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Cardiology II (Acute Rheumatic Fever)
Terms in this set (37)
This is a delayed, non-suppurative sequelae of a pharyngeal infection with group A streptococcus
Acute Rheumatic Fever
What age is most commonly affected by acute Rheumatic Fever?
Most commonly 5-15 years old.
In all instances how does Acute Rheumatic fever start?
Occurs as a delayed sequelae of group A streptococcal pharyngitis, including pharyngitis associated with scarlet fever.
Can Rheumatic fever occur as a result of a streptococcal skin infection?
T or F. Pharyngitis may have been asymptomatic in up to 50% of the cases that lead to Rheumatic fever
What are some non-specific symptoms of Acute Rheumatic Fever?
2) Joint aches
3) Abdominal pain
What are some specific symptoms of Acute Rheumatic Fever?
1) Arthritis that affects numerous joints but emerges in on joint at a time
2) Abnormal heart beat
3) Chest Pain
4) Red patches on skin
5) Small painless lumps beneath skin
6) Rapid, involuntary movements in muscles of extremities or face
If there is an index of suspicion of Acute Rheumatic fever, what must be considered?
If you have an index of suspicion, think about the Jones criteria.
- Major criteria
- Minor criteria
What are the "Major" Jones Criteria?
J = Joints (Migratory polyarthritis)
<3= Carditis (heart involvement)
N = Nodules (Subcutaneous)
E = Erythema marginatum
S = Sydenham's chorea
What are the manifestations of "J = Joints" (Migratory POLYARTHRITIS)?
Migratory Poly-ARTHRITIS (75% of patients)
- Most often affect large joints of extremities
- Extremely painful, with rubor, calor, tumor, dolor
- Typically disappears in less than 4 weeks
What are the manifestations of "<3) = Carditis?
Carditis (50-65% of patients)
- When present, appears early in course of disease
- New murmur of mitral (most common) or aortic insufficiency
- Pancarditis and pericardial friction rub
- Congestive heart failure
What are the manifestations of N = Nodules (Subcutaneous)?
Subcutaneous nodules (~3% of patients)
- Firm, painless nodules usually on wrists, elbows, knees, and Achilles tendons (pea sized)
- Nodules nearly always occur in association with carditis
What are the manifestations of S = Sydenham's chorea?
Sydenham's chorea (St. Vitus' dance) (20% of patients)
- Rapid, uncontrolled motions of face and upper extremities
- Sometimes ceases during sleep
- Rare in adults, especially males
- Appears very late in the course (3-6 months later)
What are the manifestations of E = Erythema marginatum?
Erythema Marginatum (<5% of patients)
- Non-pruritic, non-painful eruption
- Raised or flat erythematous patches, commonly on trunk and proximal extremities
- Center of each patch returns to normal in advance of margins (central clearing)
- Generally associated with subcutaneous nodules, nearly always seen in conjunction with carditis
Demonstrate the onset of symptoms in Acute Rheumatic Fever
What are the minor J<3NES criteria?
1) Other ARTHRALGIAS (without arthritis)
2) Fever: 101°F to 104°F
3) Elevated acute phase reactants (ESR and CRP)
4) Prolonged PR Interval on ECG
5) Prior history of rheumatic fever
What must I have in order to support a diagnosis of Rheumatic Fever?
Supportive evidence of antecedent group A Streptococcal pharyngitis
- Positive throat culture
- Positive rapid streptococcal antigen test
If the rapid streptococcal antigen test or and the throat culture comes back negative but I still have a high index of suspicion in diagnosing Rheumatic Fever, what can I do?
Elevated (especially rising) streptococcal antibody testing:
- ASO (antistreplysin O)
- Anti-DNase B
- ASTZ (antistreptozyme)
What are the diagnosis criteria Rheumatic Fever?
1) Must have two major manifestations
2) One major manifestation and two minor manifestations
What are exceptions to the Jones Criteria?
1) Chorea may be the sole manifestation of ARF
2) Indolent carditis may be the sole manifestation in patient who fail to seek early medical treatment
3) Individuals with a history of ARF should be presumed to have recurrence with any manifestations.
What are the labs that can be ordered in suspected Rheumatic Fever?
1) Streptococcal throat culture (swab)
2) Blood cultures
3) Streptococcal Antibody Titers:
- ASO, AntiDNase B, or ASTZ
4) Acute Phase Reactants (CRP and ESR)
What imaging studies can be ordered for Acute Rheumatic Fever?
1) CXR: Look for cardiomegaly & heart Failure
2) ECG: Look for heart blocks
3) Echo: look for carditis
Due to many systemic manifestations of ARF, the differential diagnosis is broad. A high index of suspicion must be maintained in patients who manifest with any cardinal symptoms following _________
What are the differential diagnosis for Rheumatic Fever?
1) Bacterial endocarditis
2) Viral myocarditis
3) Systemic Lupus
4) Serum Sickness
5) Rheumatoid arthritis
5) Infectious arthritis
What are the treatment considerations in Rheumatic Fever?
1) Symptomatic relief
2) Carditis treatment
3) Antibiotic treatment
4) Antibiotic prophylaxis
Most patients are hospitalized
What are the goals of treatment in Acute Rheumatic Fever?
1) Symptomatic relief of acute disease manifestations
2) Eradication of group A beta-hemolytic streptococcus
3) Prophylaxis against future infection to prevent recurrent cardiac disease
Yea but what about slowing down the progression of valvular disease in Acute Rheumatic Fever?
There is no therapy that slows the progression of valvular damage in patients with ARF
What is the symptomatic relief in Acute Rheumatic Fever?
- Aspirin: 4-8 grams qd
- Serum levels at 20-30mg/dl
- Bed rest until dramatic relief in fever and arthralgias
- Continue until all symptoms are absent and ESR levels are normalized
What is the treatment of carditis in Acute Rheumatic Fever?
1) Treat heart failure using conventional therapy
2) Treat heart block using conventional therapy
3) Corticosteroids: used if no response to ASA
- Prednisone 1-2mg/kg/day
- Usually need 4-12 weeks of therapy with tapering dose
4) Valve repair or replacement for non-responsive heart failure
What is the antibiotic treatment in Acute Rheumatic Fever?
1) Antibiotic therapy with penicillin should be started and maintained for at least 10 days, regardless of the presence or absence of pharyngitis at the time of diagnosis.
- Children: Rx: Penicillin VK, 250mg bid-tid
- Adults: Rx: Penicillin VK, 500mg bid-tid
- Bicillin LA may be used IM once in lieu of oral PCN
o Children: 600,000 UNITS
o Adults: 1.2 Million Units
2) PCN allergic patients should be treated with Erythromycin
Aside from the acute use of antibiotics, should antibiotic prophylaxis be used in Acute Rheumatic Fever?
Antibiotic prophylaxis: the goal of antibiotic prophylaxis against Group A Beta-Hemolytic Streptococcus is to prevent recurrence of acute rheumatic fever.
Prophylaxis guidelines are not clear as to the duration of therapy. Consensus seems to be that therapy should be continued at least until the patient is a young adult (18-20 years old) or five years following acute manifestation of ARF
What are the options for antibiotic prophylaxis?
1) Antibiotic prophylaxis
- IM Penicillin [1.2million units q 3-4 weeks]
- Oral penicillin VK, 250mg bid
Allergic to PCN?
- Oral sulfadiazine, 0.5 - 1mg/kg/day
- Erythromycin 250mg BID
What are the guidelines regarding antibiotic prophylaxis?
1) At least 10 years after last attack, generally until age 40
2) Patients with established rheumatic heart disease: life long therapy
Patients with rheumatic valvular disease may also need endocarditis prophylaxis.
Describe the threshold for the treatment of pharyngitis after Acute Rheumatic Fever?
After completion of therapy, there should always be a very low threshold to test/treat acute episodes of pharyngitis.
What is the most severe sequela of Acute Rheumatic Fever?
Rheumatic heart disease
What is the most commonly affected valve in Acute Rheumatic Fever?
Mitral valve most commonly affected (Mitral stenosis)
- Also commonly affects the Aortic Valve
- May rarely affect the tricuspid valve
What is the prognosis of Acute Rheumatic Fever?
1) Occurs 10-20 years after the original illness
2) Major cause of valvular heart disease worldwide
3) Likely to occur in at least 50% of patients with carditis on initial presentation
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