Acute Rheumatic Fever Overview Part 3

Acute Rheumatic Fever (ARF) Definition

• Inflammatory disease from untreated or poorly treated Group A β-hemolytic streptococcal infection in the upper respiratory tract.
• Caused by antibody cross-reactivity in an autoimmune process.

Incidence

• Predominantly affects ages 5-15 years; rare in ages 2-5.
• Environmental factors: Poor living conditions and overcrowding contribute.
• Genetic predisposition may also play a role.
• Incidence and pathogenesis do not differ by sex.

Etiology and Pathogenesis

• Follows upper respiratory tract infections with GABHS.
• Disease linked to surface antigens (hyaluronic acid, M protein) that resemble host tissues.
• Antibodies against these antigens can target connective tissues in the heart, synovial membranes, and skin.
• Repeated streptococcal infections sensitize the immune system.

Clinical Manifestations: Jones Criteria

• Major Criteria:
  • Polyarthritis (70%): Swollen, tender, migratory large joints, resolves without deformity.
  • Carditis (50%): Characterized by murmurs, arrhythmias, cardiomegaly, and pericardial rub.
  • Rheumatic chorea (10%): Jerky movements and emotional instability, more common in girls.
  • Subcutaneous nodules (5%): Painless lumps adjacent to muscles.
  • Erythema marginatum (1%): Red patches on limbs and trunk.
• Minor Criteria:
  • Fever.
  • Arthralgia: Joint pain.
  • Increased PR interval on ECG.
  • Elevated antistreptolysin O titer (ASO).

Diagnosis

• At least two major criteria or one major plus two minor criteria required, along with evidence of prior streptococcal infection.
• Confirmatory tests: Positive throat culture for GABHS, elevated ASO titers.

Management: Acute Episode

• Bed rest recommended for:
  • 2 weeks without cardiitis.
  • 4 weeks with cardiitis.
  • 8 weeks with heart failure or cardiomegaly.
• Special diet: Salt and fluid restriction if cardiitis or heart failure is present.
• Antibiotics to treat streptococcal infection:
  • First choice: Benzylpenicillin.
  • Alternative for penicillin allergy: Co-trimoxazole or erythromycin.
• Anti-inflammatories for managing inflammation:
  • Without carditis: Aspirin; dosing starts high and tapers.
  • With severe carditis: Corticosteroids, starting at 2 mg/kg/day, reduced after symptoms subside.
• Rationale for corticosteroids over aspirin in carditis: Corticosteroids can prevent serious cardiac complications which aspirin cannot.

Prevention of Recurrence Post-Acute Episode

• Prophylaxis with long-acting benzathine penicillin:
  • 1,200,000 IU every 3-4 weeks.
• Duration of prophylaxis:
  • Mild/no carditis: 3 years post-last episode.
  • Moderate carditis: Continue until age 21.
  • Severe carditis/recurrent RF: Lifelong treatment.

Precautions during Treatment of ARF with Other Conditions

• TB: Avoid corticosteroids due to immunosuppression; use alongside antituberculous therapy if necessary.
• Congestive heart failure: Implement fluid and salt restrictions; exercise caution with digoxin to prevent arrhythmias.
• Diabetes: Adjust insulin if corticosteroids are used, considering possible interactions with antidiabetics.
• Peptic ulcers: Administer salicylates carefully to avoid gastric irritation; use enteric-coated preparations and consider H2 blockers or proton pump inhibitors.

Acute Rheumatic Fever (ARF) Definition

• Inflammatory disease from untreated or poorly treated Group A β-hemolytic streptococcal infection in the upper respiratory tract.
• Caused by antibody cross-reactivity in an autoimmune process.

Incidence

• Predominantly affects ages 5-15 years; rare in ages 2-5.
• Environmental factors: Poor living conditions and overcrowding contribute.
• Genetic predisposition may also play a role.
• Incidence and pathogenesis do not differ by sex.

Etiology and Pathogenesis

• Follows upper respiratory tract infections with GABHS.
• Disease linked to surface antigens (hyaluronic acid, M protein) that resemble host tissues.
• Antibodies against these antigens can target connective tissues in the heart, synovial membranes, and skin.
• Repeated streptococcal infections sensitize the immune system.

Clinical Manifestations: Jones Criteria

• Major Criteria:
  • Polyarthritis (70%): Swollen, tender, migratory large joints, resolves without deformity.
  • Carditis (50%): Characterized by murmurs, arrhythmias, cardiomegaly, and pericardial rub.
  • Rheumatic chorea (10%): Jerky movements and emotional instability, more common in girls.
  • Subcutaneous nodules (5%): Painless lumps adjacent to muscles.
  • Erythema marginatum (1%): Red patches on limbs and trunk.
• Minor Criteria:
  • Fever.
  • Arthralgia: Joint pain.
  • Increased PR interval on ECG.
  • Elevated antistreptolysin O titer (ASO).

Diagnosis

• At least two major criteria or one major plus two minor criteria required, along with evidence of prior streptococcal infection.
• Confirmatory tests: Positive throat culture for GABHS, elevated ASO titers.

Management: Acute Episode

• Bed rest recommended for:
  • 2 weeks without cardiitis.
  • 4 weeks with cardiitis.
  • 8 weeks with heart failure or cardiomegaly.
• Special diet: Salt and fluid restriction if cardiitis or heart failure is present.
• Antibiotics to treat streptococcal infection:
  • First choice: Benzylpenicillin.
  • Alternative for penicillin allergy: Co-trimoxazole or erythromycin.
• Anti-inflammatories for managing inflammation:
  • Without carditis: Aspirin; dosing starts high and tapers.
  • With severe carditis: Corticosteroids, starting at 2 mg/kg/day, reduced after symptoms subside.
• Rationale for corticosteroids over aspirin in carditis: Corticosteroids can prevent serious cardiac complications which aspirin cannot.

Prevention of Recurrence Post-Acute Episode

• Prophylaxis with long-acting benzathine penicillin:
  • 1,200,000 IU every 3-4 weeks.
• Duration of prophylaxis:
  • Mild/no carditis: 3 years post-last episode.
  • Moderate carditis: Continue until age 21.
  • Severe carditis/recurrent RF: Lifelong treatment.

Precautions during Treatment of ARF with Other Conditions

• TB: Avoid corticosteroids due to immunosuppression; use alongside antituberculous therapy if necessary.
• Congestive heart failure: Implement fluid and salt restrictions; exercise caution with digoxin to prevent arrhythmias.
• Diabetes: Adjust insulin if corticosteroids are used, considering possible interactions with antidiabetics.
• Peptic ulcers: Administer salicylates carefully to avoid gastric irritation; use enteric-coated preparations and consider H2 blockers or proton pump inhibitors.

Acute Rheumatic Fever (ARF) Definition

• Inflammatory disease from untreated or poorly treated Group A β-hemolytic streptococcal infection in the upper respiratory tract.
• Caused by antibody cross-reactivity in an autoimmune process.

Incidence

• Predominantly affects ages 5-15 years; rare in ages 2-5.
• Environmental factors: Poor living conditions and overcrowding contribute.
• Genetic predisposition may also play a role.
• Incidence and pathogenesis do not differ by sex.

Etiology and Pathogenesis

• Follows upper respiratory tract infections with GABHS.
• Disease linked to surface antigens (hyaluronic acid, M protein) that resemble host tissues.
• Antibodies against these antigens can target connective tissues in the heart, synovial membranes, and skin.
• Repeated streptococcal infections sensitize the immune system.

Clinical Manifestations: Jones Criteria

• Major Criteria:
  • Polyarthritis (70%): Swollen, tender, migratory large joints, resolves without deformity.
  • Carditis (50%): Characterized by murmurs, arrhythmias, cardiomegaly, and pericardial rub.
  • Rheumatic chorea (10%): Jerky movements and emotional instability, more common in girls.
  • Subcutaneous nodules (5%): Painless lumps adjacent to muscles.
  • Erythema marginatum (1%): Red patches on limbs and trunk.
• Minor Criteria:
  • Fever.
  • Arthralgia: Joint pain.
  • Increased PR interval on ECG.
  • Elevated antistreptolysin O titer (ASO).

Diagnosis

• At least two major criteria or one major plus two minor criteria required, along with evidence of prior streptococcal infection.
• Confirmatory tests: Positive throat culture for GABHS, elevated ASO titers.

Management: Acute Episode

• Bed rest recommended for:
  • 2 weeks without cardiitis.
  • 4 weeks with cardiitis.
  • 8 weeks with heart failure or cardiomegaly.
• Special diet: Salt and fluid restriction if cardiitis or heart failure is present.
• Antibiotics to treat streptococcal infection:
  • First choice: Benzylpenicillin.
  • Alternative for penicillin allergy: Co-trimoxazole or erythromycin.
• Anti-inflammatories for managing inflammation:
  • Without carditis: Aspirin; dosing starts high and tapers.
  • With severe carditis: Corticosteroids, starting at 2 mg/kg/day, reduced after symptoms subside.
• Rationale for corticosteroids over aspirin in carditis: Corticosteroids can prevent serious cardiac complications which aspirin cannot.

Prevention of Recurrence Post-Acute Episode

• Prophylaxis with long-acting benzathine penicillin:
  • 1,200,000 IU every 3-4 weeks.
• Duration of prophylaxis:
  • Mild/no carditis: 3 years post-last episode.
  • Moderate carditis: Continue until age 21.
  • Severe carditis/recurrent RF: Lifelong treatment.

Precautions during Treatment of ARF with Other Conditions

• TB: Avoid corticosteroids due to immunosuppression; use alongside antituberculous therapy if necessary.
• Congestive heart failure: Implement fluid and salt restrictions; exercise caution with digoxin to prevent arrhythmias.
• Diabetes: Adjust insulin if corticosteroids are used, considering possible interactions with antidiabetics.
• Peptic ulcers: Administer salicylates carefully to avoid gastric irritation; use enteric-coated preparations and consider H2 blockers or proton pump inhibitors.

Acute Rheumatic Fever (ARF) Definition

• Inflammatory disease from untreated or poorly treated Group A β-hemolytic streptococcal infection in the upper respiratory tract.
• Caused by antibody cross-reactivity in an autoimmune process.

Incidence

• Predominantly affects ages 5-15 years; rare in ages 2-5.
• Environmental factors: Poor living conditions and overcrowding contribute.
• Genetic predisposition may also play a role.
• Incidence and pathogenesis do not differ by sex.

Etiology and Pathogenesis

• Follows upper respiratory tract infections with GABHS.
• Disease linked to surface antigens (hyaluronic acid, M protein) that resemble host tissues.
• Antibodies against these antigens can target connective tissues in the heart, synovial membranes, and skin.
• Repeated streptococcal infections sensitize the immune system.

Clinical Manifestations: Jones Criteria

• Major Criteria:
  • Polyarthritis (70%): Swollen, tender, migratory large joints, resolves without deformity.
  • Carditis (50%): Characterized by murmurs, arrhythmias, cardiomegaly, and pericardial rub.
  • Rheumatic chorea (10%): Jerky movements and emotional instability, more common in girls.
  • Subcutaneous nodules (5%): Painless lumps adjacent to muscles.
  • Erythema marginatum (1%): Red patches on limbs and trunk.
• Minor Criteria:
  • Fever.
  • Arthralgia: Joint pain.
  • Increased PR interval on ECG.
  • Elevated antistreptolysin O titer (ASO).

Diagnosis

• At least two major criteria or one major plus two minor criteria required, along with evidence of prior streptococcal infection.
• Confirmatory tests: Positive throat culture for GABHS, elevated ASO titers.

Management: Acute Episode

• Bed rest recommended for:
  • 2 weeks without cardiitis.
  • 4 weeks with cardiitis.
  • 8 weeks with heart failure or cardiomegaly.
• Special diet: Salt and fluid restriction if cardiitis or heart failure is present.
• Antibiotics to treat streptococcal infection:
  • First choice: Benzylpenicillin.
  • Alternative for penicillin allergy: Co-trimoxazole or erythromycin.
• Anti-inflammatories for managing inflammation:
  • Without carditis: Aspirin; dosing starts high and tapers.
  • With severe carditis: Corticosteroids, starting at 2 mg/kg/day, reduced after symptoms subside.
• Rationale for corticosteroids over aspirin in carditis: Corticosteroids can prevent serious cardiac complications which aspirin cannot.

Prevention of Recurrence Post-Acute Episode

• Prophylaxis with long-acting benzathine penicillin:
  • 1,200,000 IU every 3-4 weeks.
• Duration of prophylaxis:
  • Mild/no carditis: 3 years post-last episode.
  • Moderate carditis: Continue until age 21.
  • Severe carditis/recurrent RF: Lifelong treatment.

Precautions during Treatment of ARF with Other Conditions

• TB: Avoid corticosteroids due to immunosuppression; use alongside antituberculous therapy if necessary.
• Congestive heart failure: Implement fluid and salt restrictions; exercise caution with digoxin to prevent arrhythmias.
• Diabetes: Adjust insulin if corticosteroids are used, considering possible interactions with antidiabetics.
• Peptic ulcers: Administer salicylates carefully to avoid gastric irritation; use enteric-coated preparations and consider H2 blockers or proton pump inhibitors.

Acute Rheumatic Fever (ARF) Definition

• Inflammatory disease from untreated or poorly treated Group A β-hemolytic streptococcal infection in the upper respiratory tract.
• Caused by antibody cross-reactivity in an autoimmune process.

Incidence

• Predominantly affects ages 5-15 years; rare in ages 2-5.
• Environmental factors: Poor living conditions and overcrowding contribute.
• Genetic predisposition may also play a role.
• Incidence and pathogenesis do not differ by sex.

Etiology and Pathogenesis

• Follows upper respiratory tract infections with GABHS.
• Disease linked to surface antigens (hyaluronic acid, M protein) that resemble host tissues.
• Antibodies against these antigens can target connective tissues in the heart, synovial membranes, and skin.
• Repeated streptococcal infections sensitize the immune system.

Clinical Manifestations: Jones Criteria

• Major Criteria:
  • Polyarthritis (70%): Swollen, tender, migratory large joints, resolves without deformity.
  • Carditis (50%): Characterized by murmurs, arrhythmias, cardiomegaly, and pericardial rub.
  • Rheumatic chorea (10%): Jerky movements and emotional instability, more common in girls.
  • Subcutaneous nodules (5%): Painless lumps adjacent to muscles.
  • Erythema marginatum (1%): Red patches on limbs and trunk.
• Minor Criteria:
  • Fever.
  • Arthralgia: Joint pain.
  • Increased PR interval on ECG.
  • Elevated antistreptolysin O titer (ASO).

Diagnosis

• At least two major criteria or one major plus two minor criteria required, along with evidence of prior streptococcal infection.
• Confirmatory tests: Positive throat culture for GABHS, elevated ASO titers.

Management: Acute Episode

• Bed rest recommended for:
  • 2 weeks without cardiitis.
  • 4 weeks with cardiitis.
  • 8 weeks with heart failure or cardiomegaly.
• Special diet: Salt and fluid restriction if cardiitis or heart failure is present.
• Antibiotics to treat streptococcal infection:
  • First choice: Benzylpenicillin.
  • Alternative for penicillin allergy: Co-trimoxazole or erythromycin.
• Anti-inflammatories for managing inflammation:
  • Without carditis: Aspirin; dosing starts high and tapers.
  • With severe carditis: Corticosteroids, starting at 2 mg/kg/day, reduced after symptoms subside.
• Rationale for corticosteroids over aspirin in carditis: Corticosteroids can prevent serious cardiac complications which aspirin cannot.

Prevention of Recurrence Post-Acute Episode

• Prophylaxis with long-acting benzathine penicillin:
  • 1,200,000 IU every 3-4 weeks.
• Duration of prophylaxis:
  • Mild/no carditis: 3 years post-last episode.
  • Moderate carditis: Continue until age 21.
  • Severe carditis/recurrent RF: Lifelong treatment.

Precautions during Treatment of ARF with Other Conditions

• TB: Avoid corticosteroids due to immunosuppression; use alongside antituberculous therapy if necessary.
• Congestive heart failure: Implement fluid and salt restrictions; exercise caution with digoxin to prevent arrhythmias.
• Diabetes: Adjust insulin if corticosteroids are used, considering possible interactions with antidiabetics.
• Peptic ulcers: Administer salicylates carefully to avoid gastric irritation; use enteric-coated preparations and consider H2 blockers or proton pump inhibitors.

This quiz covers the definition and implications of Acute Rheumatic Fever (ARF) as an inflammatory disease. It explores the complications that arise from untreated streptococcal infections and provides insights into prevention and management.