Rheumatic fever:

epidem: more in
developed country. Connected with streptococcal
infec. Etiol: 1- streptoc viridans, 2- viruses. 1diseases of bad condition (many relatives lives
near each other transmitted from one to another,
chronic phayngitis or laryngitis). 2- genetic
predisposition: a- low immunity that cant control
cleaning of org--. Bacteremia, b- connected with
connective tissue itself ex: grand relatives suffer
from arthritis. 3- if circulation of streptoc --.
Immunity against this bacteria, such antibodies
affect connective tissua so predisposed people are
those who have long period of bacteremia or
chronical pharyngitis. Ab act in vessels,
connective tissue. Streptolysin enz from
bacteremia can affect cells of blood ex: can affect
vessels of heart but later it predispose imp
reaction allergy., called hypoallergic reaction
to strepto: cross reaction of ab or antigen with
autoantigen, streptoitself (streptolysin), hyper
allergic reaction to strepto. Periods: 1- onset of
disease: hyperergic reaction & toxicity (enz) of
strept. 2- start to predispose to autoantibody.
Stages: 1- Mucoid swelling, 2- Fibrinoid process.
3- granulomatosis, 4- sclerosis. Pathog: 1- stages
of aggrevation leads to appearnce of serous type
of effusion hypermeability of vesels lasts 2
months after appearnce of new attack of disease,
generalized but reversible. 2- after 2 mon appear
serofibrous effusion: presence of fibrin
irreversible. Fibrin starts to coagulate + lasts 2
mon, it may be partial reversible. 3- At the end
these structures prevele neutrophils, lymphoid
cells, leuk, cardiocytes. Segment small in size,
lasts over 2 mo in the center starts necrosis b/c
dec nutrition. 4- after year non reversible cells
debris, then scarring of aschoff granules result
shrinking of organs (sclerosis). Scaring of
endocardial
layer(endocarditis,
or
rheumocarditis).
Clinical
signs:
carditis,
migratory polyarthritis, chorea, erythema
marginatum, subcutaneous nodule. Jhons
describe special signs: 1- Presence of
rheumocarditis (probabely endocarditis but may
be also rheumocarditis). Signs: a- changing of
heart murmur or app of murm if not present, bdevelop of cardiac enlarg or cardiac failure, cpericardial effusion; 2 layers or 3, pancarditis
from friction ruib, big trapezoid heart, d- app of
AV block first degree b/c of total profuse edema
of heart. 2- Migratory polyarthritis; affects
primary large joints, active period of dysfunction.
They cant move b/c of pain, skin is red, hot
alive inflama, swelling, disfigure of joint. But it
is reversible even spontaneous first knees then
elbows the onset of disease , then it will not
appear, ttt leads to reversible action, it is very rare
to cause rheumatic fever as a rule it appears 10
14 y --. Acute stage, but in older patient, not
important, arthralgia shows new attack. 3Sydenham chorea: movement of extrem in

teenagers, chorea signs of vasculitis affect the

brain, under cortex, striae pallidum
uncousness mvt. 4- vasculitis of skin: erythema
marginatum, then ring shaped patches direclt
shows rheumatic fever. 5- Subcutaneous nodules:
projection of tendons in joints < 1 cm palpated
under skin, movable, unpainful. Erythema nodusa
not rheum fev but it shows tumors, sarcodiasis,
sclerosis but sometimes only shows allergy.
Typical rheumatic anamnesis: pericarditis but
inform about chronic strep. Minor criteria:
paleness of skin, temp, bleeding from nose.
Laboratory shows leukocytosis, shift to left, dec
albumin, inc globulin, dec alb/ globulin, inc
fibrinogen + c-prt, inc ESR. On ECG: Av block,
extrasystole, dec voltage, T wave change, St
segment lowers. Class: divided into active & non
active phase. If special signs --. Active but if only
structures like stenosis --. Non active. If phases r
active --. Check level (chronic, hyperergic).
Clinicaly divided to monosyndromic &
polysyndromic. If min activity hidden clinic,
symp only, dysfunction of heart, monosyndromic.
If medium activity: polysyndromic 30 %, heart
rheumocarditis, Av block, new murmurs,
vasculitis, arthralgia. If activity is max;
polysyndromic: all iner organs, febrile temp,
dysfunction of organ, heart failure, shamp
edema of lung, arthritis, fear of death, generalized
systemic disease. TTT: 1- treat inf : ATB G +
effect penicillin b/c of dec toxicity of pen 10-14
days, if old age (70 yr) exclude ATB. 2- anti
inflam drugs NSAID aspirin + other drug
combination aspirin & different endomethacin.,
hormones, 3- auto Ab besides hormones , we can
use also cytostatic when no complete affect of
hormones, but doses of cytostatic + hormones r
divided. 4- metabolites that prevent dystrophy of
other organs scaring & heart & their deformation.
5- Syndromic: failure of heart glycosides b/c
good in tired myocardium, in acute attacks no so
strong,
then
diurestics,
ACE-inhibitors,
vasodilators. Diferential diag: in RF : no chills,
fever in adult not typical ,recurrent attack of fever
at morn & nioght absent, anemia absent, no
hepatomegaly, mitral abnormalities, usually
young age. In Bacterial endocarditis; new
murmurs, kidneys lasts longer--. Failure,
extrarenal syndrom, anemia, hepatomegaly +
spleen syndrom, aortic abnormalities, vegetation
in leaflet (thikening of wall).