Lec3-Rheumatic Fever PDF - Notes on Rheumatic Heart Diseases

Lec-3 Rheumatic heart diseases By: dr. Manal Al-Abed Definition: Diffuse inflammatory disease caused by an abnormal immune response to with group A - beta hemolytic streptococci. Etiology: occur post strept group A infection; 1-Antigenic similarity 2- Altered antig...

Lec-3 Rheumatic heart diseases By: dr. Manal Al-Abed Definition: Diffuse inflammatory disease caused by an abnormal immune response to with group A - beta hemolytic streptococci. Etiology: occur post strept group A infection; 1-Antigenic similarity 2- Altered antigenicity Predisposing factors: 1-Recurrent streptococcal infections of the pharynx & tonsils. 2- Age: common between 5-15 years (rare< 5 &> 25). 3- overcrowding Clinical picture: Latent period: 1- 3 weeks Major criteria Minor criteria: 1-Carditis 1-Prolonged PR interval in the ECG: 2-Arthritis 2. ESR: elevated. 3-Chorea 3. Arthralgia: painful joints without swelling. 4-Subcutaneous Nodule 4. CRP (C reactive protein): elevated. 5-Erythema marginatum 5. Elevated temperature (fever) 1-Carditis: found in 50 % of patients a- Pericarditis: o Dry pericarditis: cause stitching pain & pericardial rub. b- Myocarditis: o Tachycardia / palpitation o Heart failure. o Arrhythmia c- Endocarditis: (valvulitis) Mitral > Aorta > Tricuspid > Pulmonary o acute stage: stenosis due to swelling of the cusps o Later on (over years): fibrosis may lead to stenosis, regurge or both. 2- Arthritis: found in 75% of patients o Polyarthritis. o Affects big joints: Knees, ankles, elbows. o Asymmetrical. o Migratory o hotness, redness, tenderness, swelling & limitation of movement. o Dramatic response to aspirin. o Duration of arthritis is about 2-6 weeks. o No deformity 3-Chorea: (Sydenham’s chorea): 10 % of cases o Involuntary, sudden movements with emotional instability o female > male. o It appears very late o self-limiting. 4-Subcutaneous Nodule: rare o Small, painless, tender, firm nodule & not adherent to skin. o Site: over bony prominences & tendons e.g. dorsum of hands & feet 5-Erythema marginatum o Non-pruritic, non-painful erythema with central pallor o Site: trunk & proximal part of limbs. - Other manifestations of rheumatic fever: Pallor. Pleurisy. Pneumonia. Peritonitis Diagnosis of rheumatic fever 2 major criteria or 1 major & 2 minor criteria. plus, -Evidence of recent strept infection (+ve throat culture, raise ASO) Complications: 1- Acute: i. Heart failure ii. Arrhythmia & heart block. 2- Chronic: Complications of valvular heart diseases 1.Calcification. 2. Rheumatic activity. 3. Infective endocarditis 4. Arrhythmia 5. Thromboembolism: stroke 6. Aterial enlargement 7. Pulmonary congestion 8. Pulmonary infection. 9. Pulmonary embolism (2ry to DVT) 10. LSHF/ RSHF. 11. Complications of surgery (artificial valves) Investigations: There is NO specific confirmatory test a) Laboratory: (evidence of recent streptococcal infection) 1-CBC: Leukocytosis. 2- ESR: raise 3- CRP raise 4- ASO titre (Anti Streptolysin O titre): raise 5- Throat culture: may reveal group A streptococci b) Cardiac: ( evidence of carditis ) 1- X ray 2- ECG 3- Echo Treatment 1- Prophylactic i. Primary prevention: (to prevent rheumatic fever) - Proper management of URT infection. - Tonsillectomy of chronically infected tonsils. ii. Secondary prevention: (to prevent recurrence of rheumatic activity) - Long acting penicillin: Benzathine penicillin (Retarpen) or - Penicillin V or - Erythromycin (in a case of allergy to penicillin) For 5 years after the last attack or till age of 25 (which is longer) & may for ever. iii. Tertiary prevention: (prevention of infective endocarditis). 2-Curative 1-Complete bed rest till improvement of all symptoms & signs 2-Diet: Light meals & salt restriction 3-Antibiotics - Benzyl penicillin G - Penicillin V - Erythromycin 4-Anti-inflammatory drugs - Aspirin: for Arthritis - Corticosteroids: for Carditis 5- Treatment of complications  Infective endocarditis Definition: Infection of the endocardium. Etiology combination of : I- Infection: a) Gram +ve cocci : o Strept. viridans (the most common): e.g. tooth extraction. o Strept. foecalis: e.g. GIT procedures. o Staph. aureus:e.g. cardiac catheterization. b) Gram –ve bacilli: Haemophilus influenza, Klebsiella, Pseudomonas. c) Others: Fungi, Rickettsia, Chlamydia …… II- Underlying cardiac disease: a) Valvular disease & Prosthetic (artificial) valve b) Congenital heart disease c) Myocardial infarction. Clinical picture: A) Cardiac manifestations : 1 -Features of the underlying cardiac disease 2 -Precipitation of heart failure. 3- New murmurs due to perforated cusps or rupture of chordae tendineae. B) Extra cardiac manifestations: 1- Face: i. Fever (usually low grade & prolonged ). ii. Pallor & toxic facies.  iii. Eye: -Subconjunctival hemorrhage -Roth spots (area of retinal hemorrhage with pale center) -Sudden blindness: due to embolism of the central retinal artery. 2- Upper & lower limbs: i. Clubbing ii. Splinter hemorrhage iii. Osler’s nodule: Small, painful, nodule in the pulps of fingers & toes. iv. Janeway’s nodule: Small painless patches on the palms. v. Abnormalities of the redial pulse: Tachycardia, Absent pulse 3- Spleen: - Infection: mild enlargement. - Infarction: Stitching pain & splenic rub. 4- Kidney : - Infection: glomerulonephritis - Infarction: loin pain & hematuria. 5- CNS : - Infection: Meningitis & encephalitis. - Infarction: Embolic hemiplegia, Subarachnoid hemorrhage. 6- Lung : - Infection : pneumonia. - Infarction Investigations : 1 -Blood culture: At least 3 samples are taken during fever 2 -Echo: Small vegitations can detected. 3 -Blood picture : Anemia. Leucocytosis. ↑ ESR. 4- Urine analysis: for proteinuria & hematuria. Treatment : I- Prophylactic : a) Correction of the underlying cardiac lesion e.g. closure of VSD. b) Prevention of infection: Antibiotics before & after any procedures II- Curative : a) Medical treatment : 1 -Antibiotics : Penicillin G , Gentamycin, vancomycin, ceftazidime or carbinicillin. For fungal infections: Amphotericin B. 2- Treatment of complications b) Surgical treatment : o Replacement of the severely damaged valve. o Replacement of infected prosthetic valve. o Removal of myocardial abscess.