Download - Rheumatic fever
&KNEE PAIN
FEVER
By: Dr Ir
fan
Ziad
AN 11-YEAR OLD PRESENTED WITHFEVERJOINT PAINAND SWELLING
SOB
O/E : tachypnea and tachycardia
T 38.2 P 160 RR 32
BP 100/60 SaO2 94%
Lungs clear CVS S1S2, pansystolic
murmur 3/6 heard at apex with radiation to axilla
Abdomen Soft, normoactive bowel sounds
Left knee is swollen and extremely tender with warmth & Limited ROM. His right ankle is very swollen and warm. He has limited subtalar motion. Both his knee and ankle are very tender even to touch.
Enlarged, erythematosus tonsils with exudates
CNS : No abnormal movements of arms, hands, or tongue are noted. He is unable to walk due to pain.
P R
CARDIOMEGALY
Differentials?
RHEUMATICFEVER
DR IRFAN ZIAD
12 millionare affected by ARF and CRHD globally
150 times
developing countries are
more susceptible than the developed countries
5-14 yearsis the most frequent age group
AN INFLAMMATORY DISEASE OF CHILDHOOD
RESULTING FROMUNTREATED STREPTOCOCCOCCAL
PHARYNGEAL INFECTION
Streptococcus
Group ARheumatogenic strain
β-hemolytic
Streptococcus
Group A B-hemolytic
Rheumatogenic strain
Immune
response
M-
Protein
Heart SkinConnective tissue
Brain
Molecularmimicry
Joints-Athralgia-Migratory polyarthritis
Skin-Subcutaneous nodules-Erythema marginatum
Subcutaneous nodules
Erythema marginatum
CNSBasal Ganglia
CHOREA
syndenham
aka San Vitus Dancerapid involuntary movement affecting the hands, feet, tongue and face.
Pericardium
MyocardiumEndocardium
Heart
Myocardium
PericardiumEndocardium
Pancarditis
Myocarditis-heart is enlarged -may develop
CCF
PericarditisMyocardiumEndocardium
“Bread and Butter”Pericarditi
s
- Completely resolved- Heal with adhesion
MyocardiumEndocardium
In patients with critical stenosis, mitral valvulotomy, percutaneous balloon
valvuloplasty, or mitral valve replacement may be indicated.
polyarthritiserythema marginatum & nodulesSydenham choreaRheumatic myocarditis & pericarditisRheumatic endocarditis
MODIFIED JONES CRITERIA FOR ACUTE RHEUMATIC FEVERMAJOR CRITERIA MINOR CRITERIA
CarditisPolyarthritis,
aseptic monoarthritis or polyathralgiaErythema marginatum
Prolonged PR interval
Subcutaneous nodules
Chorea
Fever (Temp>38oC)ESR > 30
mm/h orCRP > 30 mg/L
INVESTIGATIONS
Echocardiogram
FBC: anaemia, leucocytosisThroat swab
CXR, ECG
ASOT
How to make the diagnosisInitial episode of ARF
2MAJOR CRITERIA
1MAJOR CRITERIA 2MINOR CRITERIA
OR
++ evidence of a preceding
group A streptococcal infection
How to make the diagnosisRecurrent attack of ARF
2MAJOR CRITERIA
OR
1MAJOR CRITERIA 2MINOR CRITERIA+
+ evidence of a preceding group A streptococcal infection
3MINOR CRITERIA
OR
Evidence of a preceding group Astreptococcal infection
Increased antistreptolysin O titre (ASOT)Positive throat culture for GABHSPositive rapid antigen detection test
JONES
ITERIA
oints - artritisbvious - cardiacodules - rheumaticrythema marginatumydenham chorea
nflammatory cells (leukocytosis)emperatureSR/CRP elevatedaised PR intervaltself (Previous Hx of Rheumatic fever)thralgia
MAJO
R
MINO
R
TREATMENT
Bedrest
TREATMENTAnti-Streptococcal
TherapyIV C. Penicillin 50 000U/kg/dose 6H or
Oral Penicillin V 250 mg 6H (<30kg),
500 mg 6H (>30kg) for 10 daysOral Erythromycin for 10 days if allergic to penicillin.
TREATMENTAnti-Inflammatory
Therapymild / no carditis:
Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over
4 weeks.
TREATMENTAnti-Inflammatory
TherapyPericarditis, 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.
TREATMENTAnti-Inflammatory
TherapyMonitor Aspirin level and LFT
Watch out for
REYESSYNDROME
EncephalopathyFatty liver degenerationTransaminase elevation.
TREATMENTAnti-failure medication Diuretics, ACE inhibitors, digoxin (to
be used with caution).
TREATMENTSecondary prophylaxis
• IM Benzathine Penicillin 0.6 mega units (<30 kg)
or 1.2 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.
TREATMENTSecondary prophylaxis
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.
Accurate diagnosis is important.Jones Criteria is a good guidelineManagement include post-strep
therapy, anti-inflammatory therapy, anti-failure therapy and secondary
prophylaxisARF is a large physical, emotional and financial burden.
SummarySummary
In a case of knee swelling..
Don’t forget your stethoscope!
1. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N (2007), Robbins Basic Pathology (8th ed.), Saunders Elsevier, pp. 403–6, ISBN 978-1-4160-2973-1.2. "rheumatic fever" at Dorland's Medical Dictionary3. Jones, T Duckett (1944). "The diagnosis of rheumatic fever". JAMA 126(8):481. doi:10.1001/jama.1944.02850430015005.4. Ferrieri, P (2002). "Proceedings of the Jones Criteria workshop".Circulation (Jones Criteria Working Group) 106 (19): 2521–3.doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554.5. Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP, FACEP. Retrieved 2007-07-14.6. Malaysian Paediatric Protocol, 3rd Edition
References
References