Professional Documents
Culture Documents
ETIOLOGY
Infection with group A beta hemolytic streptococcal infection Commonly results in pharyngitis and impetigo
Strain dependent
Strains like 1, 3 , 6, 8, 14 causes pharyngitis 2-3 weeks later the resulting autoimmunity results in rheumatic fever
Age group 5 to 15yrs Endemic Asia and Africa In 100 per 1,00,000 population this is the cause of acquired heart disease
PREDISPOSING FACTORS
Over crowding and poor living conditions Lower socio economic status
For every untreated case of streptococcal pharyngitis, there is 0.3% chance of developing a rheumatic fever Both sexes are equally affected.
Antibodies produced against the Streptococcal antigen mediate inflammation - cardiac - joints - skin
Though the early manifestation is joint involvement the most damaging involvement is CARDIAC Hence the idiom, Rheumatic fever licks the joint, bites the heart
STREPTOCOCCI..
The M Serotypes 3,5,6,14,18,19 and 24 have strong association with CARDIAC Diseases Throat infection is commonly caused by serotypes 12,1,25,4 and 3. Strains of Streptococci leading to Rheumatic fever possess more of Streptolysin O than Streptolysin S.
PATHOLOGY
Pathological process consists of 1.Exudative stage.Fibrinoid necrosis of the connective tissue occur. 2.Proliferative stage - The hall mark of this stage is the formation of ASCHOFF Bodies - Composed of multinucleated giant cells surrounded by macrophages and T Lymphocytes.
CLINICAL FEATURES
Its a multisystem disorder typically following an episode of streptococcal pharyngitis. Presents withfever - anorexia - lethargy - joint pain
JONES CRITERIA
Major criteria Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous nodules
Minor criteria Fever Arthralgia Previous rheumatic fever APR s Raised ESR
C-Reactive protein Leucocytosis
Prolonged
PR interval on
ECG.
Evidence of preceding streptococcal infection: Any one of the following is considered adequate evidence of infection: -Increased antistreptolysin O or other streptococcal antibodies
Two major or one major and two minor criteria in addition to evidence of recent streptococcal infection
CARDITIS
Manifests asPANCARDITIS Involvement of Pericardium Rub can be present Myocardium Tachycardia Endocardium Valvulitis, (Murmurs - Carey Coombs) Development of cardiac enlargement or cardiac failure ECG changes of percarditis or myocarditis prolonged PR interval
ARTHRITIS
Migratory polyarthritis 40 60 % of patients Large joint involvement Knees, Elbows, Ankles and Wrists Joints are swollen,red and tender. As the inflamation recedes in one joint,the other becomes affected. Once the rheumatic process ends, the joints become NORMAL. No residual deformity
SYNDENHAMS CHOREA-[St.VITUS dance]10 20 % Occur later 3months after the episode of Acute rheumatic fever. Chorea alone is enough to diagnose acute rheumatic fever without satisfying other criteria. Involuntary movement Milk maid grip Jack in the Box tongue Hung up knee jerk Pronator sign
Erythema marginatum
5% of the patients Evanescent rash Pink rash with Slightly raised edges with central clearing Trunk and limbs
SUBCUTANEOUS NODULES
5 % of patients 0.3 3 cm in size Non tender Firm to hard nodule Freely mobile Palpable beneath the skin Particularly over tendons,joints and bony prominences. olecranon process occiput ulna shin of tibia Almost always associated with carditis
COURSE
AND
PROGRESS
Rheumatic fever tends to subside spontaneously in few weeks or months. Arthritis subsides but Carditis progresses. Recurrences and relapses occur invariably. Cardiac lesions worsens
INVESTIGATIONS
Throat Swabs-culture ESR,C-Reactive protein. ECG,---ECHO-Shows MR with dialatation of Mitral annulus and prolapse uf the Antr. Mitral leaflet.AR, Pericardial Effusion. SerodiagnosisASO Titre Evidence of Carditis-Chest x.ray;ECG,ECHO.
MANAGEMENT
Treatment of Acute attack Single dose of Inj. Benzathine Penicillin 1.2 Million units Oral Phenoxy methyl Penicillin 500 mg bd 10 days ALLERGIC to Penicillin
Erythromycin or Cephlosporin.
TRT..CONTD,.
Bed rest lessen joint pain reduces cardiac workload
Duration of Bed rest - Guided by fall of Temperature Leucocyte count,ESR. No sternuous excerise Cardiac failure has to be treated.
Aspirin 75 100 mg/kg body weight Example of a Therapeutic diagnosis 14 days later tapered Joint pain relief is dramatic
Corticosteroids Absolutely indicated in patients with carditis Prednisolone 1-2mg/kg/day in divided doses for 14 days , then tapered.
SECONDARY PREVENTION
Benzyl Penicillin 1.2 million units i.m. monthly Oral Phenoxymethyl Penicillin250mg bd daily Residual heart diseases -Prophylaxis life long Carditis without residual involvement No carditis