ACUTE RHEUMATIC FEVER

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Introduction

ARF is an inflammatory auto

immune disorder that affect
several organs of body
characterized by Arthritis,
Carditis, chores, Rheumatic
nodule, erythema margination &
fever caused group A-B-
hemolytic streptococcus
(GABHS).

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ETIOLOGY-

ARF is Exclusively caused by GABHS (Serotype M-1, 3, 5, 6, 14, 18 & 24)

-Group C& G streptococcus may also cause ARF
- GAS

EPOEMIOLOGY

More than 80% of word cares of ARF & RHD occur in people living in
developing countries, Reasons are- Poverty, Unhygienic Environment, lack
of medical care & household overcrowding.

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(1). Exudative Phase
Mainly seen in joints that occurs in first
2-3-weeks after disease occurred and
characterized by interstitial Edema,
cellular infiltrate (T-Cell & B-Cell &
macrophages), fragmentation of
collogen and scattered deposition of
fibrinoid (Eosinophilic Granular material)
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(2). Proliferative Or
Granulomatous Phase
Care for months to year and is mainly seen in heart
& subcutaneous tissue.
- The pathological hallmark of Rheumatic carditis
in Pan carditis involving Pericardium,
myocardium & endocardium. The area of central
neurosis is surrounded by the ring of plump
histiocyte ANITCHOW cells. Pericarditis is
characterized by deposition of serofibrinous
exudate giving bread & butter appearance.
Myocardium is edematous & shows non-specific
inflammation. There is no evidence of cell damage.
Endocardial inflammatory changes are responsible
for vulvitis and may result in MS, MR, AR. There is
fibrotic thickening of posterior left atrial wall k/a-
Mc Callum patch.
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 Mc Callum patch.

- Generalized vasculitis involving coronary AR Aorta can be seen.

-Histology of subcutaneous nodule reveals central fibrinoid neurosis surrounded by histiocyte, fibroblast
& occasional lymphocyte & rarely polymorphs.

CLINICAL FEATURE: -
5 major manifestations during first episode of ARF
1) Carditis = 50%-70%
2) Arthritis = 35%-66%
3) Chores = 10%-30%
4) Subcutaneous Nodule = 0%-10%
5) Erythema marginatum= <6%

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Subcutaneous nodules
& chores are manifestation
1) Carditis
- More common in young age
- Pan carditis is hallmark
- m/c cause of morbidity & mortality
- Varied manifestation

2) POLYARTHRITIS- Occur in 35%-66% of ARF

- Involve major Joint like knee, ankle, wrist & elbow, rarely small joint like metacarpophalangeal
joint, spine & TM Joint may involve.
- Are charlatanically migratory &fleeting passes from one joint to other
- Joints are swollen, got red & tender
- Duration of arthritis in 2-4 weeks and spontaneous restitution occur without residual defect
except Jaccoud Arthritis, where an erosion of metacarpal head resulting in hook like deformity.

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Subcutaneous nodules
& chores are manifestation
3) Carditis
- More common in young age
- Pan carditis is hallmark
- m/c cause of morbidity & mortality
- Varied manifestation

4) POLYARTHRITIS- Occur in 35%-66% of ARF

- Involve major Joint like knee, ankle, wrist & elbow, rarely small joint like metacarpophalangeal
joint, spine & TM Joint may involve.
- Are charlatanically migratory &fleeting passes from one joint to other
- Joints are swollen, got red & tender
- Duration of arthritis in 2-4 weeks and spontaneous restitution occur without residual defect
except Jaccoud Arthritis, where an erosion of metacarpal head resulting in hook like deformity.

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Subcutaneous nodules
& chores are manifestation
5) SYDENHAM CHOREA- (St. Vitus Dance)
- Due to inflammatory involvement of subthalamic & caudate nucleus of CNS
- It is delayed manifestation & usually female predilection & increased after puberty.
- It is involuntary movement, quasi purposive, non-repetitive & jerky movement, hypotonia muscle
weakness mainly involving dental part of body
- Important sign are-
i. Darting tongue or snake tongue flicks
ii. Hypertension of raised hand
iii. Choreic hand & Extended hand
iv. Milkmaid grip
v. Dancing gail
6) MINOR MANIFESTATION
i. Fever- Usually seen in early stage and usually lane less than 2 weeks and rarely exceeds beyond
39%
ii. Arthralgia- Polyarthralgia in low rise population & Mon arthralgia in moderate to high rise
population
iii. Increased PR interval.

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Laboratory Finding
(1) ESR=ESR>60- In low rise population
ESR= ESR>30- Moderate in high rise population
CRP: Increased
- Other feature like- Anaemia, Epitaxis, Weightless, pillar, pain (due to
non-specific mesenteric adenitis or congestive hepatomegaly
- SECONDARY PROPHYLAXIS- Defined as continuous administration of
specific antibiotic to patient with previous attack of RF, purpose is to
prevent colonization or URI by GABHS and development of reccural
RF

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DURATION OF SECONDARY PROPHLAXIS
I. No Carditis: 5 Year/18 year of age whichever is longer
II. Mild to moderate carditis & herald carditis: 10 Year/25 Year of Age whichever is longer.
III. Severe ds or Posti: Life long or one may opt secondary prophylaxis upto age of 40
years

DURATION OF SECONDARY PROPHLAXIS

I. Use like or diazepam. If no response hello Pada 0.252 20.5 mg / kg / d aur sodium
valproate - 15 MG / kg / D or carbamazepine- 7- 20 MG / kg / may be used
II. resistance cases may be treated plasmapheresis PIMOZIDE.
III. minimum of AF
IV. anti-coagulation for prosthetic heart valve
V. anticoagulation therapy is indicated in patient with AF for history of embolization aur
calling prosthetic or bioprosthetic valve replacement

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RHEUMATIC HEART DISEASE
AND MITRAL VALVE LESION

RHD is only long-term sequel of the ARF

- it is known separative immune meditate complication of streptococcal

Phamyngeal infection

- mitral valve is most commonly affected and maximally damage structure in

children's RHD.

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EPIDEMIOLOGY
- RHD constitute 5 percent- 50% it of cardial patient in Indian hospital

- effect 5-15 year of age

- rare before 3 years after 30 year year of age

- male and female almost equally affected

- C/F of RHD

MITRAL REGURGITATION

- more common in in and seen in in RHD in children.

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HEMODYNAMIC
MR- results in in systolic leak of blood to LA
regurgitate blood reaches the LA during
ventricular systole at it almost systolic treasure
- Thus LA pressure increases during systole
and drop during diastoli
- increased in volume of blood handled by LA &
L resulting in in pulmonary congestion and failure of
- MR provide to exi
forward- Arctic valve , backward- L
forward output become insufficient during
exertion results in fatigue MIC symptom in MR
with LV failure diabolic pressure increases that
lead to to increase in LV Pressure and put it mostly
venom congestion
increased l pressure lead to increased in AHM
in acculi MR LA size is normal hand increase
volume reaching LA pulmonary Venom pressure
LVF. But in long standing MRLA size is increased
to accommodate the regurgitate volume without
increasing LA pressure so future of lvf absent in
long standing MR
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C/F
  
Apex beat- downward and outward
hyperdynamic
 S1- soft systolic
S2- wide and spirit
Pansystolic Murmur best heard Apex beat and radiating to excelled and back as well as external
border- diagonostive
EIG- sinus tachycardia
LVH
Echo- enlarge LV and LA
- MV can be seen by 2D Echo aur 3D Echo
COLOUR DOPPLER- quantify MR non-invasively

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TREATMENT OF MR
mild-to-moderate well venerated long period
medical m/n use of
-
-
PENICILLIN PROPHYLAXIS
- Ace inhibiter
- in spite of maximally tolerated medication wraut consideration of surgery
especially in presence of Pulmonary A HJN

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 WRITE SUMMARY

Summary

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PRESENTATION
REHUMATIC MITRAL STEIXOSIS

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Introduction

Rheumatic MS is less common

then MR in children
HEMODYNAMICS: MS results in
obstruction to flow across mitral
valve during LV Diastole, LA
pressure increase- LA
hypertrophy- increased
pulmonary congestion- Dyspher

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C/F M: F=2:1
SOB, DOE, or Dyspher at rest depending upon severity
cough, Hemophlysis, PIX D, attack of acute pulmonary edema and at typical
low volume pulse
on may not be sign of our RVF
JVP shows prominent wave

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O/E- Normal Size Heart
and Tapping Apex Beat

S2 Maybe Palpable Act 2nd ICS

S2 Split Loud P2
delete diastolic murmur put
ECS=RAD-RVH-P MITRATE
Echo- can quantify narrowing of mitral valve

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TREATMENT

B- blocker or digoxin work equally well by reducing HR and improved diastolic filling
Diuretic= decrease pulmonary valve congestion
Balloon Mitral valvotomy

FEATURE OF SEVERE MS
- narrow-S2-OS gap
- longer duration of MDM

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Thank you

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