and Management Didik Hariyanto Indry Putri Festari SymCARD 4 th 2014 Pediatric Cardiology Subdivision Division of Cardiology and Vascular Medicine Faculty Medicine Universitas ID: 682326
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Acute Rheumatic Fever: Diagnostic and Management
Didik HariyantoIndry Putri Festari
SymCARD
4
th
2014
Pediatric Cardiology Subdivision
Division of Cardiology and Vascular Medicine
Faculty Medicine
Universitas
Andalas
General Hospital dr. M.
Djamil
PadangSlide2
Introduction
Rheumatic fever (RF) is nonsuppurative complications of Group A streptococcal pharyngitis due to a delayed immune responseContinues to be problem worldwideUnderdiagnosed and undertreatedEstimated 30 million people suffer from ongoing heart disease from ARF, 70% dying at average age 35 years oldRHD 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: 112:1065-68Slide3
Case:
A 11 year-old girl, brought to hospital because she has pain in her right knee that is preventing her from walkingThere’s breathlessness during activity History of sorethroat
2 weeks before
Diff
Dx
?
Septic arthritis
Rheumatic fever
Juvenille Rheumatoid ArthritisCongenital Heart
DIsease
etc
ARTRITIS and DISPNEU
IS IT ACUTE RHEUMATIC FEVER?Slide4
Arthritis in Acute Rheumatic FeverMost common feature: present in 80% of patients
Painful, migratory, short duration, excellent response of salicylatesUsually affected and large joints preferred knees, ankles, wrists, elbows, shouldersSmall joints and cervical spine less commonly involvedDifferenciate with athralgia
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WHO. Rheumatic Fever and Rheumatic Disease. 2001
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide5
CarditisMost serious manifestation
May lead to death in acute phase or at later stageAny cardiac tissue may be affectedValvular lesion most common: mitral and aorticClinical manifestations:BreathlessnessTachycardiaMurmur (MR and AR)CardiomegalyHeart failureSymCARD 2014
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Park MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide6
Major Manifestation
Minor ManifestationCarditis
PolyarthritisChoreaErythema
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, orA 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. 2001Slide7
Criteria Diagnosis ARFTwo mayor manifestation, orCombination 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. 2013Slide8
2002–2003 WHO criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on the revised Jones criteria)
Diagnostic categoriesCriteriaPrimary episode of RFTwo 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 infectionRheumatic chorea.
Insidious onset rheumatic carditisOther 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 diseaseSlide9
Syndenham’s ChoreaExtrapyramidal disorder
Fast, clonic, involuntary movements (especially face and limbs)Muscular hypotonusEmotional labilityFirst sign: difficulty walking, talking, writingUsually a late manifestation: months after infectionOften the only manifestation of ARF1 Park MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide10
Subcutaneous NodulesUsually 0.5 - 2 cm longFirm, non-tender, isolated or in clusters
Most common: along extensor surfaces of joint knees, elbows, wristsAlso: on bony prominences, tendons, dorsi of feet, occiput or cervical spine1 Park MK. Pediatric Cardiology for Practitioners. 20082Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide11
Erythema MarginatumPresent in 7% of patientsHighly
specific to ARFCutaneous lesion:Reddish pink borderPale centerRound or irregular shapeOften on trunk, abdomen, inner arms, or thighsHighly suggestive of carditisSlide12
FeverOccurs in almost all rheumatic attacks at the onset, usually ranging from 38.4–40.0
°CDiurnal variations are common, but there is no characteristic fever pattern.AthralgiaArthralgia without objective findings is common in RFLess commonabdominal pain and epistaxisECG Prolong PR interva
l
Minor Manifestation
Supporting evidence
1 Park MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc
Med. 2013Slide13
Therapy
Arthritis aloneMild CarditisModerate CarditisSevere CarditisBed rest1-2 week3-4 week
4-6 weekAs long as CHF is presentIndoor ambulation
1-2 week3-4 week4-6 week
2-3 month
General guideline for bed rest and indoor ambulation
Arthritis Alone
Mild Carditis
Moderate CarditisSevere CarditisPrednisone
0002-6 week
Aspirin1-2 week3-4 week
6-8 week2-4 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
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Park MK. Pediatric Cardiology for Practitioners. 2008Slide14
Therapy…
Primary prevention of rheumatic fever: recommended treatment for streptococcal pharyngitis1 WHO. Rheumatic Fever and Rheumatic Disease. 2001Slide15
Therapy….
Antibiotics used in secondary prophylaxis of RF1 WHO. Rheumatic Fever and Rheumatic Disease. 2001Slide16
ARF and Heart FailureManagement:Diuretic
ACE-inhibitorAldosterone antagonistInotropicWhen and How to Use it?
1 WHO. Rheumatic Fever and Rheumatic Disease. 20012Hampole CV. Rheumatic Fever. Manual of
Cardiovasc Med. 2013Slide17
Monitoring and Evaluation ARFARF could become Rheumatic Heart DiseaseMonitoring:
EchocardiographyCheck inflammation marker if needed1Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide18
ComplicationRheumatic Heart DiseaseHeart Failure
Other issues:When the patient need to perform surgery?Repair/replacement?1Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013Slide19
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.Slide20
terimakasih
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