Written by Dr.Md.Redwanul Huq (Masum)

Sunday, 17 March 2013 12:17

Definition:

Acute Rheumatic fever is a multi system non-supporative inflammatory disease that involves heart, joints, skin or subcutaneous tissue, CNS and caused by infection of group A beta haemolytic streptococcus in the upper respiratory tract.

Predisposing factors:

• Overcrowding
• Poor socio economic condition
• Unhygienic living status.

Clinical features:

History:

History of sore throat 1 -3 weeks ago in case of children usually between 5 – 15 years of age.

Signs-symptoms:

1. Fever
2. Carditis:
It can be of following types-
a)      Pericarditis: It results following features-
i)        Sharp or stabbing retro-sternal chest pain which is provoked by deep breathing, movement or swallowing and may have radiation to shoulder or neck.
ii)      Pericardial friction rubs.
iii)    If pericardial effusion develops- there is breathlessness and retro-sternal oppression.

b)      Myocarditis: It results following features-
i)                    Central chest pain
ii)                  Palpitation and sinus tachycardia
iii)                May have features of heart failure due to muscular dysfunction

c)      Endocarditis: It results following features-
i)                    Palpitation and fatigability
ii)                  Reduced intensity in 1^st heart sound
iii)                Presence of 3^rd heart sound (gallop rhythm)
iv)                New or altered cardiac murmur
v)                  Conduction defect may cause syncope
vi)                Features of heart failure due to mitral or aortic regurgitation.

3. Polyarthritis:
a)      Symmetrical migratory polyarthritis (features are-pain, tenderness, swelling, redness and impaired movements of joints) affecting large joints e.g. knee, ankle, wrist, elbow.
b)      Subsides within 3 weeks of onset without any residual abnormality.
4. Sydenham’s chorea:
a)      It develops six months or more after initial infection.
b)      Spasmodic, semi-purposeful, involuntary, non-repetitive jerky movement of various joints of the body most noticeable in the face and there is changed speech and hand writing.

5. Erythema marginatum:
These are temporary pink rashes with a little raised edge, which progressively fades at the centre resulting in red rings on margins. These are mostly found on the trunk and limbs of children and may join together or overlie.

6.Sub- cuteneous nodules:
These are small, firm, painless nodules (less than 0.5 mm) which are best felt over bones, tendons or joints and are associated with more severe carditis.

Diagnosis of rheumatic fever:

Revised Jones criteria for diagnosis of Acute Rheumatic fever:

Major criteria	Minor criteria
CarditisMigratory PolyarthritisSydenham’s ChoreaErythema marginatum Subcutaneous nodule	Clinical criteria- Fever Arthralgia (pain in joints) Previous history of rheumatic fever or rheumatic heart disease   Laboratory findings- Increased ESR Increased C reactive protein level Leukocytosis Prolonged PR interval on ECG

In addition to the above criteria- evidence of previous group A beta haemolytic streptococcus infection:

• Throat swab for C/S-Positive
• Rapid antigen test
• Increased streptococcal antibody titer (ASO titer).

Investigations:

TC, ESR, CRP, ASO titer, throat swab for C/S, ECG, Chest X-ray, Echocardiogram.

Interpretation:

2 major criteria and evidence of preceding group A beta haemolytic streptococcus infection

Or,

1 major and 2 minor jones criteria and evidence of preceding group A beta haemolytic streptococcus infection.

Exceptions of Jones criteria:

1. Chorea- if other causes of chorea are excluded
2. Insidious or late onset carditis with no other explanations.

Treatment for rheumatic fever:

[HINTS: Contd-To be continued, M- Month, ±M- Before or After Meal, AM- After Meal, ½HBM- ½ Hour Before Meal,W- Week, D-Day.2HAM- 2 Hour After Meal,bid-Twice daily, tid-Three times daily,qid-Four times daily.]

1.Tab. Phenoxymethyl Penicillin (250 mg)

1 tab – 6 hourly ( 1 HBM)—————10 D

Or,

Cap.Cefradine (500 mg)

1 cap – 6 hourly (AM)—————10 D

Or,

Tab. Erythromycin (500 mg) [If Patient is sensitive to Penicillin]

1tab – 6 hourly (1 HBM or 2 HAM)—————10 D

Or,

Inj. Benzathine Penicillin (30 Kg – 12 lac U/vial)

1 vial Deep IM (in buttock) – Stat

Then,

* Tab.Phenoxymethyl Penicillin (250 mg)

1 tab – 12 hourly

Or,

* Inj.Benzathine Penicillin (30 Kg – 12 lac U/vial)

1 vial Deep IM (in buttock)—————————3 Wkly

for following durations:

*RF without Carditis – Upto 21 yrs or 5 yrs – whichever is longer

*RF with Carditis but no residual valvular lesion – Upto 30 yrs or 10 yrs – whichever is longer

*RF with Carditis with residual valvular lesion – Life long.

2.Tab. Aspirin

At beginning- 60 mg/kg/day in 6 divided doses

Then,

maximum 120mg/kg/day [ Not more than 8gm/day] in 6 divided doses for 4-6 Weeks, then

tapered over 2-3 Weeks (Reducing by 25% in each week).

3.Tab. Prednisolone  [If carditis or severe arthritis]

1-2 mg/kg/day in 4 divided doses until ESR becomes normal, then

tapered over 2-4 weeks, during this tapering period Tab. Aspirin should be given

75 mg/kg/day in 6 divided doses.

4.Cap. Omeprazole (20/40 mg)/ Tab. Esomeprazole (20/40 mg)

1 cap/tab-bid (½ HBM) —————1 / 2 M

Complications:

1. Rheumatic valvular diseases–

Mitral regurgitation and its complications

Mitral stenosis and its complications

Aortic regurgitation.

2. Infective endocarditis
3. Pericardial effusion.