Download - Acute Rheumatic Fever 2003
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Acute rheumatic fever
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Acute rheumatic fever Non-suppurative sequel to Group A
hemolytic streptococcal infection of throat
Latent priod 2-3 weeks following streptococcal
pharyngitis
Peak incidence 5-15 years of age
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Diagnosis
2 major or 1 major and 2 minor
evidence of preceding group A streptococcalinfection
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Carditis Valvulitis: new murmur, most= MR, AR
Cardiomegaly
Congestive heart failure: from myocarditis Pericarditis: chest pain, pericardial friction rub
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Migratory polyarthritis Typically involves larger joints, particularly the
knees, ankles, wrists, and elbows
Generally hot, red, swollen, and exquisitely
tender
A severely inflamed joint can become normal
within 1-3 days without treatment
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Sydenham chorea milkmaid's grip: irregular contractions of the
muscles of the hands while squeezing theexaminer's fingers
spooning and pronation of the hands whenthe patient's arms are extended
wormian darting movements of the tongue
upon protrusion examination of handwriting to evaluate fine
motor movements
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Erythema Marginatum erythematous, serpiginous, macular lesions
with pale centers that are not pruritic
It occurs primarily on the trunk andextremities
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Subcutaneous Nodules 1% of patients
firm nodules approximately 1 cm in diameter
along the extensor surfaces of tendons nearbony prominences
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Minor Manifestations Fever(typically temperature 102F and
occurring early in the course of illness)
Arthralgia(in the absence of polyarthritis as amajor criterion)
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Investigation Evidence of Group A hemolytic streptococcal
infection
serum antistreptococcal antibody titers: increase
in 80-85%
anti-DNase B
Antihyaluronidase
If 3 different Ab: 95-100%
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Investigation Except
Sydenham Chorea
Insidious onset rheumatic carditis
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Investigation Serum ESR: increase
Serum CRP: positive
EKG: prolonged P-R interval CXR: cardiomegaly
Echocardiogram: subclinical valvulitis
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Treatment Antibiotics
Symptomatic treatment
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Antibiotics Appropriate antibiotic therapy before the 9th
day :highly effective in preventing 1st attacksof acute rheumatic fever from that episode.
10 days of orally administered penicillin orerythromycin or a single intramuscularinjection ofbenzathine penicillin
After this initial course of antibiotic therapy,the patient should be started on long-termantibiotic prophylaxis
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Symptomatic treatment
Anti-inflammatory therapy
Acetaminophen :
patient is being observed for more definite signs of
acute rheumatic fever or for evidence of anotherdisease.
Aspirin:
typical migratory polyarthritis and those with carditiswithout cardiomegaly or congestive heart failure
100 mg/kg/day in 4 divided doses PO for 3-5 days,
followed by 75 mg/kg/day in 4 divided doses PO for4 wk.
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Symptomatic treatment
Anti-inflammatory therapy Prednisone:
carditis and cardiomegaly or congestive heart failure
2 mg/kg/day in 4 divided doses for 2-3 wk
followed by a tapering of the dose that reduces the dose by5 mg/24 hr every 2-3 days
At the beginning of the tapering of the prednisone dose,aspirin should be started at 75 mg/kg/day in 4 divided dosesfor 6 wk
Supportive therapies for patients with moderate to severecarditis include digoxin, fluid and salt restriction, diuretics,and oxygen
The cardiac toxicity of digoxin is enhanced with myocarditis.
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Symptomatic treatment
Supportive therapy
bed rest: allowed to ambulate as soon as the signsof acute inflammation have subsided
patients with carditis require longer periods ofbed rest
Chorea:
phenobarbital (16-32 mg every 6-8 hr PO) is the drug of
choice. haloperidol (0.01-0.03 mg/kg/24 hr divided bid PO)
chlorpromazine (0.5 mg/kg every 4-6 hr PO)
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Secondary PreventionDRUG DOSE ROUTE
Penicillin G benzathine
600,000 U for children, 60 lb
1.2 million U for children >60 lb,
every 4 wk*
Intramuscular
OR
Penicillin V 250 mg, twice a day Oral
OR
Sulfadiazine or sulfisoxazole0.5 g, once a day for patients 60 lb
Oral
1.0 g, once a day for patients >60 lbFOR PEOPLE WHO ARE ALLERGIC TO PENICILLIN AND SULFONAMIDE DRUGS
Macrolide or azalide Variable Oral
http://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0015&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0015&appID=MDC -
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Secondary PreventionCATEGORY DURATION
Rheumatic fever without carditis5 yr or until 21 yr of age, whichever is
longer
Rheumatic fever with carditis but withoutresidual heart disease (no valvular
disease*)
10 yr or until 21 yr of age, whichever is
longer
Rheumatic fever with carditis and residual
heart disease (persistent valvular
disease*)
10 yr or until 40 yr of age, whichever is
longer, sometimes lifelong prophylaxis
http://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDChttp://www.mdconsult.com/books/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00176-7--tn0020&appID=MDC -
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