Rheumatic Fever

(Modified) Centor Criteria

What criteria is this?

strep throat

What is the centor criteria used to assess?

1, 2-3, 4-5

Centor Criteria Scoring

• < _ → no antibiotic or further testing recommended

• _-_ → rapid strep testing and/or culture

  • Tx if rapid antigen detection or throat cx (+)

• _-_ → Rapid strep testing and/or culture

  • Empiric tx is okay w/o testing

immune, streptococcal, 5-15, 2-3, 5

Acute Rheumatic Fever

• Systemic ______ process that is a sequela of beta-hemolytic __________ infection of the pharynx

• More common in developing countries

• Peak incidence in ages _-__

  • Rare before 4 and after 40

• Signs usually being _-_ weeks after throat infection

  • But may begin as early as 1 week or as late as _ weeks after infection

genetic, injury, cross-reactive, proteins, mitral,

Acute Rheumatic Fever Pathophysiology

• Not completely understood

• _______ susceptibility may be present

• Tissue ______ is thought to be caused by an autoimmune process generated by cross-reactive antibodies and T cells between group A strep (GAS) antigens and human ________

• Affects the valves:

  • _______ valve in 75-80% of cases

  • Aortic valve in 30%

  • Tricuspid and pulmonary valves in <5%

rheumatic fever, cusps, chordae tendineae, regurgitation, mitral, aortic, mitral

Chronic Rheumatic Heart Disease

• A complication of Acute Rheumatic Fever

• Results from a single or repeated attacks of ________ _____

• Causes rigidity and deformity of the valve _____ and shortening and fusion of the ______ _________ → results in valvular stenosis and/or ____________

• Affects the ______ valve alone in 50-60% of cases

  • Combined lesions of the ______ and ______ valves occur in 20%

Jones Criteria

What criteria is used to diagnose rheumatic fever?

2, 1, 2

Jones Criteria

• The presence of _ major criteria OR _ major and _ minor criteria establishes the diagnosis

carditis, marginatum, subcutaneous, Sydenham, polyarthritis

Jones Criteria - Major Criteria

• ________

  • Pericarditis, cardiomegaly, heart failure, mitral or aortic regurgitation murmurs

  • Occurs most often in children and adolescents

• Erythema __________

  • Rapidly enlarging macules → annular or crescent shaped

  • Trunk and proximal extrimities

  • “migrates”

• __________ Nodules

  • Small (<2cm), firm, and nontender

  • days-weeks and are recurrent

  • Uncommon except in children

• _______ Chorea (“Saint Vitus Dance”)

  • Disorder of CNS: sudden, purposeless, irregular, involuntary movements

  • face, tongue, upper extremities

  • MC in children (Females > males)

• ____________

  • Acute migratory and asymmetrical → involves the large joints

Carey-Coombs murmur

short mid-diastolic mitral murmur may be present due to inflammation of the mitral valve

Erythema Marginatum

Subcutaneous Nodules

• Small, firm, and nontender

• Attached to fascia or tendon sheaths over bony prominences

• Indistinguishable from rheumatoid nodules

Fever, algia, PR, elevated, streptococcal

Jones Criteria - Minor Criteria

• _____

• Polyarthr_____

• Prolonged __ interval

• ________ ESR or CRP

• Evidence of preceding __________ infection

bed rest, antipyretic, baseline, penicillin

Rheumatic Fever Treatment

• Strict ___ ____ until:

  • Temp returns to normal without the use of __________ medications

  • ESR, resting pulse rate, and ECG have all returned to ________

• Medications

  • Salicylates

  • __________

  • Corticosteroids

fever, aspirin, lower, NSAID, 8

Salicylates

• Markedly reduces _____ and joint pain/swelling

• _______ 4 to 8 g/day in 4-5 doses

  • Children are treated with _____ doses or ______

• Continue treatment until symptoms resolve (typically 1-2 weeks, possibly up to _ weeks)

benzathine, erythromycin

Penicillin

• _________ penicillin, 1.2 million units IM once

• ___________ may be substituted (40mg/kg/day)

• Other penicillins, cephalosporins, and macrolides may also be used

salicylates, prednisone, cardiac

Corticosteroids

• Indicated when response to _________ has been inadequate

• _________, 40-60 mg orally daily with tapering over 2 weeks

• No proof of preventing or minimizing _______ damage

prevented, carditis, children, severe, recurrent, penicillin G benzathine

Prevention of Recurrent Rheumatic Fever

• The initial episode of rheumatic fever can usually be _________ by early treatment of strep throat

• recurrences are most common in:

  • Patients who had ________ during their initial episode

  • ________

• Rheumatic heart disease becomes more _______ with each recurrent episode

• Therefore, the most effective method to limit progression of RHD severity is prevention of ________ GAS strep throat

• Preferred prophylaxis

  • __________ _ _______ 1.2 million units IM every 4 weeks

21, 5, 21, 10, 40, 10

Prevention of Recurrent Rheumatic Fever

• Rheumatic Fever without carditis

  • Continue prophylaxis until age __ or _ years after last episode (whichever is longer)

• Rheumatic fever with carditis but no residual heart disease

  • Age __ or __ years after last episode (whichever is longer)

• Rheumatic fever with carditis and residual heart disease

  • Age __ or __ years after last episode (whichever is longer)

1-2, poor, 10, valvular, single

Rheumatic Fever Prognosis

• Immediate mortality rate is _-_%

• Persistent rheumatic carditis with cardiomegaly, HF, and pericarditis implies a ____ prognosis

  • 30% of children affected die within __ years after the initial attach

• After 10 years, 2/3 of patients with RF will have detectable ________ abnormalities

  • Usually thickened valves with limited mobility

• Significant symptomatic valvular heart disease or persistent cardiomyopathy occurs in <10% of patients with a _____ episode