Rheumatic fever .pdf

RHEUMATIC FEVER For faculty of nursing Sohag university  RHEUMATIC FEVER (RF) Definition Rheumatic fever (RF) is an inflammatory disease of connective tissues. It involves mainly the joints and heart. Less frequently, it may involve CNS, skin and subcutaneous tissues. RHEUMATIC FEVER (RF)...

RHEUMATIC FEVER For faculty of nursing Sohag university  RHEUMATIC FEVER (RF) Definition Rheumatic fever (RF) is an inflammatory disease of connective tissues. It involves mainly the joints and heart. Less frequently, it may involve CNS, skin and subcutaneous tissues. RHEUMATIC FEVER (RF) Etiology Both initial and recurrent attacks are nonsuppurative complications of group A beta hemolytic streptococcal upper respiratory tract infection. Streptococci Tonsillitis  RHEUMATIC FEVER (RF) Epidemiology 1.It affects both males and females equally. 2.Usually occurs between 5-15 y 3.Usually follows 3% of untreated or inadequately treated attacks of upper respiratory tract infection with group A beta hemolytic streptococci.  Epidemiology 4-It has 50% tendency to recur in same child with previous attack. 5-It has 10% tendency to occur in child with a family history of rheumatic fever. 6-It is more common in overcrowded poor societies  RHEUMATIC FEVER (RF) Clinical Picture and Diagnosis There is no single clinical or laboratory manifestation that makes a definite diagnosis of rheumatic fever. Jones criteria are a group of findings that make the diagnosis of rheumatic fever highly probable  RHEUMATIC FEVER (RF) Clinical Picture and Diagnosis Jones Criteria  RHEUMATIC FEVER (RF) Clinical Picture and Diagnosis The diagnosis of rheumatic fever is highly probable when the patient have: 1.Two major criteria + evidence of preceding streptococcal infection. 2.One major + 2 minor criteria + evidence of preceding streptococcal infection.  RHEUMATIC FEVER (RF) 1. Carditis 1.Rheumatic carditis is pancarditis affecting all layers of the heart; myocardium, endocardium and pericardium. 2.It affects about 50 to 70% of patients with acute rheumatic fever within the first 3 weeks of the attack. 1. Carditis 3- It is the most serious manifestation as it results in residual chronic valvular damage. 4- Carditis may be so mild that mitral regurge can be missed on auscultation or may be severe and fulminant leading to death.  1. Carditis 1. Cardiomegaly 2. Tachycardia disproportionate to fever. 3. Rapid sleeping pulse 4. Arrhythmia: 1st degree heart block or other arrhythmias. 5. Congestive heart failure in severe cases.  RHEUMATIC FEVER (RF) 2. Arthritis 1.The joint is red, hot, swollen, tender and with limited movement Migratory; several joints are affected one after another or may be together. 2.Large joints are typically affected as knees, wrists, ankles and elbows. Rarely affects fingers, toes and spines (Picture)..  Arthritis 3- It disappears within one weak without treatment and within one day from start of salicylate therapy. 4- It leaves the joint intact and does not result in chronic joint disease. 5- Arthralgia is not used as a minor criterion when arthritis is included as a major criterion.  RHEUMATIC FEVER (RF) 3. Rheumatic Chorea 1.It occurs in about 10% of patients. It occurs after a longer latent period than carditis(2-6 months). 2.It may be the only manifestation of rheumatic fever(pure chorea) or associated with carditis.  RHEUMATIC FEVER (RF) 5. Subcutaneous Nodules It occurs in only 1% of cases and mainly in patients with severe carditis. They appear as pea sized, firm and painless nodules over bony prominences as elbows, knees, occipital region and over the spine (Picture).  RHEUMATIC FEVER (RF) Other Investigations Echocardiography is very useful in patients with suspected to have rheumatic fever. It can detect: 1. Valvular regurge even in the absence of clinical murmur 2. Cardiac dilatation. 3. Decreased ventricular function. 4. Pericardial effusion.  RHEUMATIC FEVER (RF) Differential Diagnosis 1. Other causes of carditis as viral myocarditis. 2. Other causes of arthritis as rheumatoid arthritis and other collagen diseases, septic arthritis and leukemia. 3. Other causes of chorea as degenerative diseases and encephalitis. 4. Other causes of pericarditis as tuberculosis, septic or viral pericarditis.  RHEUMATIC FEVER (RF) Complications 1.Chronic valvular disease. 2.Heart failure. 3.Infective endocarditis. 4.Arrhythmia. 5.Thromboembolism and stroke. 6.Death: from severe carditis.  RHEUMATIC FEVER (RF) Primary prophylaxis :early and adequate treatment of streptococcal upper respiratory tract infection to prevent an initial attack of rheumatic fever. One of the followings is given: 1. Benzathine penicillin 1.200.000 Unit IM every once. 2. Procaine penicillin 400.000 U/day for 10 days. 3. Oral penicillin V 125-250mg /dose 3 times per day for 10 days. 4. Erythromycin 40mg/kg/day orally in 3 divided doses. Secondary prophylaxis: to prevent recurrence of streptococcal infection and hence recurrence of rheumatic fever. One of the followings is given: 1. Benzathine penicillin 1.200.000 unit IM every 2-3 weeks. 2. Penicillin V orally 400.000 Unit twice daily. 3. Erythromycin 250 mg oral twice daily  Secondary prophylaxis should be continued till the age of 25 years or 5 years after last attack of rheumatic fever or for life depending on various factors.  RHEUMATIC FEVER (RF) Treatment…. Medical treatment 1. Eradication of streptococcal infection: as in primary prophylaxis 2. Treatment of arthritis (without carditis): salicylates 3. Treatment of carditis (with or without arthritis): prednisone  RHEUMATIC FEVER (RF) Treatment…. Other supportive measures 1.Treatment of heart failure 2.Bed rest: duration of rest varies with the nature of involvement. It is strictly needed in cases with carditis and heart failure. 3.Treatment of Rheumatic Chorea