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Name : Mareta Anggun M.S
Tutor : dr.Liza Chairani,Sp.A.M.Kes

• Introduction
• Literature review
• Conclusion


Reumatic Fever

Streptococcus Most in 5-15 years

Betahemolyticus old.
group A
Literature review

Definition, epidemiology, etiology, pathogenesis, clinical features, diagnosis

,treatment, prevention, complication, prognostic.

Rheumatic fever is a syndrome due to infection of Group A

Streptococcus Betahemolyticus, with one or more major
symptoms, acute migrans polyarthritis, carditis, Chorea minor,
subcutaneous nodules or erythema marginatum.
10-30 new cases
every 10.000
people each year.

Endemic in Indonesia,
India, Africa, America.
Etiology and Predisposition

Streptococcus beta hemolyticus Group A infection in the throat

is always as predisposition of rheumatic fever, both in the first
attacks and in recurrent attacks.
1. Genetic
2. Gender
3. Age
Individual 4. Nutrition and
other disease

1. Social economic
Environment 2. Climate and
3. Weather

are attached in
Clinical manifestations

Divided in 3 stadiums, as :
• Stadium I (early infection)
• Stadium II (latent phase)
• Stadium III (clinical manifestations)
Stadium I
• Early infection of Streptoccous B-Hemolythicus Group A

• Clinical Manifestations of this stadium are fever, coughs. swallowing pain,

vomiting (rare), diarrhea can occur.

• On physical examination, the tonsillar exudates present following other signs

of`` inflammation. Submandibular lymph nodes often enlarge.

• This infection usually lasts 2-4 days and can heal itself without treatment.

• It usually occurs 10-14 days before the first manifestation of rheumatic fever
Stadium II

• This stage is also called the latent period, the period between

Streptococcus infection and the onset symptoms of rheumatic fever,

• Usually, this period lasts 1-3 weeks, except for Chorea which can

occur 6 weeks or more.

Stadium III

• an acute phase of rheumatic fever, when various clinical feature

of rheumatic fever occurs.

• Clinical manifestations can be classified as general

inflammation symptoms (minor manifestation) and specific
manifestations (major manifestation) of rheumatic fever.
Stadium IV

• Also called an inactive stadium, at this stage people with fever

without interference with heart abnormalities or without
Specific manifestations
Poliartritis migrans
• Migratory polyarthritis, involving
major joints such as knee joints,
ankles, elbows, and wrists.
• inflammatory symptoms such as
swelling, redness, heat around the
joints, pain and joint dysfunction.
• Rheumatic arthritis is asymmetric
Source : medicinestuff, 2017
• Rheumatic carditis is an active
inflammatory process that can affect
the endocardium, myocardium or
• Carditis is the only manifestation of
rheumatic fever that leaves a sequelae
& permanent damage to the organ
Sydenham Chorea
• Sydenham chorea in acute rheumatic fever is
mainly due to molecular mimicry with
autoantibodies to the ganglion.
• May appear even 6 months after the attack of
rheumatic fever
• Clinically manifest as-clumsiness,
deterioration of handwriting, emotional
lability or grimacing of face

Source : Market Research Future, 2018

Eritema marginatum
• Occur in 10%
• Usually children, rare in adults
• Unique, transient lesions of 1-2 inches in
• Pale center with red irregular margin
• Often associated with chronic carditis

Source : Medical Tips and Advice, 2011

Subcutaneous nodules
• Occur in 10%
• Painless,pea-sized,palpable nodules
• Mainly over extensor surfaces of
joints,spine,scapulae & scalp
• Associated with strong
• Always associated with severe
carditis Source : Medical stuff, 2017
General inflammatory manifestations
(minor symptoms)
• Previous history of rheumatic fever
• Fever
• Artralgia
• Increased levels of acute phase reactants
• The P-R interval is elongated
DIAGNOSIS OF Major criteria Minor criteria Clinical findings that
RHEUMATIC FEVER support infection with
Streptokokus beta
hemolitik A
Jones criteria • Carditis Clinical found: Throat culture of bacterial

• The presence of 2 major •
Streptokokus beta hemolitik
A (+)
criteria are found and or 1 • Erythema - Previous history of
major criteria plus 2 marginatum rheumatic fever Increased antistreptolisin
minor criteria, supported • Subcutaneous Laboratory found: O/ antibody Streptokokus
evidence of previous nodule - Increased acute phase
streptococcal infection, reactants Prevous history of scarlet
positive throat smear - increased erythrocyte fever
culture or increase in sedimentation
streptococcal antibody - Increased CRP
(ASTO> 200). - PR interval extends
Diagnostic Criteria Criteria
 Rheumatic fever first attack  Two major or one major and two
minor plus previous evidence of
• WHO Criteria 2002-  Rheumatic fever recurrent SGA infection
2003 for attack without RHD  Two major or one major and two
Diagnosting minor plus previous evidence of
Rheumatic Fever  Rheumatic fever recurrent SGA infection
and Rheumatic attack with RHD
Heart Disease  Chorea sydenham  Two minor plus proof of
(Based on Jones previous SGA infection
Criteria Revision)  RHD (pure mitral stenosis or  No other major criteria or proof
combined with mitral of SGA infection are needed
insufficient and/or Aortic  No other criteria are needed to
valve disorder) diagnose as RHD
Differential diagnosis
Reumatic fever Artritis reumatoid Lupus eritomatosus
Aged 5-15 years 5 years 10 years
Sex ratio likely woman 1,5:1 woman 5:1
Joint Disorders severe moderate mild
Swollen Pain Not spesific Not spesific Not specific
Abnormalities Ro none often rarely
Efloresention Eritema marginatum Macular Butterfly rash
carditis yes rare advance
Laboratory rare
Lateks ± 10%
Aglutination cel - ± 10%
- ± 5%
preparat cel LE
response to salicylates immidiate late Late / -
Comprehensive management of patients with rheumatic fever
• Treatment of acute manifestations, recurrence prevention and
prevention of endocarditis in patients with valve abnormalities
• Examination of ASTO, CRP, LED, complete throat and blood
smear. Echocardiography for cardiac evaluation
• Antibiotics: penicillin, or erythromysis 40 mg / kg/weight per
day during the day for patients with penicillin allergies.
• Varies bed rest depend on the severity of the disease.
Clinical manifestations Bed rest Anti-inflammatory drugs Activity
Arthritis without carditis Total : 2 weeks Acetosal 100mg / kgbb for 2 Attend to school after 4 weeks,
weeks no restriction in sport activity
Gradual mobilitation 2weeks 75mg / kg for the next 4 weeks

Arthritis + carditis without Total 4 weeks Acetosal 100mg / kgbb for 2 Attend to school after 8 weeks,
cardiomegaly weeks no restriction in sport activity
Gradual mobilitation 4 weeks 75mg / kg for the next 4 weeks

Arthritis + cardiomegaly Total 4 weeks Prednisone 2 mg / kg body Attend to school after 12 weeks,
weight for 2 weeks, tapering do not do heavily exercise
Gradual mobilitation 4 weeks off for 2 weeks
75mg / kg starting from the 3rd
week for 6 weeks
Arthritis + cardiomegaly + Total : during decompesation Prednisone 2 mg / kg body Attend to school 12 weeks,
decompesatio cordis cordis weight for 2 weeks, tapering decompensation is resolved.
off for 2 weeks Don’t do exercise 2-5 years
Gradual mobilitation Acetosal
75mg / kg starting from the 3rd
week for 6 weeks

Recommended use of anti-inflammatory

• The aim of primary prevention is to eradicated Group A
Streptococcus, patients with bacterial pharyngitis and with
positive Group A Streptococcus should treat early on
supurative phase.
Secondary Preventions
• Secondaryions is given following primary preventions. The
best method to prevent rellaps is benzath penicilin (iv) given
continuously every 4 weeks, in endemic area every 3 weeks is
• Secondary Preventions is to prevent another new strain of
these bacteria, which can cause reccurrent or chronic.
• Some studies reccomend intramuscular injection of
Benzylpenicillin every 3-4 weeks after rheumatic fever.
Route Antibiotic Dose Duratiom
Primary Prevention: Treatment of Pharyngitis Streptococci to prevent Rheumatic Heart Disease
Intramuscular Benzatin 1,2m unit (600.000 unit if Once
penisilin G <27kg)

Oral Penisilin V 250mg/kgs/24hours (not more bid for 10 days

than 1 g/24) tid atau qid for10
Eritromisin 40mg/kg/24hours (not more days
Secondary Preventions: to prevent rellaps
Intramuscular Benzatin 1,2m unit Severy 3 -4 weeks
penisilin G
Oral Penisilin V 250mg Bid
Eritromisin 250mg Bid

• Rheumatic heart fever is the largest complication of acute rheumatic fever

and major cause of mitral stenosis and insufficient of mitral in the world.
Depends on permanent damage of the organ (heart)
• Ad vitam : dubia ad bonam
• Ad sanationam : dubia ad bonam
• Ad fungsionam : dubia ad malam

Betahemolyticus The presence of 2 major criteria
group A are found and or 1 major
criteria plus 2 minor criteria,

Rheumatic fever

Preventions are needed before rheumatic heart disease happened

Ages 5-15 yrs are most

susceptible Antibiotic treatment is the best approac for management and preventions of rhemuatic
In Indonesia, the incidence fever
are 0,3 until 0,8 per 1.000
The best method to prevent rellaps is benzath penicilin (iv) given continuously every 4
weeks, in endemic area and crowded area every 3 weeks is recommeded.
• Madiyono, B, Rahayuningsih, SE & Sukardi, R. 2005, Penanganan Penyakit
Jantung Pada BAyi dan Anak, UUK Kardiologi IDAI. Jakarta
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karakteristik gagal jantung pada anak di RSUP Prof. Dr. R. D. Kandou
Manado, Vol.4 No.2
• Behrman, Kliegman, & Arvin, 2000. Ilmu Kesehatan Anak, EGC, Jakarta
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of Cardiovascular Medicine, M.P.L. Eugene Braunwald, MD Robert O.
Bonow, MD, Editor. 2007, Saunders Elsevier: Philadelphia
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Jakarta: Badan Penerbit IDAI, 2004. hal 149-153
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Gambaran karakteristik gagal jantung pada anak di RSUP Prof. Dr.
R. D. Kandou Manado, Vol.4 No.2
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Harrison's Principles of Internal Medicine. 16th. ed. Hamburg.
McGraw-Hill Book. 2005 : 1977-79
• World Health Organization, 2004. Technical Report
Series:Rheumatic Heart disease, Indian Pediatrics, vol 45, pp.565-
• National Heart Foundation of Australisa and the Cardiac Society of
Australia an New Zealand, 2006. Diagnose and Management of
Acute Rheumatic Fever and Rheuamtic Heart Disease in Australia:
an Evidence-based review, National Heart Foundation of Australia