o Post

streptococcal infection
Rheumatic Heart disease manifested as (Pharyngitis) or
(URTI) from Group A B-hemolytic .
Alaa Abujabal o Most common affected valve :
1. Mitral
2. Aortic
Rheumatic Heart disease
Alaa Abujabal

Clinical Manifestation
A. Carditis
Carditis is the most serious consequence of rheumatic fever
and varies from minimal to life-threatening HF.
it implies :
-pancardiac inflammation, but it may be limited to valves, myocardium, or
pericardium.
-Valvulitis :
Mitral/Aortic insufficiency -à acute rheumatic carditis.(Children)
Mitral stenosis is -à in adults .(5-10) years after 1st episode
Aortic stenosis is -à in adults at age of (20)

An early decrescendo diastolic murmur consistent with

aortic insufficiency is occasionally encountered as the sole
valvular manifestation of rheumatic carditis.
Rheumatic Heart disease
Alaa Abujabal

Clinical Manifestation
B. Polyarthritis
The large joints (knees, hips, wrists, elbows, and shoulders)
are most commonly involved and the arthritis is typically
Migratory( so always examine the other joint)
. Joint swelling and associated limitation of movement should be present. This is one of the
more common major criteria, occurring in 80% of patients.
Arthralgia alone is not a major criterion.
C. Sydenham Chorea
characterized by involuntary and purposeless movements
These symptoms become progressively worse and may
be accompanied by ataxia and slurring of speech.
Muscular weakness becomes apparent following the onset of the
Involuntary movements. Chorea is self-limiting, although it may
last up to 3 months.
Chorea may not be apparent for months to years after the acute episode of rheumatic fever.
D. Erythema Marginatum
E. Subcutaneous Nodules
These usually occur only in severe cases, and then most
commonly over the joints, scalp, and spinal column. The
nodules vary from a few millimeters to 2 cm in diameter and
are nontender and freely movable under the skin.
Rheumatic Heart disease
Alaa Abujabal

Risk factors :

Family history.
Type of strep bacteria.
Environmental factors. A greater risk of rheumatic fever is associated with
overcrowding, poor sanitation . ( ask in Hx about living area)
Complications:

•Valve stenosis/ regurgitation this leads later to atrial fibrillation/ heart failure
•Damage to heart muscle.
Rheumatic Heart disease
Alaa Abujabal

Investigation :
Test Explanation Result
CBC To see (Leukocyte count) as If not elevated look for ESR or The WHO criteria include
it’s an acute phase reactant CRP only elevated ESR or
leukocyte count as acute-
C-reactive protein (CRP) elevated inflammatory phase reactants. The Jones
ESR markers (minor criterion)
criteria include only
Antistreptolysin O-titer elevated CRP or elevated
ESR
Blood cultures Useful, if patient is febrile, to No growth
exclude sepsis.
Throat culture should be sent in all patients Growth
with acute rheumatic fever
Rheumatic Heart disease
Alaa Abujabal

Imaging :
Test Explanation Result
ECG Prolonged PR interval

Chest x-ray should be performed in all may demonstrate chamber

cases in which carditis is enlargement and congestive
suspected. Congestive heart cardiac failure
also seen on chest x-ray
results from valvular
dysfunction
Echocardiogram

Blood cultures may reveal morphological changes to the mitral and/or aortic
valves; severity of regurgitation (mitral, aortic, and tricuspid);
pericardial effusion if pericarditis present
 Rheumatic Heart disease
Alaa Abujabal

Mangement:
if valvular Disease :
Treatment of the Acute Episode : • Keep on Aspirin for 8 weeks
1. Anti-infective therapy—for Eradication of the
• Prophylactic AB IM every month till age
streptococcalInfection.
(18-25) or a lifetime.
Long-acting benzathine penicillin is the drug of choice.
• give a single intramuscular injection of 0.6–1.2 million units
monthly. Normal valve :
• or give penicillin V, 125–250 mg orally four times a day for 10 • Prophylactic AB IM every month for 5
days. years to prevent 2nd attack.
• Erythromycin if the patient is allergic to penicillin, 250 mg orally
four times a day.

2. Anti-inflammatory agents HF :
a. Aspirin—50-100 mg/kg/d, is given in four divided doses. • Aspirin + omeprazole
b. We add omeprazole to protect stomach 10 mg\day • Oral pincillin
• Add HF Rx:
c. Corticosteroids— if aspirin fails to relive fever and arthritis.
• Furosemide (lasix) +captopri
given as follows:
prednisone, 2 mg/kg/d orally for 2 weeks; • If HF with Pancrditis:
reduce prednisone • IV steroids for 2weeks then
to 1 mg/kg/d during the third week. add aspirin 50mg mg/kg/d; gradually decrease for 2 weeks
• Replace it by aspirin
stop prednisone at the end of 3 weeks, and continue aspirin for
8 weeks or until the C-reactive protein is negative and the
sedimentation rate is falling.
Never use it in patient with severe carditis and HF.

3.Complete bed rest.