Rheumatic Fever
Rheumatic Fever
Rheumatic Fever
EPIDEMIOLOGY
The epidemiology of acute rheumatic fever
is identical to that of group A streptococcal
upper respiratory tract infections.
Acute rheumatic fever most often occurs
in children; the peak age-related incidence
is between 5 and 15 years.
Most initial attacks in adults take place at
the end of the second and beginning of
the third decades of life.
Rarely, initial attacks occur as late as the
fourth decade and recurrent attacks have
been documented as late as the fifth
PATHOGENESIS
Historically, approaches to understanding
the pathogenesis of rheumatic fever have
been grouped into three major categories:
(1) direct infection by the group A
streptococcus;
(2) a toxic effect of streptococcal
extracellular products on the host tissues;
(3) an abnormal or dysfunctional immune
response to one or more as yet
unidentified somatic or extracellular
antigens produced by all (or perhaps only
by some) group A streptococci.
disease
Outcomes:
1. Recovering
2. Chronic rheumatic heart
disease
with valve lesion
without valve lesion (fibrosis
of the valves border)
DIAGNOSIS
There is no specific laboratory
test that can establish a diagnosis
of rheumatic fever.
The diagnosis, therefore, is a
clinical one but requires
supporting evidence from the
clinical microbiology and clinical
immunology laboratories.
Minor Criteria
Carditis
Migratory polyarthritis
Sydenhams chorea
Subcutaneous nodules
Erythema marginatum
Clinical
Fever
Arthralgia
Laboratory
Elevated acute
phase reactants
Prolonged PR interval
Plus
Supporting evidence of a recent group A streptococcal
infection
(e.g., positive throat culture or rapid antigen detection
test; and/
or elevated or increasing streptococcal antibody test)
1. Carditis
Carditis is characterized by
one or more of the following:
sinus tachycardia,
the murmur of mitral
regurgitation,
an S3 gallop, a pericardial
friction rub,
cardiomegaly.
rheumatic valvulitis
2. Migratory polyarthritis
Is present in as many as 75% of
cases, most often affecting the:
Ankles
Wrists
Knees
Elbows
3. Sydenham's chorea.
Occurs in fewer than 10% of patients
with rheumatic fever.
The latent period may be as long as
several months.
Patients with Sydenham's chorea should
be given secondary prophylaxis for
prevention of recurrent attacks, even if
they do not appear to have rheumatic
heart disease.
TREATMENT
There are two necessary
therapeutic approaches to patients
with acute rheumatic fever:
anti-streptococcal antibiotic
therapy
therapy for the clinical
manifestations of the disease.
Secondary prophylaxis
Recommendations of the American
Heart Association and of the World
Health Organization:
intramuscular injection of 1.2 million
units of benzathine penicillin G every 4
weeks, or
oral penicillin V (250 mg twice daily), or
oral sulfadiazine (1.0 g daily).
Secondary prophylaxis is
always given during the first 5
years after the attack
Medical therapy for the
manifestations of rheumatic
fever depends on the clinical
status of the patient.
Salicylates
In doses escalating to 2 g four times
daily are very effective and will result
in marked clinical improvement, often
within 12 h.
Salicylates may be given for 4 to 6
weeks and gradually tapered so as to
prevent a rebound.