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Rheumatic Fever

Study guide:

Definition:
An acute systemic inflammatory disease of children and young adults caused by pharyngeal infection with Group A beta-haemolytic streptococci (GAS).

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Epidemiology​

  • Affects age between 5 and 15 years old.

  • Females > Males.

Estimated number of 12 million individuals suffered from RF and RHD worldwide.

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Pathophysiology:

  1. In genetically susceptible individuals, cross reactivity of M proteins of the infecting group A streptococci and cardiac myosin and laminin (the sarcolemmal membrane protein).

  2. Type II hypersensitivity.

  3. Typically 1-3 week following the onset of the pharyngeal GAS infection.

  4. GAS M proteins share epitopes with proteins found in synovium, heart muscle, and heart valve, suggesting that molecular mimicry contributes to the arthritis, carditis, and valvular damage.

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Risk Factors:

  1. Genetic host risk factors.

  2. Under nutrition.

  3. Overcrowding.

  4. Lower socioeconomic status.

 

Clinical Presentation:

  • Jones criteria

* Diagnosis requires 2 major or 1 major and 2 minor. 

Heart failures symptoms (Dyspnea without rales, nausea and vomiting, epigastric ache, hacking, nonproductive cough, and marked lethargy and fatigue).

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Diagnosis:

  1. Clinical (Jones criteria).

  2. ECG will show PR prolongation or ST segment and T wave changes.

  3. Echocardiography will detect carditis and differentiate between rheumatic carditis and other heart diseases.

 

Management:

  • Treatment of acute episode:

    1. High-dose aspirin (to reduce inflammation).

    2. Penicillin (to eliminate residual streptococcal infection).

  • Primary treatment (when the patient comes with sore throat but not yet developed the rheumatic fever):

    1. IM injection one dose (benzathine penicillin G). Erythromycin if allergic.

    2. If the ESR is high (indicating inflammation) à corticosteroids (Prednisone) or NSAIDs should be given until it stays normal for a week.

  • Secondary treatment (The patient already had rheumatic fever but we want to prevent it from occurring again):

    1. One injection of IM benzathine penicillin G every one month (sulfadiazine, then erythromycin if allergic).

 

Prognosis:

  1. 50% of patients will eventually develop RHD.

  2. Some patients will have heart failure.

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References:

  • Kumarp,clarkm. Kumar&clark'sclinicalmedicine.8thed.edinburgh:saunders elsevier; 2012.

  • Colledgen,walkerb,ralstons.davidson'sprinciplesandpracticeofmedicine. 21st ed. London: elsevier; 2010.

  • Lillyl. Pathophysiology of heart disease.1sted.philadelphia:wolters kluwer/lippincott williams & wilkins; 2010.

  • Pesslerf,sherryd. Rheumatic fever: merckmanual professional[internet]. Merckmanuals.com. 2012 [13 may 2014]. Available from: http://www.merckmanuals.com/professional/pediatrics/rheumatic_fever/rheumatic_ fever.html

  • Lissauert,claydeng. Illustrated textbook of paediatrics. 4th ed.london: elsevier; 2012.

  • Tally n, O’Connor’s. Clinical examination:a systematic guide to physical diagnosis. 6th ed. Australia: elsevier; 2010.

  • Emedicalhub.com. Erythema Marginatum - Pictures, Symptoms and Treatment [Internet]. 2015 [cited 25 December 2015]. Available from: http://emedicalhub.com/erythema-marginatum/

  • Riciu A. Rheumatic Fever Symptoms, Clinical Signs, Evolution And Treatment [Internet]. Doctor Tipster. 2011 [cited 25 December 2015]. Available from: http://www.doctortipster.com/1789-rheumatic-fever.htm

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Written by:     Lama Al Luhidan


Reviewed by:    Roaa Amer


Format editor:  Bader Altamimi

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Web Publisher: Bayan Alzomaili

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