acute rheumatic fever: diagnostic and management
DESCRIPTION
4. th. 2014. SymCARD . Acute Rheumatic Fever: Diagnostic and Management. Didik Hariyanto Indry Putri Festari. Pediatric Cardiology Subdivision Division of Cardiology and Vascular Medicine Faculty Medicine Universitas Andalas General Hospital dr. M. Djamil Padang. Introduction. - PowerPoint PPT PresentationTRANSCRIPT
Acute Rheumatic Fever: Diagnostic and
ManagementDidik HariyantoIndry Putri Festari
SymCARD 4 th 2014
Pediatric Cardiology SubdivisionDivision of Cardiology and Vascular Medicine
Faculty Medicine Universitas AndalasGeneral Hospital dr. M. Djamil Padang
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Introduction• Rheumatic fever (RF) is nonsuppurative complications of Group A
streptococcal pharyngitis due to a delayed immune response• Continues to be problem worldwide• Underdiagnosed and undertreated• Estimated 30 million people suffer from ongoing heart disease from
ARF, 70% dying at average age 35 years old• RHD developed in 44% of patients who initially had no clinical
evidence of carditis
Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Lioyd T et all, Pediatrics 2003: 112:1065-68
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Case: A 11 year-old girl, brought to hospital because she has pain in
her right knee that is preventing her from walking There’s breathlessness during activity History of sorethroat 2 weeks before
Diff Dx?• Septic arthritis• Rheumatic fever• Juvenille Rheumatoid
Arthritis• Congenital Heart DIsease• etc
ARTRITIS and DISPNEU
IS IT ACUTE RHEUMATIC FEVER?
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Arthritis in Acute Rheumatic Fever• Most common feature: present in 80% of patients• Painful, migratory, short duration, excellent response of
salicylates• Usually affected and large joints preferred knees, ankles, wrists,
elbows, shoulders• Small joints and cervical spine less commonly involved• Differenciate with athralgia
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1 WHO. Rheumatic Fever and Rheumatic Disease. 20012Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
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Carditis• Most serious manifestation• May lead to death in acute phase or at later stage• Any cardiac tissue may be affected• Valvular lesion most common: mitral and aortic
• Clinical manifestations:• Breathlessness• Tachycardia• Murmur (MR and AR)• Cardiomegaly• Heart failure
SymCARD 20144 th
1 Park MK. Pediatric Cardiology for Practitioners. 20082Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
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Major Manifestation Minor Manifestation- Carditis- Polyarthritis- Chorea- Erythema marginatum- Subcutaneous nodules
- Clinical : fever, poliathralgia- Laboratory: elevated acute phase
reactans (erythrocyte sedimentation rate or leucocyte count)
Supporting evidence of a preceding streptococcal infection within the last 45 days
- Electrocardiogram: Prolonged P-R interval- Elevated or rising antistreptolysisn-O or other streptococcal antibody,
or- A positive throat culture, or- Rapid antigen test for group A streptococci, or- Recent scarlet fever
WHO Criteria for diagnosis of rheumatic fever (based on revised Jones criteria)
1 WHO. Rheumatic Fever and Rheumatic Disease. 2001
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Criteria Diagnosis ARF
• Two mayor manifestation, or• Combination 1 mayor and 2 minor manifestations and• Supporting evidence of a preceding streptococcal
infection
1 WHO. Rheumatic Fever and Rheumatic Disease. 20012Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014th4 SymCARD 2014th
2002–2003 WHO criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on the revised Jones
criteria)Diagnostic categories CriteriaPrimary episode of RF Two major *or one major and two minor**
manifestations plus evidence of apreceding group A streptococcalinfection***.
Recurrent attack of RF in a patient without established rheumatic heart disease
Two major or one major and two minor manifestations plus evidence of a preceding group A streptococcal infection.
Recurrent attack of RF in a patient with established rheumatic heart disease.
Two minor manifestations plus evidence of a preceding group A streptococcal infection
Rheumatic chorea.Insidious onset rheumatic carditis
Other major manifestations or evidence of group A streptococcal infection not required
Chronic valve lesions of RHD (patients presenting for the first time with pure mitral stenosis or mixed mitral valve disease and/or aortic valve disease).
Do not require any other criteria to be diagnosed as having rheumatic heart disease
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Syndenham’s Chorea• Extrapyramidal disorder• Fast, clonic, involuntary movements (especially face and limbs)• Muscular hypotonus• Emotional lability
• First sign: difficulty walking, talking, writing• Usually a late manifestation: months after infection• Often the only manifestation of ARF
1 Park MK. Pediatric Cardiology for Practitioners. 20082Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014th4 SymCARD 2014th
Subcutaneous Nodules• Usually 0.5 - 2 cm long• Firm, non-tender, isolated or in clusters• Most common: along extensor surfaces
of joint knees, elbows, wrists• Also: on bony prominences,
tendons, dorsi of feet, occiput or cervical spine
1 Park MK. Pediatric Cardiology for Practitioners. 20082Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014th4 SymCARD 2014th
Erythema Marginatum• Present in 7% of patients• Highly specific to ARF• Cutaneous lesion:• Reddish pink border• Pale center• Round or irregular shape
• Often on trunk, abdomen, inner arms, or thighs• Highly suggestive of carditis
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• Fever• Occurs in almost all rheumatic
attacks at the onset, usually ranging from 38.4–40.0 °C
• Diurnal variations are common, but there is no characteristic fever pattern.
• Athralgia• Arthralgia without objective
findings is common in RF• Less common• abdominal pain and epistaxis
• ECG Prolong PR interval
Minor ManifestationSupporting evidence
1 Park MK. Pediatric Cardiology for Practitioners. 20082Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014th4 SymCARD 2014th
TherapyArthritis alone
Mild Carditis Moderate Carditis
Severe Carditis
Bed rest 1-2 week 3-4 week 4-6 week As long as CHF is present
Indoor ambulation
1-2 week 3-4 week 4-6 week 2-3 month
General guideline for bed rest and indoor ambulation
Arthritis Alone
Mild Carditis Moderate Carditis
Severe Carditis
Prednisone 0 0 0 2-6 weekAspirin 1-2 week 3-4 week 6-8 week 2-4 month
Recommended anti-inflammatory therapy
Dosages: Prednisone, 2 mg/kg/day, in four divided doses; aspirin, 100 mg/kg/day, in four to six divided doses
1 Park MK. Pediatric Cardiology for Practitioners. 2008
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Therapy…
Primary prevention of rheumatic fever: recommended treatment for streptococcal pharyngitis
1 WHO. Rheumatic Fever and Rheumatic Disease. 2001
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Therapy….
Antibiotics used in secondary prophylaxis of RF
1 WHO. Rheumatic Fever and Rheumatic Disease. 2001
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ARF and Heart Failure•Management:• Diuretic• ACE-inhibitor• Aldosterone antagonist• Inotropic
When and How to Use it?
1 WHO. Rheumatic Fever and Rheumatic Disease. 20012Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
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Monitoring and Evaluation ARF
• ARF could become Rheumatic Heart Disease• Monitoring:• Echocardiography• Check inflammation marker if needed
1Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
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Complication• Rheumatic Heart Disease• Heart Failure
• Other issues:• When the patient need to perform surgery?• Repair/replacement?
1Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
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Take Home Message• Acute Rheumatic Fever leading to Rheumatic Heart Disease
is a major problem world wide.• Appropriate treatment of group A strep pharyngitis necessary
to prevent disease.• Preventing recurrences causing chronic heart disease simple,
universally available, and costeffective.
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SymCARD 2014th