Erythema marginatum —

evanescent, pink or faintly red, non-pruritic rash involving the trunk and sometimes the limbs.The outer edge of the lesion is sharp; the inner edge is diffuse. The lesion is also known as"erythema annulare“ since the margin of the lesion is usually continuous, making a ring.

Subcutaneous nodules —

• firm, painless lesions ranging from a few millimeters to 2 cm in size.

•located over a bony surface or prominence or near tendons (usually extensor surfaces)and are usually symmetric.

•The overlying skin is not inflamed and usually can be moved over the nodules The number of nodules varies from a single lesion to a few dozen; the averagenumber is three or four.

Sydenham chorea —chorea minor or "St. Vitus dance"abrupt, nonrhythmic involuntary movements, muscular weakness, and emotional disturbances.

The movements frequently are more marked on one side, are occasionally unilateral (hemichorea),and cease during sleep. Muscle weakness is best demonstrated by asking the patient to squeeze the examiner's hands. The pressure of the patient's grip increases and decreases capriciously, a phenomenon known asrelapsing grip or "milk maids sign.“.

Carditis —pancarditis, affecting the pericardium, epicardium, myocardium, and endocardium.

mild to moderate chest discomfort and pleuriticchest pain.

Physical examination may demonstrate new or changing murmurs;

mitral regurgitation is the most common early valvular manifestation.

Pericardial friction rub is indicative of pericarditis.

Severe valvular damage together with myocardial dysfunction due to myocarditis can lead to heart failure.

Ecg findings may demonstrate any degree of heart block, including atrioventriculardissociation. Chest radiography may demonstrate cardiomegaly.

Arthritis —

The knees, ankles, elbows, and wrists are affected most commonly

The onset of arthritis in different joints usually overlaps, giving the appearance that the disease "migrates" from joint to joint.

Onset and resolution of arthritis may be rapid (within 1 to 2 days) and the arthritis may be severe enough to severely limit movement.

Analysis of the synovial fluid in rheumatic fever with arthritis generally demonstrates sterile inflammatory fluid.

Treatment and prevention• There is no therapy that slows progression of valvular damage in the

setting of Acute Rheumatic Fever (ARF). There are three major goals of treatment:

• Symptomatic relief of acute disease manifestations

• Eradication of the group A beta-hemolytic streptococcus (GAS)

• Prophylaxis against future GAS infection to prevent recurrent cardiac disease

TREATMENT —

• Antibiotic therapy — Patients with acute rheumatic fever should be initiated on antibiotic therapy to eradicate GAS carriage.– management of streptococcal pharyngitis, – throat cultures performed,if positive a full course of antibiotic therapy

• Carditis — Patients with severe carditis (significant cardiomegaly, congestive heart failure, and/or third-degree heart block) should be treated with conventional therapy for heart failure.

• Valve surgery may be necessary when heart failure due to regurgitant lesions cannot be managed with medical therapy alone.

• Aspirin (80 to 100 mg/kg per day in children and 4 to 8 g/day in adults) is the major anti-inflammatory agent for relief of symptoms due to acute rheumatic fever.

• Arthritis and rash — Aspirin (80 to 100 mg/kg per day in children and 4 to 8 g/day in adults) is helpful for reducing discomfort related to arthritis and fever.

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