Rheumatic Fever Overview

Rheumatic Fever

• Rheumatic fever is an inflammatory disease that can affect the heart, joints, brain, and skin.
• It is caused by a bacterial infection with group A Streptococcus (GABHS).
• The bacteria can trigger an autoimmune response, where the body's immune system attacks its own tissues.

Clinical Features

• Rheumatic fever usually develops 2-3 weeks after a streptococcal infection like strep throat or scarlet fever.
• Major criteria:
  • Carditis: inflammation of the heart (40-50% of cases)
  • Polyarthritis: inflammation of multiple joints
  • Chorea: involuntary movements, more common in girls (8-12 years old)
  • Erythema Marginatum: a rash that looks like a red ring
  • Subcutaneous Nodules: small, painless lumps under the skin
• Minor Criteria:
  • Fever (38.4- 40 °C)
  • Arthralgia (joint pain)
  • Prolonged P-R interval on ECG
  • Elevated acute phase reactants (ESR, C-reactive protein, leukocytosis)
  • Anti-DNAse B test
• Jones Criteria: diagnosis requires 2 major criteria, OR 1 major and 2 minor criteria, supported by evidence of a recent strep infection.

Treatment

• Primary Prevention (eradication of streptococci):
  • Treatment of streptococcal pharyngitis with penicillin or erythromycin for 10 days.
• Secondary Prevention (prevention of recurrence):
  • Long-acting penicillin (Benzathine penicillin) - given every 3-4 weeks for a minimum of 5 years after the last episode for individuals without carditis.
  • For those with carditis, long-term prophylaxis is recommended for at least 10 years or until the age of 40 for cases with residual valve damage.
• Step II: Anti-inflammatory Treatment:
  • Oral salicylates (aspirin) for typical migratory polyarthritis and carditis without cardiomegaly or congestive heart failure.
  • Corticosteroids (prednisone) for carditis with cardiomegaly and/or congestive heart failure.
• Step III: Supportive Management & Management of Complications:
  • Bed rest
  • Treatment of congestive cardiac failure (diuretics, vasodilators, digoxin cautiously)
  • Treatment of chorea (phenobarbital or haloperidol)
  • Rest to joints and supportive splinting

Diagnosis

• Rheumatic fever diagnosis is primarily clinical.
• No single diagnostic test exists.

Complications

• Congestive Heart Failure:
  • Acute: due to myocarditis
  • Chronic: episodes of acute failure precipitated by rheumatic activity, infective endocarditis, chest infections
• Cardiomegaly: heart enlargement due to carditis, heart failure, or multivalvular lesions.
• Chronic Valve Lesions: permanent damage to heart valves due to carditis, especially in recurrences.
• **Rheumatic Activity (Recurrences): **
  • Suggested by fever, arthritis/arthralgia, changes in heart murmurs.
  • Can diagnose rheumatic fever attacks in the presence of recent streptococcal infections.
• Pulmonary Hypertension:
  • Due to long-standing mitral valve lesions.

Prognosis

• Rheumatic fever can recur with new GABHS infections, especially if not on prophylactic medication.
• Good prognosis for older age groups and those without carditis during the initial attack.
• Bad prognosis for younger children and those with carditis with valvular lesions.

This quiz covers the key features and clinical aspects of rheumatic fever, an inflammatory disease linked to streptococcal infections. It includes information on major and minor criteria as well as associated symptoms and complications. Test your understanding of this complex condition and its impact on the body.