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20.12 Acute Rheumatic Fever

Table of Contents

It is a non–suppurative sequela of a group A ß haemolytic streptococcal (GABHS) pharyngeal infection.

Diagnostic Criteria Jones Criteria updated 1992 See table 20.9 below

Definitive Diagnosis

  • Two major criteria or
  • One major criterion with two minor criteria, with evidence of antecedent streptococcal infection

Table 20.10: Criteria for Acute Rheumatic Fever Diagnosis

Major Criteria Minor Criteria
Carditis

Migratory polyarthritis

Sydenham’s chorea

Erythema Marginatum

Clinical

Fever

Arthralgia

Laboratory

Elevated Acute Phase Reactants eg CRP

Prolonged PR interval

Plus

Supporting evidence of recent group A streptococcal infection e.g. positive throat culture or antigen detection and/or elevated streptococcal antibody tests*
*Anti –Streptolysin O, Anti –Deoxyribonuclease B

Non–Pharmacological Treatment Acute stage:

  • Bed rest and supportive care until all evidence of active carditis has resolved  Patient education.
  • Intensive health education for prevention of sore throats.

Pharmacological Treatment

Treatment of acute attack for eradication of streptococci in throat: Regardless of the presence or absence of pharyngitis at the time of diagnosis.

A: Benzathine Penicillin 1.2MU single dose im

Paediatric> 5 years 0.3MU, 5–10 years 0.6 MU > 10 years 1.2.mu single dose IM.

OR

A: Penicillin V 500mg two to three times daily for 10 days orally.

Children > 10years 500mg, 5–10 years 250mg, < 5years 125mg two to three times daily for 10 days orally

Patients allergic to penicillin

A: Erythromycin 500mg or 40mg/kg 4 times per day for 10 days orally.

Treatment of Acute Arthritis and Carditis:

A: Aspirin orally 25mg/kg* 4 times a day as required.

Aspirin should be continued until fever, all signs of joint inflammation and the ESR have returned to normal and then tapered gradually over 2 weeks. If symptoms recur, full doses should be restarted. *dose should be reduced if tinnitus or other toxic symptoms develop

In severe carditis with development of increasing heart failure or failure of response to aspirin,
Add

A: Prednisolone 1–2mg/kg once a day for 3–4 weeks.

Then review and gradual reduction and discontinuation of prednisolone may be started after 3–4 weeks when there has been a substantial reduction in clinical disease.

Heart failure should be managed in the usual way (see Heart Failure Section 20.7).

Treatment of Sydenham’s Chorea:

B: Haloperidol 1.5–3mg (O) 8hourly a day as required (Adult). Paediatrics 50µg/kg in 2 divided doses.

Referral: Ideally all patients should be referred to high level of care a specialized hospital care; where surgery is contemplated

Antibiotic prophylaxis after rheumatic fever:

Prophylaxis should be given to all patients with a history of acute rheumatic fever and to those with rheumatic heart valve lesions. The optimum duration of prophylaxis is controversial, but should be continued up to at least 21 years of age.

Note: Specific situations requiring prophylaxis for longer periods (up to 30 years as a guide):

  • definitive carditis in previous attacks
  • high risk of exposure to streptococcal infection at home or work (crowded conditions, high exposure to children)

Medicine of choice

A: Benzathine Penicillin IM Adult 2.4MU monthly or every three weeks*

Paediatrics <12yrs 1.2MU every 4 weeks or 3 weeks* up to 21–30yrs

OR

A: Penicillin V (PO) 250mg 12 hourly Adult

Paediatric<12yr 125–250mg 12 hourly a day up to 21–30yrs

OR

A: Erythromycin 250mg 12hourly a day Adult

Paediatric <12yr 125–250mg 2 times a day up to 21–30yrs

*Every 3week regimen is more effective

Valvular Heart Disease and Congenital Structural Heart Disease

Description: Valvular Heart Disease

These are chronic acquired sequelae of Acute Rheumatic Fever or Acute Sequelae of Infective Endorcaditis or Ischaemic Heart Disease, consisting of valvular damage, usually left heart valves, with varied progression of severity and complications.

Description: Congenital Heart Disease

It is a congenital chamber defects or vessel wall anomalies

Valvular Heart Disease and Congenital Structural Heart Disease may be complicated by:

  • Heart failure
  • Infective endocarditis
  • Atrial fibrillation
  • Systemic embolism eg Stroke

Non–Pharmacological Treatment

General measures

  • Advise all patients with a heart murmur regarding the need for prophylaxis treatment prior to undergoing certain medical and dental procedures
  • Advise patients to inform health care providers of the presence of the heart murmur when reporting for medical or dental treatment

Referral:

Should be considered from low level of care to high level of care where specialized (physician`s care) or super–specialized care (Cardiologist`s care) can be offered, those includes;

  • All patients with heart murmurs for further assessment such as ECG, Echocardiogram
  • All patients with heart murmurs not on a chronic management plan
  • Development (New) of cardiac signs and symptoms
  • Worsening of clinical signs and symptoms of heart disease
  • Any newly developing medical condition, e.g. fever
  • All patients with valvular heart disease for advice on prophylactic antibiotic treatment
  • prior to any invasive diagnostic or therapeutic process

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