Rheumatic Fever & Infective Endocarditis PDF

RHEUMATIC FEVER By Dr. Sameh Mosaad, M.D. Assistant professsor of cardiology Definition: An acute inflammatory complication of pharyngeal infection by group A streptococci. It involves heart, joints, CNS, skin & subcutaneous tissues. Pathophysiology: It is an auto-immune disease. Pr...

RHEUMATIC FEVER By Dr. Sameh Mosaad, M.D. Assistant professsor of cardiology Definition: An acute inflammatory complication of pharyngeal infection by group A streptococci. It involves heart, joints, CNS, skin & subcutaneous tissues. Pathophysiology: It is an auto-immune disease. Predisposing factors: 1. Age: most common between ages of 5-15 years. 2. Sex: No sex predilection exists, except that mitral stenosis and chorea occur more commonly in females than in males. 3. Familial: there is familial tendency, mostly d.t. similar environment. 4. Recurrent streptococcal infection 5. Low socioeconomic status: d.t. Malnutrition, overcrowding and poor medical care Clinical picture: 1- Arthritis: Affecting large joints (e.g.: knees, ankles, elbows..) Fleeting in character (migrating from one joint to another leaving the joint without residual lesion) Dramatic response to salicylates. The affected joint is red, hot & swollen, with marked limitation of the movement. Clinical picture: 2- Carditis: Pancarditis affection. Pericarditis: dry pericarditis or with pericardial effusion associated with chest pain. Myocarditis: acute heart failure (tic-tac rhythm with gallop) Endocarditis: mitral & aortic valvulitis with either stenosis or regurgitation. Clinical picture: 3- Chorea (Sydenham’s chorea): 1.Not associated with arthritis. 2.More common in females. 4- Subcutaneous nodules: 1.Painless, non-tender swellings. 2.Over bony prominences & tendons. 5- Erythema marginatum: 1.Painless, erythematous non tender spots. 2.They enlarge with fading of the center. 3.Affects mainly trunk (centripetal). Erythema Marginatum & S.C. nodules Investigations: E.C.G.: prolonged PR interval, tachycardia. C.X.R.: pulmonary venous congestion, cardiac enlargement. Echocardiography: assess functions, valvular lesions & pericardial effusion. C.B.C.: anemia & leucocytosis. C.R.P.: positive. E.S.R.: elevated. A.S.O.T.: more than 400 todd units & rising. Throat culture: may reveal group A streptococci. Clinical picture & diagnosis: Diagnosis: Jones Criteria Major Criteria Minor Criteria A. Arthritis a) Prolonged PR interval in B. Carditis ECG b) Previous R.F.. C. Chorea c) Arthralgia. D. Erythema marginatum d) Acute phase reactants E. Subcutaneous Nodules e) Fever Diagnosis= (2 major or 1 major + 2 minors) + Evidence of inf.  Treatment: I- Prophylactic: A. Primary: (to prevent the occurrence of rheumatic fever) 1.Proper treatment of upper respiratory tract infections. 2.Tonsillectomy for recurrent tonsillitis. B. Secondary: (to prevent the recurrence of rheumatic fever) 1. 1.2 million units of long acting penicillin, given I.M. monthly till age of 21 years or 5 years after the last attack or till age of 45 years in cardiac affection. 2. In case of penicillin sensitivity, erythromycin is given. Treatment: II- Curative: ✓ Bed rest ✓ Diet should be light with low salt ✓ Anti-biotics (penicillin or erythromycin) ✓ Salicylates (aspirin): for arthritis. ✓ Corticosteroids. ✓ For chorea: complete mental & physical rest, sedatives & tranquilizers (as diazepam) are given. ✓ Antifaliure measures (digoxin, diuretics…) in heart failure. INFECTIVE ENDOCARDITIS  Endocarditis Definition: Inflammation of the endocardial surface of the heart. Types: Infective endocarditis: caused by infection of the heart valves or endocardium. Non-infective endocarditis: as rheumatic fever or collagen diseases. Infective endocarditis: It is usually bacterial (Gm +ve or Gm –ve), but the infecting organism may be a rickettsia or fungus. According to the virulence of the organism, it is either acute or subacute. There should be combination of infection (e.g. bactremia) & underlying cardiac lesion (valvular lesion, congenital heart disease or prosthetic valve) for infective endocarditis to occur. Source of infection may be dental procedures, GIT or genitor- urinary procedures or invasive cardiac procedures. N.B.: Infection in normal hearts occurs on the tricuspid valve in massive infections in I.V. addicts. Clinical picture: Symptoms: 1- Fever which may be continuous, and usually of low grade. 2- Deterioration of general condition, anorexia and weakness. 3- Symptoms of complications as blindness or loin pains. Clinical picture: Signs: a) General Signs: 1. Marked pallor and toxemia. 2. Fever is a constant finding but may be very mild. 3. The hands may show: (a)Pale clubbing. (b)Osler's nodules. (c)Splinter hemorrhages. (d)Janeway lesions. Clinical picture: Signs: a) General Signs: 4- Pulse: Tachycardia is a constant feature. 5- The eye may show: (a) Petechiae in the conjunctiva. (b) Sudden blindness. (c) Roth spots which are white centered petechiae in the retinae. 6- The spleen is enlarged and tender in 80% of cases. 8- The kidneys may manifest: (a)Acute diffuse glomerulo-nephritis. (b)Focal embolic glomerulonephritis (flea-bitten kidney). (c)Renal infarction. 9- The nervous system may show: (a) Embolic hemiplegia. (b) Subarachnoid hemorrhage. 10- The chest shows: Recurrent pulmonary infractions and chest infections. Complications: 1. Heart failure. 2. Kidney involvement ending in chronic renal failure. 3. Systemic and pulmonary embolization. 4. Complications of treatment. Investigations: I. Lab investigations: 1. Two to five blood cultures. 2. There is a marked elevation in E.S.R. & C.R.P. 3. Anemia & leucocytosis. 4. Microscopic or macroscopic hematuria. II. Echocardiography: To detect vegetations in 80% of cases. III. Chest X-ray: 1. Evidence of early congestive heart failure. 2. Multiple small patchy infiltrates in the lungs. Treatment: Points to be considered: 1. Any obscure fever more than a few days in a predisposed person should be considered IE until proved otherwise 2. Start antibiotic therapy after withdrawal of the blood culture (do not wait for the results). 3. Antibiotic therapy at least for 6 weeks to avoid relapse. Treatment: Prophylaxis against IE: 1. Correction of congenital defects when possible. 2. High standard dental care is essential to all cardiac patients. 3. The preferred regimen of antibiotic is to give a big dose of antibiotics two hours before the dental work or the surgical procedure and another big dose 4 hours later. 4. Antibiotics used depend on the procedure performed. Treatment: Surgical Treatment: 1. Valve replacement may be urgently needed if severe valvular incompetence develops. 2. The tricuspid valve may be resected without replacement in drug addicts. 3. Prosthetic valve endocarditis usually needs replacement of infected prosthesis. 4. Ligation and excision of an infected ductus may be necessary to cure infection. THANK YOU