Test questions for a lecture

on
Acute Rheumatic Fever
NAME : Cinderella Coutinho
Group no :40

1. What is the population risk of developing acute rheumatic fever?

➡️The risk of developing ARF :
● Low risk - In developed nation, due to better housing, better health care, good
hygiene (incidence of ARF <2 per 100 000 children from 5 to 15 years): European
countries, Russia, USA, CANADA.
● Medium and high risk: In developing countries or 3rd world countries, due to bad
hygiene, too much crowdness, not so good health care system. Chances of
developing ARF are much higher than developed nation. (incidence of ARF 100-200
per 100 000 children from 5 to 15 years) Fiji, India, Bangladesh, Africa, Kosovo,
NORTH-WESTERN Ontario (Canada), Australia and New Zealand (indigenous),
North CAUCASUS (Russia).

2. List the main factors of virulence of the hemolytic streptococcus of group A.

➡️Beta-hemolytic streptococcus of group A (Streptococcus pyogenes, Streptococcus
haemolyticus) is represented in nature by 80 strains. However, not all strains of Group A
streptococcus are able to cause ORL.
● More often than others, rheumatism is associated with strains M1, M3, M5, Mb, M14,
M18, M19, M24, M27, M29. It is suggested that these strains of streptococcus carry a
"rheumatogenic factor" ( having M-protine stands on their cell wall).
In recent years, superantigens such as exotoxin F (mitogenic factor), streptococcal
superantigen (SSA), erythrogenic toxins SpeX, SpeG, SpeH, SpeJ, SpeZ, Sme Z-2 have
been discovered. All of them can interact with the antigens of the main histocompatibility
complex of class II, expressed on the surface of antigen presenting cells, and in the variable
regions of the B chain of T lymphocytes, causing their proliferation and powerful release
of cytokines, especially such as tumor necrosis factor and interferon.
○ With rheumatic fever, the level of IL-1, neopterin, and TNFa sharply
increases.
○ Thus,"rheumatogenic" streptococcus is characterized by high contact, rapid
transmission of infection from the patient to a healthy body, and has all the signs of an
invasive, virulent microbe.

3. What is Ashoff-Talalaeva granuloma?

➡️Fibrinoid degeneration of connective tissue,inflammatory edema, inflammatory cell
infiltration & proliferation of specific cells resulting in formation of Ashcott nodules, resulting
-Pancarditis in the heart
-Arthritis in the joints
-Ashcott nodules in the subcutaneous tissue
-Basal ganglia lesions resulting in chorea.
 Aschoff bodies consist of fibrinoid change in connective tissue, lymphocytes,occasional
plasma cells, and abnormal characteristic histiocytes. These may disrupt the electrical
conduction pathways leading to prolongation of the PR interval on electrocardiogram.

4. Kissel-Jones criteria used for the diagnosis of acute respiratory infections

(as amended bAPP, 2003).
➡️ Two separate sets of criteria:
A. low-risk settings (i.e., those with a rheumatic fever incidence <2 per 100,000 school-
aged children or all-age rheumatic heart disease prevalence <1 per 1000 population
per year)
B. moderate- to high-risk populations
The diagnosis of possible rheumatic fever. This category of diagnosis allows for the situation
when a given clinical presentation may not fulfil the revised Jones criteria but the clinician
may still have good reason to suspect the diagnosis. Any of the following criteria are met.
● Evidence of a recent group A streptococcal infection with at least 2 major
manifestations or 1 major plus 2 minor manifestations present.
● Rheumatic chorea: can be diagnosed without the presence of other features and
without evidence of preceding streptococcal infection. It can occur up to 6 months
after the initial infection.
● Chronic rheumatic heart disease: established mitral valve disease or mixed
mitral/aortic valve disease, presenting for the first time.

5. The duration of secondary prevention of acute respiratory infections.

The duration of secondary prevention of acute respiratory infections.

Category of patients Duration of prophylaxis

Patient without proven carditis For 5 years after the last attack or 18
years of age (whichever is longer)

Patient with carditis For 10 years after last attack or 25

(mild mitral regurgitation or Healed years of age ( whichever is longer)
carditis)

More severe valvular disease Lifelong

Valvular surgery Lifelong

 Test questions for a lecture
on
valvular heart disease

1. Stage progression of valvular heart disease.

2. What pressure gradient on the aortic valve in symptomatic patients wit haortic
stenosis is an indication for surgical treatment?
➡️Intervention is indicated in symptomatic patients with severe, high gradient aortic stenosis
(mean gradient >_40 mmHg or peak velocity >_4.0 m/s).
● Intervention is indicated in symptomatic patients with severe low-flow, low-gradient
(<40 mmHg) aortic stenosis with reduced ejection fraction and evidence of flow
(contractile) reserve excluding pseudo severe aortic stenosis. Intervention should be
considered in symptomatic patients with low-flow, lowgradient (<40 mmHg) aortic
stenosis with normal ejection fraction after careful confirmation of severe aortic
stenosis.
● Intervention should be considered in symptomatic patients with low-flow, low-gradient
aortic stenosis and reduced ejection fraction without flow (contractile)
reserve, particularly when CT calcium scoring confirms severe aortic stenosis.
Intervention should not be performed in patients with severe comorbidities when
the intervention is unlikely to improve quality of life or survival.

3. At what vice and its severity against the background of atrial fibrillation, the
mandatory use of warfarin is recommended?
➡️Patient with high or moderate risk of having stroke, eIn valvular atrial fibrillation, No
additional vascular risk factor.

4. Indications for TAVI.

➡️TAVI is recommended in patients who are not suitable for SAVR aassessed by the Heart
Team. TAVI being favoured in elderly patients (>75) suitable for transfemoral access .The
use of TAVI over surgery in elderly patients at increased surgical risk. TAVI is not
recommended in asymptomatic patients. In patients with low-flow, low-gradient aortic
stenosis and reduced ejection infraction in whom the depressed ejection fraction is
predominantly caused by excessive afterload.
5. What drugs are contraindicated in severe aortic stenosis?
➡️Afterload reducing agents-
● ACEi,
● CCB

CASE 1

1. Formulate and justify the provisional diagnosis.

➡️Acute rheumatic fever with endocarditis (mitral valve regurgitation), Complication is
mitral valve regurgitation, Can lead to CHF. Justification- Sore throat (pharyngitis)
within 2 weeks, fever, heart pain

2. What are the necessary additional investigations for confirming of diagnosis?

➡️Anamnesis (pharyngitis within 2 weeks), biochemical test-
● High ESR
● Anemia, leucocytosis (rare!)
● Elevated C-reactive protein
● Elevated ASO titer,
● Anti-DNAse B test,
● Throat culture-GABH streptococci,
● ECG (prolonged PR interval, 2nd or 3rd degree blocks, ST depression, T
inversion),
● 2D Echo cardiography (valve edema,mitral regurgitation,LA & LV
dilatation,pericardial effusion,decreased contractility),
● Chest Xray

3. List possible complications.

➡️Complications are :
● Subcutaneous nodules,
● Sydenham chorea or chorea minor.
● rheumatic arthritis,
● Erythema Marginatum,
● CHF

4. Define your tactics regarding the patient, tell about the principles of treatment,
prognosis and prevention of the disease.

➡️ STEP I: Primary Prevention of ARF- phenoxymethylpenicillin potassium- 500 MG orally 2

to 3 times daily for 10 days, benzathine benzylpenicillin, amoxicillin,erythromycin,
clindamycin.

STEP II: Anti inflammatory treatment- aspirin (NSAIDS), ibuprofen, GCS (endocarditis)-
prednisolone: 1-2 mg/kg/day orally for 7 days, maximum 80 mg/day.

STEP III: Supportive management & management of complications- Bed rest.

STEP IV : Secondary Prevention of Rheumatic Fever- antibiotics penicillin V,

 erythromycin.

Prognosis • Rheumatic fever can recur whenever the individual experience new GABH
streptococcal infection, if not on prophylactic medicines.

CASE 2

1. Formulate and justify the provisional diagnosis.

➡️Rheumatic fever with rheumatic arthritis, Complication is rheumatic arthritis. Can
cause endocarditis (valvular defect. )Justification- Throat infection 2 weeks ago, pain
in main joints, fever.

2. What are the necessary additional investigations for confirming the diagnosis?
➡️Anamnesis (pharyngitis within 2 weeks), biochemical test-
● High ESR
● Anemia, leucocytosis (rare!)
● Elevated C-reactive protein
● Elevated ASO titer,
● Anti-DNAse B test,
● Throat culture-GABH streptococci,
● Examination of joints (In addition to arthralgia, the joints are red, warm and
swollen),
● ECG,
● Echocardiogram.

3. List possible complications.

➡️Complication are :
● Subcutaneous nodules in tendon endings,
● Mainly over extensor surfaces of joints (particularly knees, wrists and elbows),
bony protuberances (spine, scapulae & scalp),
● Erythema marginatum,
● Endocarditis .

4. Define your tactics regarding the patient, tell about the principles of treatment,
prognosis and prevention of the disease.

➡️STEP I: Primary Prevention of ARF- phenoxymethylpenicillin potassium- 500 mg

orally two to three times daily for 10 days, benzathine benzylpenicillin, amoxicillin,
erythromycin, clindamycin.

STEP II: Anti inflammatory treatment- aspirin (NSAIDS)- rheumatic arthritis, ,ibuprofen.

STEP III: Supportive management & management of complications- Bed rest

STEP IV : Secondary Prevention of Rheumatic Fever- antibiotics penicillin V, erythromycin.

Prognosis :
● Rheumatic fever can recur whenever the individual experience new GABH
streptococcal infection,if not on prophylactic medicines
● Goodprognosis for older age group & if no carditis during the initial attack.