Rheumatic Fever PDF
Document Details
Uploaded by Deleted User
Tags
Summary
This document provides an overview of Rheumatic Fever, including its causes, symptoms, diagnosis, treatment, and prevention. It details the various risk factors and potential complications. This document is intended for medical education or reference purposes.
Full Transcript
Case Of Rheumatic Fever Rheumatic Fever o Acute rheumatic fever (ARF) is a complication of pharyngeal infection with group A Streptococcus. Signs and symptoms of ARF develop two to three weeks following pharyngitis and include arthritis, carditis, chor...
Case Of Rheumatic Fever Rheumatic Fever o Acute rheumatic fever (ARF) is a complication of pharyngeal infection with group A Streptococcus. Signs and symptoms of ARF develop two to three weeks following pharyngitis and include arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum. o Risk factors: 1- Age: more common in children than adults; in School-age children (5-15 years old). 2- Genes: Some people have one or more genes that might make them more likely to develop rheumatic fever. 3- Environmental factors: Overcrowding, poor sanitation and other conditions can cause bacteria to easily spread among many people. o Causes: 1- Rheumatic fever can happen after a throat infection from group A beta hemolytic streptococci. Improperly treated strep throat infections cause rheumatic fever. 2- Group A strep infections of the skin or other parts of the body rarely cause rheumatic fever. o Pathogenesis: The pathogenic mechanism of molecular mimicry involves autoantibodies and T cells directed against group A streptococcal cell wall (M protein) and proteins of many tissues as they mimic bacterial one. o Presentation: - History of streptococcal pharyngitis or skin infections in high-risk populations about 2 – 4 weeks before attack of ARF. - Symptoms: Arthritis (painful wrist, knee, elbow or ankle joints). Chorea (jerky, uncontrollable body movements). Fatigue (tiredness). Fever. Nodules near joints. Rash. - Complications: if ARF is not treated promptly, rheumatic heart disease may occur. Rheumatic heart disease weakens the valves. Patient may present with: Chest pain. Tachycardia. Dyspnea. Murmurs o Diagnosis of ARF based on modified Jones Criteria as following: The presence of 2 major criteria or 1 major and 2 minor criteria is required for the diagnosis of an initial episode of ARF in any risk population. The diagnosis of a recurrent episode of ARF requires 2 major criteria, 1 major and 2 minor criteria, or 3 minor criteria. - Major criteria: 1- Rheumatic arthritis. 2- Rheumatic carditis. 3- Rheumatic chorea. 4- Subcutaneous nodules. 5- Erythema marginatum. - Minor criteria: 1- Polyarthralgia. 2- Fever ≥38.5° C. 3- ESR >60 mm/h and/or CRP >3.0 mg/dL. 4- ECG with prolonged PR interval. 5- Laboratory serological testing to assess recent infection. Antistreptolysin O (ASO) or antideoxyribonuclease antibody titer are most utilized. These titers usually rise 2 to 3 weeks after infection. o Treatment of rheumatic fever: 1- Treatment of Acute Rheumatic fever. 2- Prevention of Rheumatic fever. 3- Prevention against bacterial endocarditis. Treatment of Acute Rheumatic Fevre The goals of ARF therapy are to: - Relieve symptoms. - Eradicate streptococcal infection. - Prevent future recurrences. - Mitigate cardiac damage. Lines of ARF treatment: I- Hospitalisation are recommended to confirm the diagnosis and facilitate prompt access to an echocardiogram. II- Treatment of symptoms that include: 1- Arthritis: a. Naproxen and ibuprofen (NSAIDs) are the first-line anti-inflammatory analgesics for rheumatic arthritis. Aspirin is now used second line due to its safety profile. Dose of therapy, 100mg/kg/day for 2 weeks, then give 75mg/kg/day for other 2 weeks then 50mg/kg/day for last 2 weeks. b. Proton pump inhibitor (Omeprazole) for gastric protection for patients requiring prolonged anti-inflammatory treatment. c. Analgesic antipyretic only without anti-inflammatory effect as paracetamol; safer than NSAIDs with no gastric affection. 2- Carditis: a. Carditis without heart failure: 1- Anti-inflammatory drugs: Prednisolone 2 mg/kg/day for 2 weeks, then 1 mg/kg/day for month. 2- Intravenous immunoglobulin (IVIG). 3- Arrhythmia management: beta-blocker (propranolol) or amiodarone. 3- Anti-coagulant drugs: Rivaroxaban. 4- Proton pump inhibitor (Omeprazole). b. Carditis with heart failure: The same of the above treatment + Angiotensin-converting enzyme (ACE) inhibitors (Captopril), and diuretics (Frusemide). C- Carditis with valve deformity: The same of the above treatment + surgical treatment by open heart surgery to correct valve deformity. 3- Subcutaneous nodules and erythema marginatum are self-limited. 4- Sydenham chorea is generally self-limited, but Pharmacotherapy is recommended as it negatively impacts activities. Lines of treatment: a. Rest and avoidance of overstimulation. b. Corticosteroids (Intravenous methylprednisolone and oral prednisone). c. Receiving IVIG or plasmapheresis therapy are effective. d. As for refractory cases Haloperidol and Carbamazepine are effective. III- Eradication of streptococci: Patients are treated with either: 1- Amoxicillin: - Patients receives 50 mg per kg (maximum, 1 g) orally once daily for 10 days OR 2- Penicillin V: - Patients weighing 27 kg or less: 250 mg orally 3 times daily for 10 days. - Patients weighing more than 27 kg: 500 mg orally 3 times daily for 10 days. OR 3- Procaine penicillin G: - Patients weighing 27 kg or less: 600,000 units IM once. - Patients weighing more than 27 kg: 1,200,000 units IM once. For patients who are allergic from penicillin: These patients are treated with: 1- Azithromycin: 12 mg/ kg orally (maximum, 500 mg) once daily for 5 days. OR 2- Clarithromycin: 15 mg/kg orally/day (maximum, 250 mg twice daily) divided into 2 doses for 10 days. OR 3- Clindamycin: 20 mg/kg orally/day (maximum, 1.8 g/day) divided into 3 doses, for 10 days. OR 4- Cephalosporin (cephalexin): 1 g orally/ 12h for 10 days. Prevention of Rheumatic fever Reduce the spread of group A strep bacteria with standard infection control, including good hand hygiene and respiratory etiquette. I- Preventing first attack of rheumatic fever: Diagnosis and adequate treatment of group A strep pharyngitis and skin infections are the primary means of preventing initial attack of acute rheumatic fever. II- Preventing recurrent attacks of rheumatic fever: Recurrent rheumatic fever is associated with worsening or development of rheumatic heart disease. Prevention of recurrent streptococcal pharyngitis is the most effective method of preventing severe rheumatic heart disease. Duration of antibiotic prophylaxis: 1- If rheumatic fever without carditis; antibiotic prevention for 5 years from last rheumatic attack. 2- If rheumatic fever with carditis with no valve deformity; antibiotic prevention up to 21 years old. 5 years or till being 21, which is closer 3- If rheumatic fever carditis and valve deformity; antibiotic prevention for life. Antibiotic members are used: 1- Benzathine Penicillin G: - Patients weighing 27 kg or less: 600,000 units IM every month. - Patients weighing more than 27 kg: 1,200,000 units IM every month. Injection of benzathine penicillin G every four weeks is the recommended prophylactic regimen for secondary prevention in most circumstances. In certain patients, administration every three weeks is justified because serum drug levels may fall below a protective level before four weeks after the initial dose. A three-week dosing regimen is recommended only for patients who have recurrent acute rheumatic fever despite adherence to a four-week regimen. OR 2- Penicillin V: 250 mg orally twice daily. OR 3- Sulfadiazine: - Patients weighing 27 kg or less: 0.5 g orally once daily. - Patients weighing more than 27 kg: 1 g orally once daily. OR 4- Oral erythromycin or Clarithromycin (500mg twice/ day) or Azithromycin (500mg once/ day); if the patient is allergic to penicillin or sulphonamides. Prevention against bacterial endocarditis Prophylaxis of infective endocarditis is recommended before dental or invasive respiratory surgery (Tonsillectomy) in most patients with rheumatic heart disease, specially in the following conditions: 1- Patients with prosthetic valves or valves repaired with prosthetic material. 2- Patients with previous endocarditis or specific forms of congenital heart disease. 3- Cardiac transplant recipients who develop cardiac valvopathy. Antibiotic Prophylactic Regimens for Dental Procedures: Regimen – Single dose 60 minutes before procedure with one of the following agents: 1- Oral Amoxicillin 2 g. 2- Oral Cephalexin 2 g. 2- If the patient is unable to take oral medication, takes either: a- Ampicillin 2 g IM or IV Or b- Ceftriaxone 1 g IM or IV. 3- If the patient is allergic to penicillin, takes either: a. Azithromycin or clarithromycin 500 mg. Or c. Doxycycline 100 mg.