thought to be the basis of this cross-reactivity.

Both cross-reactive anti-bodies and cross-reactive t cells are believed to havea role in the disease.

Interaction between a group a streptococcal strain and a host seems to leadto an abnormal immune response and the development of autoimmunity.



Predominantly affects the mitral valve and, less commonly, the aorticvalve.

Mitral insufficiency is the most common valvular lesion, particularly inthe early stages of the disease.

Mitral stenosis develops later as a result of persistent or recurrentvalvulitis, although rapid progression has been described in somedeveloping countries.

Patients with mitral insufficiency can remain relatively asymptomatic forup to 10 years, as a result of compensatory left atrial and left ventriculardilatation before the onset of left ventricular systolic dysfunction.

Tricuspid regurgitation can occur as a result of volume overload, usuallycaused by mitral stenosis.

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DIAGNOSTIC CRITERIA & CATEGORY FOR

ARF & RHD

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1) 2 MAYOR/ 1 MAYOR + 2 MINORMANIFESTATIONS PLUS …

2) 2 MINOR MANIFESTATIONS PLUS …

… PLUS EVIDENCE OF A PRECEDING GROUP

A STREPTOCOCCAL INFECTION



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CARDITIS

POLYARTHITISMIGRANS

CHOREA

ERYTHEMAMARGINATUM

SUBCUTANEUSNODUL

Commonly presents as a heart murmur; Chest pain and/ordifficulty breathing may be present in more severe cases

Pain and swelling in more than one large joint (ankles, knees,wrists); Often the first complaint; Usually ‘migratory’ – finishesin one joint, begins in another

Twitchy, jerking movements and muscle weakness (most obvious in the face,hands and feet); May occur on both sides or only one side of body; Morecommon in teenagers and females (rare after age 20); May begin up to 3-6months after the streptococcal throat infection, and often occurs withoutother symptoms; Usually resolves within 6 weeks rarely (may last 6 monthsor more)

Painless, flat pink patches on the skin that spread outward in acircular pattern; Usually occurs early, may last months, rarelylasts years; Usually on the back or front of body, almost neveron the face; Hard to see in dark-skinned people

Painless lumps on the outside surfaces of elbows, wrists, knees,ankles in groups of 3-4 (up to 12) ; The skin is not red orinflamed; Last 1-2 weeks (rarely more than 1 month); Nodulesare more common when Carditis is also present



MANAGEMENT &

PREVENTION OF ARF

& RHD

Secondary

Primary



Group AStreptococcus β

heamolyticus

infection

ACUTE RHEUMATICFEVER

PRIMARY

PREVENTION

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SORE THROATTREATMENT (Y)

VACCINE (N)

1) Oral penicillin V 500mg 2 –3 times per

day for 10 days [250mg for children], 50mg/kg amoxicillin per day for 10 days, or

2) A single 1,200,000u [600,000u forchildren ≤27 kg] dose of intramuscular

benzathine penicillin G



CLINICAL GROUPS BED REST (WEEKS) MOBILIZATION (WEEKS)

CARDITIS (+),ARTHRITIS (-)

2 2

CARDITIS (+),

CARDIOMEGALY (-)

4 4

CARDITIS (+),

CARDIOMEGALY (+)

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CARDITIS (+), CHF (+) > 6 > 12Paracetamol; Salisilat : 100mg/kg in 4-5 dose (Max 6mg/d)

2weeks then 60-70mg/kg/d for 3-6weeks; Prednison :

2mg/kg/d (max 80mg/d) 2weeks tappering off 20-25% every

week; Carbamazepine, valproic acid, diazepam

FEVER,ARTHRITIS,CHOREA

Eradication; For 10days; QIDERYTHROMYCIN

Eradication; For 10days; 25-20mg/kg/d in 3

dose (max adults 50-1000mg/d)AMOXCILLINA

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DIURETICS, ACE-I/ARB, DIGOXIN, BB, A-THROMBOTIC

CARDITIS(PERICARDITIS,MYOCARDITIS,ENDOCARDITIS)



RHD MORBIDITY (CHF, AF, IE, CVD)

DEATH

CLINICAL MANAGEMENT

CHF MEDICATION

A-COAGULANTSURGERY/ INVASIVE NON

SURGERY

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SYMPTOMATIC THERAPY

MONITORING INR IN A-COAGULANT TH/ FOR AF &

POST REPLACEMENTSURGERY

SURGERY : REPAIR ORREPLACEMENT

INVASIVE NON SURGERY :BMV



CHF

AF

IE

CVD

DIURETICS, ACE-I/ARB, DIGOXIN, BB, A-THROMBOTIC

DIGOXIN, BB, A-THROMBOTIC, A-COAGULANT

ANTIBIOTICS, OPERATION

CARDIAC EMBOLI IN AF/ VEGETATIONS IN IE(CONTROLED AF, A-COAGULANT, OPERATION);NEUROLOGIST

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Eritema marginatum = RF

Nodul subkutan = RF

acute rheumatic fever (arf) & rheumatic

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