ACUTE RHEUMATIC FEVER and

Rheumatic heart disease

FIJI GUIDELINES
Dr. Florecilla D. Nelmida-Ecube
Senior Lecturer
INTRODUCTION
• ARF occurs following a group A streptococcal (GAS) infection
• The incidence of ARF in Pacific islanders is among the highest in the world
• Predominantly affects children 5 to 15 years old
• Crowding in the household and poverty re associated with an increase risk of developing RF
• Accurate diagnosis involves clinical criteria, laboratory work ups and echocardiogram
• A first attack of RF is potentially preventable if the individual presents with GAS pharyngitis
and receives effective antibiotic treatment
• ARF patients are at 10x the risk for subsequent episodes of ARF
• Delivery of regular benzylpenicillin G injections to ARF cases is the mainstay of secondary
prevention, preventing recurrence of ARF and progression to RHD
DEFINITION
• ACUTE RHEUMATIC FEVER ( ARF ) is an illness caused by a reaction to a bacterial infection by
group A streptococcus ( GAS ).
• It causes an acute, generalized inflammatory response and an illness that targets specific parts of
the body including the heart, joints, brain, and skin
• Individuals with ARF are often unwell, have significant joint pains and require hospitalization
• ARF generally leaves no lasting damage to the brain, skin or joints but can cause persisting and
life threatening heart damage which is called Rheumatic heart disease (RHD )
FIJI EPIDEMIOLOGY
• In Fiji estimates of the incidence of the first episodes of ARF in children and young adults
range from 15 to 25 per 100,000 per year
• Many children present late with valve damage ( RHD ) because many ARF presentations are
not recognized in Fiji
• Many clinical staff working in the high incidence setting of Fiji are not familiar with the
symptoms of ARF
eg. No murmur means no work up
no presenting joint involvement with ARF, a diagnosis can be dismissed
• Nearly 1% of all Fijians have evidence of RHD with ECHO confirmation in school aged children
estimated at 8.4 per 1000
DIAGNOSIS
Where possible, all patients with suspected ARF (first episode or recurrence) should
be hospitalized as soon as possible after the onset of symptoms
ARF CATEGORIES
1. ARF
• Fulfills Fiji diagnostic criteria ( table 2 )
• Note that ARF can be diagnosed on the basis of chorea without other
manifestations or evidence of GAS infection

2. Probable ARF
• testing for evidence of GAS infection ( ASOT or throat swab ) is unavailable or
pending
• testing for ESR and WCC is unavailable
• Echocardiography is unavailable
• The history is not considered reliable or documentation of clinical features is not
clear
ARF CATEGORIES
2. PROBABLE ARF
• Specific scenarios where a diagnosis of “Probable ARF” ca be considered
• Carditis on echocardiography with only 1 minor manifestation
• Arthritis or polyarthralgia with 0 or 1 minor manifestations, Note that migratory
polyarthritis or migratory polyarthralgia affecting the large joints is highly
suggestive of ARF
MANAGEMENT OF ARF
MANAGEMENT OF RHD
• Main goal is to prevent disease progression and to avoid or at least delay valve
surgery
• Secondary prophylaxis for prevention of recurrent ARF is the main strategy to
achieve this
• Regular clinical review and follow up echocardiography is important to follow the
progress of valve lesions
• Dental care – will increase risk of Infective endocarditis if not done