Transcript Investigation

Definition: Acute, immunologically mediated
multisystemic inflammatory disease following group A
streptococcal pharyngitis .affecting joints, skin, heart and
brain
•Occures in 3% of patients with group A
streptococcal pharyngitis.
•Increase risk of reactivation with new
pharyngeal infections
Diagrammatic structure of the group A
beta hemolytic streptococcus
Antigen of outer
protein cell wall
of GABHS
Cell wall
induces antibody
Protein antigens
response in
victim which
Group carbohydrate result in
autoimmune
Peptidoglycan
damage to heart
valves,
Cyto.membrane
sub cutaneous
tissue,tendons,
Cytoplasm
joints & basal
ganglia of brain
Capsule
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Pathogenesis of rheumatic fever
ARF is a hyper sensitivity reaction induced
by group A streptococci.
Antibodies directed against M proteins of
streptococci cross-react with glycoproteins
of heart,joints,skin and brain.
Oncet of symptoms is 2-3 weeks after
infection,and absence of bacteria in
leasions.
Multinucleated giant cells, macrophages
And T lymphpcytes seen only in the heart
Found in myocardial biopsy
Clinical features
Peak incidence 5-15 years
Fever ,anorexia ,Lethargy ,joint pain 2-3 weeks after
an episode of streptococcal pharingitis
Arthritis : migratory ,asymmetrical affecting large
joints {elbows ,wrists, knees ,ankles }
Skin lesions: Erythema marginatum , subcutaneous
nodules
Cardites : usually pancarditis ,cardiomegaly ,
murmurs, tachycardia ,chest pain,
Sydenhams chorea :occurs 3 m after acute RF
Rare manifestations: pleurisy ,pleural effusion
,pneomonia
Migratory asymmetrical non -deforming
Polyarthritis affects large joints
Responds quickly to aspirin
Occurs in 75%
Joints are painful, red and warm
For 1-7 days
10%-15%, painless mobile
over joints with normal skin
color, small and transient
0.5-2mm in size, occures 3w
after onset
Associated with carditis
Transient skin rash red macules
over trunk proximal part of
extremities pale center red margins
which coalesce as snake like
appearance, non pruritic, >10%
Dyspnoea, crdiomegaly, pericarditis,
murmers, tachycardia, chest pain
May be pancarditis incidence decrease
with age 30% in adults
ECG changes
St.Vitus`s dance
Occures in 10% of patients, it is
late manifestation of RF 3m
Nonpurpossive, nonrepititive
involantory movement of hands,
face, or feet, more in females,
Explosive speech ..Emotional
liability ………………. last 2-6m ,
spontaneous recovery is usual
25% go on to develop chronic
RVD
TR : halloperidole,
phenobarbitone, Na-vlproate
Carbimezapine
Jones criteria for diagnosis of RF
Major manifestations :*Cardtids *Polyarthritis * Chorea
*Erythema marginatum *Subcutaneous nodules
Minor manifestations :*Fever *Arthralgia *Previous RF
Raised ESR or CR-protein * Leukocytosis * 1st an 2nd AV block
Evidence of preceding streptococcal infection:
*Raised ASO titer * Positive throat swab culture
For diagnosis of RF:
2 Major or { 1 Major + 2 Minor } + Evidence of recent streptococcal
Infection.
Investigations:
*Nonspecific : raised ESR, CRP, WBC
*Evidence of preceeding strept. Infection :
_ Throat swab culture for group A beta haemolytic
strept.
_ ASO titer > 200 u { adults }, and > 300 u { children}
*Evidence of carditis :
_Chest XR : cardiomegaly, pulmonary congestion
_ ECG : 1st and 2nd AV block , ST , T , changes
_ ECHO. : chamber dilatation , valve abnormalities
*
Treatment of acute rheumatic fever
Benzathine penicillin 1.2m units i.m to eliminate residual
Strepto. infection
* Bed rest and supportive measures : rest till symptoms
improve
* Aspirin 60-120mg /kg b.w in 6 doses for 3-4 ws
* Corticosteroids in cases of carditis or severe arthritis
prednisolone 1-2 mg/kg b.w in divided doses 2-3 ws
tapering 20%/w
* Secondary prevention
_ Benzathine penicillin 1.2 million units i.m monthly
or phenoxymethylpenicillin 250mg b.d or erythromycin
until 21 year at least 5 years after last attack of acute RF
Chronic rheumatic carditis
*occurs in 50% of those affected with RF with carditis
*History of RF or chorea elicited only in 5o% of
patients with chronic RVD
*MV is affected in 90% of cases ,AV next most frequent
then TV and least frequently PV
isolated MS occurs in 25% of all cases
*Symptoms usually delayed for years or decades after acute
RF
* Predominant pathology is progressive fibrosis mainly
affecting the valves causing thickening ,deformity and
calcification ending in varying degree of stenosis and /or
regurgitation
*Clinical features and complications depend on valves
involved and include
* Cardiac murmurs *Cardiac hypertrophy and dilatation
*Congestive heart failure * Thromboembolic incidents
*Infective endocarditis * Arrhythmias mainly AF