Transcript Acute Rheumatic Fever: Diagnostic and Management

4 SymCARD 2014
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Acute Rheumatic Fever:
Diagnostic and
Management
Didik Hariyanto
Indry Putri Festari
Pediatric Cardiology Subdivision
Division of Cardiology and Vascular Medicine
Faculty Medicine Universitas Andalas
General Hospital dr. M. Djamil Padang
Introduction
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Rheumatic fever (RF) is nonsuppurative complications of Group A streptococcal
pharyngitis due to a delayed immune response
Continues to be problem worldwide
Underdiagnosed and undertreated
Estimated 30 million people suffer from ongoing heart disease from ARF, 70%
dying at average age 35 years old
RHD developed in 44% of patients who initially had no clinical evidence of carditis
Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
Lioyd T et all, Pediatrics 2003: 112:1065-68
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Case:
 A 11 year-old girl, brought to hospital because she has pain in her right knee
that is preventing her from walking
 There’s breathlessness during activity
 History of sorethroat 2 weeks before
ARTRITIS and DISPNEU
Diff Dx?
•Septic arthritis
•Rheumatic fever
•Juvenille Rheumatoid Arthritis
•Congenital Heart DIsease
• etc
IS IT ACUTE RHEUMATIC FEVER?
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Arthritis in Acute Rheumatic Fever
• Most common feature: present in 80% of patients
• Painful, migratory, short duration, excellent response of salicylates
• Usually affected and large joints preferred knees, ankles, wrists, elbows,
shoulders
• Small joints and cervical spine less commonly involved
• Differenciate with athralgia
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Carditis
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Most serious manifestation
May lead to death in acute phase or at later stage
Any cardiac tissue may be affected
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Valvular lesion most common: mitral and aortic
Clinical manifestations:
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Breathlessness
Tachycardia
Murmur (MR and AR)
Cardiomegaly
Heart failure
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1 Park
MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
WHO Criteria for diagnosis of rheumatic fever
(based on revised Jones criteria)
Major Manifestation
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Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor Manifestation
- Clinical : fever, poliathralgia
- Laboratory: elevated acute phase
reactans (erythrocyte sedimentation rate
or leucocyte count)
Supporting evidence of a preceding streptococcal infection within the last 45 days
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Electrocardiogram: Prolonged P-R interval
Elevated or rising antistreptolysisn-O or other streptococcal antibody, or
A positive throat culture, or
Rapid antigen test for group A streptococci, or
Recent scarlet fever
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
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Criteria Diagnosis ARF
• Two mayor manifestation, or
• Combination 1 mayor and 2 minor manifestations and
• Supporting evidence of a preceding streptococcal infection
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
2002–2003 WHO criteria for the diagnosis of rheumatic fever and rheumatic
heart disease (based on the revised Jones criteria)
Diagnostic categories
Criteria
Primary episode of RF
Two major *or one major and two minor**
manifestations plus evidence of a
preceding group A streptococcal
infection***.
Recurrent attack of RF in a patient without
established rheumatic heart disease
Two major or one major and two minor
manifestations plus evidence of a preceding group A
streptococcal infection.
Recurrent attack of RF in a patient with established
rheumatic heart disease.
Two minor manifestations plus evidence of a
preceding group A streptococcal infection
Rheumatic chorea.
Insidious onset rheumatic carditis
Other major manifestations or evidence of group A
streptococcal infection not required
Chronic valve lesions of RHD (patients presenting
for the first time with pure mitral stenosis or mixed
mitral valve disease and/or aortic valve disease).
Do not require any other criteria to be diagnosed as
having rheumatic heart disease
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Syndenham’s Chorea
• Extrapyramidal disorder
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Fast, clonic, involuntary movements (especially face and limbs)
Muscular hypotonus
Emotional lability
• First sign: difficulty walking, talking, writing
• Usually a late manifestation: months after infection
• Often the only manifestation of ARF
th
1 Park
MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Subcutaneous Nodules
• Usually 0.5 - 2 cm long
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Firm, non-tender, isolated or in clusters
Most common: along extensor surfaces of joint
knees, elbows, wrists
• Also: on bony prominences, tendons, dorsi
of feet, occiput or cervical spine
th
1 Park
MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Erythema Marginatum
• Present in 7% of patients
• Highly specific to ARF
• Cutaneous lesion:
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Reddish pink border
Pale center
Round or irregular shape
• Often on trunk, abdomen, inner arms, or thighs
• Highly suggestive of carditis
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Minor Manifestation
• Fever
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Supporting evidence
Occurs in almost all rheumatic
attacks at the onset, usually ranging
from 38.4–40.0 °C
Diurnal variations are common, but
there is no characteristic fever
pattern.
• ECG  Prolong PR interval
• Athralgia
• Arthralgia without objective
findings is common in RF
• Less common
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abdominal pain and epistaxis
th
1 Park
MK. Pediatric Cardiology for Practitioners. 2008
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Therapy
General guideline for bed rest and indoor ambulation
Arthritis alone
Mild Carditis
Moderate Carditis
Severe Carditis
Bed rest
1-2 week
3-4 week
4-6 week
As long as CHF is
present
Indoor ambulation
1-2 week
3-4 week
4-6 week
2-3 month
Recommended anti-inflammatory therapy
Arthritis Alone
Mild Carditis
Moderate Carditis
Severe Carditis
Prednisone
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2-6 week
Aspirin
1-2 week
3-4 week
6-8 week
2-4 month
Dosages: Prednisone, 2 mg/kg/day, in four divided doses; aspirin, 100 mg/kg/day, in four to six divided doses
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1 Park
MK. Pediatric Cardiology for Practitioners. 2008
4 SymCARD 2014
Therapy…
Primary prevention of rheumatic fever: recommended treatment for streptococcal pharyngitis
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
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Therapy….
Antibiotics used in secondary prophylaxis of RF
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
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ARF and Heart Failure
• Management:
• Diuretic
• ACE-inhibitor
• Aldosterone antagonist
• Inotropic
When and How to Use it?
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1 WHO.
Rheumatic Fever and Rheumatic Disease. 2001
2Hampole CV. Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Monitoring and Evaluation ARF
• ARF could become Rheumatic Heart Disease
• Monitoring:
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Echocardiography
Check inflammation marker if needed
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1Hampole CV.
Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Complication
• Rheumatic Heart Disease
• Heart Failure
• Other issues:
• When the patient need to perform surgery?
• Repair/replacement?
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1Hampole CV.
Rheumatic Fever. Manual of Cardiovasc Med. 2013
4 SymCARD 2014
Take Home Message
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Acute Rheumatic Fever leading to Rheumatic Heart Disease is a major
problem world wide.
• Appropriate treatment of group A strep pharyngitis necessary to prevent
disease.
• Preventing recurrences causing chronic heart disease simple, universally
available, and costeffective.
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“
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terimakasih
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