rheumatic fever
TRANSCRIPT
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&KNEE PAIN
FEVER
By: Dr Ir
fan
Ziad
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AN 11-YEAR OLD PRESENTED WITHFEVERJOINT PAINAND SWELLING
SOB
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O/E : tachypnea and tachycardia
T 38.2 P 160 RR 32
BP 100/60 SaO2 94%
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Lungs clear CVS S1S2, pansystolic
murmur 3/6 heard at apex with radiation to axilla
Abdomen Soft, normoactive bowel sounds
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Left knee is swollen and extremely tender with warmth & Limited ROM. His right ankle is very swollen and warm. He has limited subtalar motion. Both his knee and ankle are very tender even to touch.
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Enlarged, erythematosus tonsils with exudates
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CNS : No abnormal movements of arms, hands, or tongue are noted. He is unable to walk due to pain.
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P R
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CARDIOMEGALY
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Differentials?
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RHEUMATICFEVER
DR IRFAN ZIAD
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12 millionare affected by ARF and CRHD globally
150 times
developing countries are
more susceptible than the developed countries
5-14 yearsis the most frequent age group
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AN INFLAMMATORY DISEASE OF CHILDHOOD
RESULTING FROMUNTREATED STREPTOCOCCOCCAL
PHARYNGEAL INFECTION
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Streptococcus
Group ARheumatogenic strain
β-hemolytic
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Streptococcus
Group A B-hemolytic
Rheumatogenic strain
Immune
response
M-
Protein
Heart SkinConnective tissue
Brain
Molecularmimicry
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Joints-Athralgia-Migratory polyarthritis
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Skin-Subcutaneous nodules-Erythema marginatum
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Subcutaneous nodules
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Erythema marginatum
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CNSBasal Ganglia
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CHOREA
syndenham
aka San Vitus Dancerapid involuntary movement affecting the hands, feet, tongue and face.
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Pericardium
MyocardiumEndocardium
Heart
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Myocardium
PericardiumEndocardium
Pancarditis
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Myocarditis-heart is enlarged -may develop
CCF
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PericarditisMyocardiumEndocardium
“Bread and Butter”Pericarditi
s
- Completely resolved- Heal with adhesion
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MyocardiumEndocardium
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In patients with critical stenosis, mitral valvulotomy, percutaneous balloon
valvuloplasty, or mitral valve replacement may be indicated.
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polyarthritiserythema marginatum & nodulesSydenham choreaRheumatic myocarditis & pericarditisRheumatic endocarditis
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MODIFIED JONES CRITERIA FOR ACUTE RHEUMATIC FEVERMAJOR CRITERIA MINOR CRITERIA
CarditisPolyarthritis,
aseptic monoarthritis or polyathralgiaErythema marginatum
Prolonged PR interval
Subcutaneous nodules
Chorea
Fever (Temp>38oC)ESR > 30
mm/h orCRP > 30 mg/L
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INVESTIGATIONS
Echocardiogram
FBC: anaemia, leucocytosisThroat swab
CXR, ECG
ASOT
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How to make the diagnosisInitial episode of ARF
2MAJOR CRITERIA
1MAJOR CRITERIA 2MINOR CRITERIA
OR
++ evidence of a preceding
group A streptococcal infection
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How to make the diagnosisRecurrent attack of ARF
2MAJOR CRITERIA
OR
1MAJOR CRITERIA 2MINOR CRITERIA+
+ evidence of a preceding group A streptococcal infection
3MINOR CRITERIA
OR
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Evidence of a preceding group Astreptococcal infection
Increased antistreptolysin O titre (ASOT)Positive throat culture for GABHSPositive rapid antigen detection test
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JONES
ITERIA
oints - artritisbvious - cardiacodules - rheumaticrythema marginatumydenham chorea
nflammatory cells (leukocytosis)emperatureSR/CRP elevatedaised PR intervaltself (Previous Hx of Rheumatic fever)thralgia
MAJO
R
MINO
R
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TREATMENT
Bedrest
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TREATMENTAnti-Streptococcal
TherapyIV C. Penicillin 50 000U/kg/dose 6H or
Oral Penicillin V 250 mg 6H (<30kg),
500 mg 6H (>30kg) for 10 daysOral Erythromycin for 10 days if allergic to penicillin.
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TREATMENTAnti-Inflammatory
Therapymild / no carditis:
Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over
4 weeks.
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TREATMENTAnti-Inflammatory
TherapyPericarditis, or moderate to severe carditis:
Oral Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks,
taper with addition of aspirin as above.
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TREATMENTAnti-Inflammatory
TherapyMonitor Aspirin level and LFT
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Watch out for
REYESSYNDROME
EncephalopathyFatty liver degenerationTransaminase elevation.
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TREATMENTAnti-failure medication Diuretics, ACE inhibitors, digoxin (to
be used with caution).
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TREATMENTSecondary prophylaxis
• IM Benzathine Penicillin 0.6 mega units (<30 kg)
or 1.2 mega units (>30 kg) every 3 to 4 weeks.
• Oral Penicillin V 250 mg twice daily.
• Oral Erythromycin 250 mg twice daily if allergic to Penicillin.
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TREATMENTSecondary prophylaxis
Duration of prophylaxis• Until age 21 years or 5 years after last
attack of ARF whichever was longer • Lifelong for patients with carditis and
valvular involvement.
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Accurate diagnosis is important.Jones Criteria is a good guidelineManagement include post-strep
therapy, anti-inflammatory therapy, anti-failure therapy and secondary
prophylaxisARF is a large physical, emotional and financial burden.
SummarySummary
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In a case of knee swelling..
Don’t forget your stethoscope!
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1. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N (2007), Robbins Basic Pathology (8th ed.), Saunders Elsevier, pp. 403–6, ISBN 978-1-4160-2973-1.2. "rheumatic fever" at Dorland's Medical Dictionary3. Jones, T Duckett (1944). "The diagnosis of rheumatic fever". JAMA 126(8):481. doi:10.1001/jama.1944.02850430015005.4. Ferrieri, P (2002). "Proceedings of the Jones Criteria workshop".Circulation (Jones Criteria Working Group) 106 (19): 2521–3.doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554.5. Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP, FACEP. Retrieved 2007-07-14.6. Malaysian Paediatric Protocol, 3rd Edition
References
References