Rheumatic Fever

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Acute Rheumatic fever

delayed sequelae
of group A streptococcal pharyngitis, including
pharyngitis associated with scarlet fever.

• Joint aches
• Abdominal pain
• Weakness
• Fatigue

Non specific symptoms

Specific symptoms of Rheumatic fever

• Arthritis that affects numerous joints but emerges in on joint at a
• Abnormal heart beat
• Chest Pain
• Red patches on skin
• Small painless lumps beneath skin
• Rapid, involuntary movements in muscles of extremities or face

Jones Criteria

Must have two major manifestations or
• One major manifestation and two minor

Exceptions to Jones Criteria

• Chorea may be the sole manifestation of ARF
• Indolent carditis may be the sole manifestation
in patient who fail to seek early medical
• Individuals with a history of ARF should be
presumed to have recurrence

Diagnostic criteria

Must have supportive evidence of antecedent
group A Streptococcal pharyngitis
• Positive throat culture
• Positive rapid streptococcal antigen test
• Elevated (especially rising) streptococcal
antibody testing:

Minor Manifestations:

• Other arthralgias
• Fever: 101 F to 104 F
• Elevated acute phase reactants (ESR and CRP)
• Prolonged PR Interval on ECG
• Prior history of rheumatic fever

Major Manifestations:

Migratory Poly-arthritis
Subcutaneous nodules
Sydenham's chorea
Erythema Marginatum

CXR findings:

• Cardiomegaly
• Kerly B lines
• Heart Failure


Heart block

Lab findings:

• + Streptococcal Antibody Titers:
• AntiDNase B
• + Streptococcal throat culture
• Elevated Acute Phase Reactants (CRP and ESR)

Differential diagnosis (ARF has many systemic manifestations and could be confused with these due to s/s)

• Bacterial endocarditis
• Viral myocarditis
• Systemic Lupus
• Serum Sickness
• Rheumatoid arthritis
• Infectious arthritis

Treatment goals for your pt with ARF

• Symptomatic relief of acute disease
• Eradication of group A beta-hemolytic
• Prophylaxis against future infection to
prevent recurrent cardiac disease

What therapy will slowdown the valvular portion of the disease process

There is no therapy that slows the progression of valvular damage in patients with ARF

Symptomatic relief:

Anti-inflammatory agents

Anti-inflammatory agents used for symptomatic relief of ARF

• Aspirin: 4-8 grams qd
• Serum levels at 20-30mg/dl
• Dramatic relief in fever and arthralgias
• Continue until all symptoms are absent and
ESR levels are normalized

Treatment of Carditis:

• Treat heart failure using conventional therapy
• Treat heart block using conventional therapy
• Corticosteroids:
• Prednisone 2mg/kg/day
• Valve repair or replacement for non-
responsive heart failure


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.

What ABX should you use to treat a pt with ARF that also has a penicillin allergy?

• PCN allergic patients should be treated with

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 penicillin

Children Bicillin Rx

600,000 UNITS

Adults Bicillin Rx

1.2 million UNITS

Antibiotic prophylaxis:

the goal of antibiotic prophylaxis against Group A Beta-Hemolytic Streptococcus is to prevent recurrence of acute rheumatic fever.

How long should you continue a pt on ABX prophylaxis?

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

According to WHO guidelines Patients with proven carditis should remain on ABX therapy until?

5 years therapy or until age 18

According to WHO guidelines Patients with mild mitral regurgitation should remain on ABX therapy until?

at least 10 years prophylaxis or until age 25

According to WHO guidelines Patients with severe valve
disease/replacement should remain on ABX therapy until?

Lifelong therapy

What is the most severe sequela
of ARF

Rheumatic heart disease
• Occurs 10-20 years after the original illness
• Major cause of valvular heart disease worldwide
• Likely to occur in at least 50% of patients with carditis on initial presentation

What valve is most commonly affected in rheumatic heart disease

Mitral valve (mitral stenosis)

Other than the mitral valve what other valve is commonly affected

The Aortic Vavlve

The Valve rarely affected in rheumatic heart disease

Tricuspid valve

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