Rheumatic Fever

 

Immune mediated reaction to Gr A beta hemolytic Streptococcus, usually after 3 – 6 weeks of sore throat.

Common in children 5- 15 years old and more in females.

 

Presentation:

Acute rheumatic fever is diagnosed using the Revised Jones Criteria, which consist of clinical and laboratory findings.

Diagnosis requires either 2 major criteria or 1 major and 2 minor criteria; along with evidence of preceding streptococcal infection like scarlet fever, positive throat swab or raised ASOT.

 

Major criteria:

 – Carditis (includes endocarditis/myocarditis/pericarditis, with tachycardia, new murmur or heart failure)

 – Polyarthritis (migratory to other joints & self-resolving)

 – Sydenham’s chorea

 – Erythema marginatum (pink macules with serpiginous border and central clearing)

 – Subcutaneous nodules (hard lumps over extensor surfaces)- late sign

 – Chorea (Sydenham chorea or St. Vitus dance) or Choreoathetosis- late sign

 

Minor criteria:

 – Fever (temperature > 38 C)

 – Raised ESR > 30 mm/h or CRP > 30 mg/L

 – Raised WCC

 – Prolonged PR interval

 – Arthralgias (don’t include if Arthritis already counted)

 – Previous Rheumatic fever

 

Investigations:

 – Look for raised WCC, ESR & CRP

 – Evidence of Strep infn: Throat swab, ASOT/ Anti DNAase

 – Blood culture

 – CXR, ECG: look for cardiomegaly or heart failure

 – Echocardiogram: Evidence of Pan-Carditis, Percardial Effusion or Valvular heart disease

 

Treatment

 – Acute management includes treatment of Streptococcal infection with Pen V or Erythromycin for 10 days

 – Anti-inflammatory drug to minimize cardiac damage

    If no carditis: Oral Aspirin for 4 weeks, then taper over 4 weks

    If moderate carditis or pericarditis: Aspirin + Prednosolone for 4 weeks, then taper

 – Careful use of Diuretics or ACE inhibitors if heart failure

 – Bedrest until CRP, ESR and ASOT normalizes

 – Consider early referral to paediatric cardiology

 

Secondary Prophylaxis

 – IM Benzathine Penicillin every 3 to 4 weeks

 – Oral Penicillin V twice daily (or Erythromycin twice daily if Penicillin allergy)

 

Duration of prophylaxis:

 – Lifelong prophylaxis if Carditis or Acquired Valvular Heart Disease

 – Otherwise, at least 5 years after the last episode of Acute Rheumatic Fever OR until 21y age

 

Prognosis

 – Early identification and prophylaxis may avoid cardiac damage

 – Risk of cardiac damage increases with each recurrence of rheumatic fever