RHEUMATIC FEVER

Definition: It is a systemic inflammatory disease that occurs as a result of naturally acquired group A
beta-hemolytic streptococcal infection. It is the most common cause of acquired heart disease in
children worldwide.

Anatomy and Physiology

Etiology: The onset of rheumatic fever usually occurs 2 to 6 weeks after an untreated upper respiratory
tract infection with group A beta-hemolytic streptococci.
 It is believed that a genetic susceptibility to rheumatic fever is associated with a state of immune
hyperactivity to the streptococcal antigens; however, the exact cause of rheumatic fever is
unknown.

Symptomatology:
 Clinical manifestations vary and depend on the site of involvement, the severity of the attack,
and the stage at which the child is first examined. The Jones Criteria, which divides signs and
symptoms into major and minor characteristics of the disease, is used when assessing the child
with suspected rheumatic fever.
 Major Characteristics
o Carditis signs and symptoms include tachycardia, cardiomegaly, murmur, muffled heart
sounds, precordial friction rub, precordial pain, and a prolonged PR interval. It can lead
to heart failure, cardiomegaly, and aortic or mitral valve insufficiency.
o Polyarthritis consists of swollen, hot, painful joints (usually large joints). Polyarthritis is
the most common presenting symptom, and it occurs in about 75% of all cases of
rheumatic fever.
o Chorea (also called Sydenham’s chorea or St. Vitus’ dance) is demonstrated by sudden
aimless, irregular movements of the extremities, involuntary facial grimaces, speech
disturbances, emotional lability, muscle weakness, and movements with stress and
decreased with rest. It occurs in about 10% of all cases.
o Erythema marginatum consists of clear-centered, transitory, nonpruritic macules with
defined borders. They are noted mostly on the trunk and proximal extremities. It occurs
in about 5% of all cases.
o Subcutaneous nodules are nontender lesions that may persist, then resolve. They are
located over bony prominences. These are rarely to occur in rheumatic fever.
 Minor characteristics include fever, arthralgia, and specific laboratory findings.

Medical Management

1. Lab tests

 Laboratory findings consistent with the Jones criteria include:

o Erythrocyte sedimentation rate is elevated
o C-reactive protein in elevated
 Complete blood count reveals transient anemia and elevated white blood cell count
 Throat culture findings may be positive for streptococcal infection
 Chest radiography studies may disclose cardiac enlargement
 Electrocardiogram may reveal a prolonged PR interval
 2. Medications

 Penicillin, sulfadiazine or erythromycin during the acute phase

 Salicylates, such as aspirin, to relieve fever and minimize joint swelling and pain
 Corticosteroids if carditis is present or salicylates fail to relieve pain and inflammation
 Low-dose antibiotics after the acute phase subsides to prevent recurrence

3. Treatment/Surgery

 Effective management eradicates the streptococcal infection, relieves symptoms, and prevents
recurrence, reducing the chance of permanent cardiac damage
 Supportive treatment requires strict bed rest for about 5 weeks followed by a progressive
increase in physical activity, depending in clinical and laboratory findings and the response of
the treatment
 Rheumatic heart failure demands continued bed rest and diuretics
 Severe mitral or aortic valve dysfunction that cause persistent heart failure requires corrective
vulvar surgery

Nursing Management

1. Before giving penicillin, ask the patient or his parents if he had a hypersensitivity reaction to it.
Report immediately if he develops rash, fever, chills or other signs of allergy at any time of
penicillin therapy.
2. Instruct the patient or his parents to watch out and report for early signs of heart failure such as
dyspnea and nonproductive cough.
3. Stress the need for bed rest during the acute phase.
4. Teach the patient or the family about the disease and treatment. Warn parents to watch for and
immediately report signs and symptoms of recurrent streptococcal infection – sudden sore
throat, diffuse throat redness, difficulty swallowing, has temperature of 38 to 40 degrees
Celsius, headache and nausea.
5. Urge the family to keep the child away from people with any respiratory infection.
6. Monitor temperature frequently, and patient’s response to antipyretics.
7. Monitor the patient’s pulse frequently, especially after activity to determine degree of cardiac
compensation.
8. Auscultate periodically for development of possible heart murmur or pericardial or pleural
friction rub.
9. Administer medications punctually and at regular intervals to achieve constant therapeutic
blood levels.
10. Provide safe, supportive environment for the child with chorea.

Priority Nursing Diagnosis

1. Deficient diversional activity related to prescribed bed rest

2. Acute pain related to arthralgia
3. Risk for injury related to choreic movements
 4. Risk for ineffective child’s health management related to insufficient knowledge of condition,
signs and symptoms of complications, long-term antibiotic therapy, prevention of recurrence
and other risk factors
5. Risk for complications of endocarditis

Prognosis

There is a cardiac involvement in about 50% of cases. Rheumatic fever usually occurs in children
between ages 6 and 15 years, with peak incidence at 8 years of age. There are more frequent outbreaks
in late winter and early spring when streptococcal infections are most common .