Acute Rheumatic Fever: Diagnostic - PowerPoint Presentation

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Acute Rheumatic Fever: Diagnostic and Management

Didik HariyantoIndry Putri Festari

SymCARD

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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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