Rehumatic Fever

							Rheumatic Fever (RF)
        Owais (A1)
                Definition
 Acute rheumatic fever is systemic disease,
  that follows group A beta hemolytic
  infection (GABH) .
 It is delayed URTI non-suppurative caused
  by GABH.
 NO GABH = NO rheumatic fever
                         Epidemiology
 Age: 5-15 year more susceptible, rare < 3 year
  (important in exam to exclude RF if age <5)
 It is affected by environmental factors such
  as: over crowding, poor sanitation,
  poverty…
 Girls>boys
               Pathogenesis
 Delayed immune response to infection with GABH.
 After a latent period of 1-3 weeks, antibody
  induced immunological damage occur to heart
  valves, joints, subcutaneous tissue & basal
  ganglia of brain.
 (imp.) Skin infection produced by GABH leads to
  post streptococcal glomerulonephritis only not RF,
  while pharyngitis produced by GABH can lead to
  acute RF, rheumatic heart disease, post strept.
  GN.
pharyngitis
  Clinical features, 5 Major criteria:

 1-arthritis:
 Migratory polyarthritis, appear in new joint
  and disappear from last joint.
 Commonly involved joints (major joints):
  knee, ankle, elbow & wrist
 In children below 5 yrs arthritis usually mild
  but carditis more prominent
 Arthritis do not progress to chronic disease
                  2. Carditis
 Manifest as pancarditis (endocarditis, myocarditis
  and pericarditis), occur in 40-50% of cases
 Carditis is the only manifestation of RF that leaves
  a sequelae & permanent damage to the organ (in
  acute stage valve regurgitation, chronic stage
  valve stenosis + heart failure.
 Valvulitis occur in acute phase
 Chronic phase- fibrosis, calcification & stenosis of
  heart valves
Acute Carditis
Aortic Valvulitis.
Mitral stenosis
         3.Sydenham Chorea

 Occur in 5-10% of cases, Mainly in girls of
  1-15 yrs age, May appear even 6 months
  after the attack of rheumatic fever.
 Clinically manifest as-clumsiness(‫,)أخرق‬
  deterioration (‫ )يفسد‬of handwriting, emotional
  liability or grimacing(‫ )تكشير‬of face.
      4.Erythema Marginatum
 Occur in <5%.
 Unique, transient lesions of 1-2 inches in
  size.
 Pale center with red irregular margin.
 More on trunks & limbs & non-itchy.
 Worsens with application of heat.
 Often associated with chronic carditis
Erythema marginatum
        Erythema marginatum
 Red margin




 Pale center
    5.Subcutaneous nodules
 Occur in 10%.
 Painless, pea-sized, palpable nodules.
 Mainly over extensor surfaces of joints,
  spine, scapulae & scalp.
 Associated with strong seropositivity.
 Always associated with severe carditis.
Subcutaneous nodules
Subcutaneous nodules
  Clinical features, Minor criteria:
 Previous RF or rheumatic heart disease.
 Fever – Low grade.
 Arthralgia.

 Pallor.
 Anorexia.         These were written in doctor slides not in
 Loss of weight.   Modified Jones criteria, which will talked
                    about it later
                Lab. finding
   High ESR.
   Anemia, leucocytosis.
   Elevated C-reactive protien.
   ECG- prolonged PR interval.

 These lab. Finding are included as minor criteria
  in Modified Jones criteria.
        Lab. Finding (contd)
Evidence of streptococcal infections:
 ASO titre >200.
    (Peak value attained at 3 weeks, then
    comes down to normal by 6 weeks)
 Anti-DNAse B test.
 Throat culture-GABH streptococci.
             Diagnosis;
 2 major criteria or 1major criteria &
           2minor criteria
       + evidence of GABHS
 Rheumatic fever is mainly a clinical
  diagnosis
 Diagnosis based on MODIFIED JONES
 CRITERIA
   Jones Criteria (Revised) for Guidance in the
         Diagnosis of Rheumatic Fever*
Major Manifestation             Minor                     Supporting Evidence
                             Manifestations             of Streptococal Infection
       Carditis        Clinical        Laboratory
     Polyarthritis     Previous        Acute phase
       Chorea          rheumatic       reactants:      Increased Titer of Anti-
Erythema Marginatum    fever or        Erythrocyte     Streptococcal Antibodies ASO
Subcutaneous Nodules   rheumatic       sedimentation          (anti-streptolysin O),
                       heart disease   rate,           others
                       Arthralgia       C-reactive     Positive Throat Culture
                       Fever           protein,        for Group A Streptococcus
                                       leukocytosis    Recent Scarlet Fever
                                        Prolonged P-
                                       R interval

*The presence of two major criteria, or of one major and two minor criteria,
indicates a high probability of acute rheumatic fever, if supported by evidence of
Group A streptococcal nfection.
               Treatment.
 Step I: primary prevention (eradication of
   streptococci, usually give benzathine
   penicillin G.
 Step II: anti inflammatory treatment
   (aspirin, steroids).
 Step III: 2 points:
1. Supportive management (bed rest, rest to
   joints and supportive splinting).
            Treatment.(contd)
2. Management of complications:
   a- treatment of congestive heart failure:
      digitalis, diuretics.
   b- treatment of chorea by diazepam or
      haloperidol.
 Step IV: Secondary prevention (prevention of
     recurrent attacks) by giving prophylactic
     antibiotics such as benzathine penicillin G
     every month.
   ‫قال تعالى:( قل هل ننبئكم باألخسرين (301) أعماال‬
‫الذين ضل سعيهم في الحياة الدنيا وهم يحسبون أنهم‬
                          ‫يحسنون صنعا (401)) الكهف‬

‫ما أسوأ أن يكون اإلنسان ضاال وهو يعتقد أنه يسير باالتجاه الصحيح, ومن أهم‬                   ‫‪‬‬
 ‫مسببات هذا األمر عدم قبول هللا ألعمال العبد، فما هي شروط قبول العمل إذاً؟؟‬
                                                                    ‫لقبول العمل شرطان:‬     ‫‪‬‬
     ‫1( إخالص النية هلل عز وجل, فال يشوب العمل رياء وال نفاق وإنما يكون العمل‬
                                                                        ‫خالصا لوجه هللا.‬
    ‫2( أن يكون العمل موافقا لهدي نبينا محمد --صلى هللا عليه وسلم- , فنبتعد عن اتباع الهوى‬
                                                                  ‫ونبتعد عن اتباع البدع.‬
  ‫هذان الشرطان ال يتبعان فقط أعمال اآلخرة, بل كل عمل نعمله يجب أن ينطبق عليه‬
‫هذان الشرطان, ونحن يا أحبتي كما تعلمون نقضي أوقات كثيرة بالعلم والدراسة‬
     ‫فإذا لم نجدد النية من وقت آلخر نخشى من إحباط العمل وبالتالي نكون ممن‬
     ‫ذكرتهم هذه اآلية, فسألوا هللا دائما أن يثبتنا وأن يجعل أعمالنا خالصة لوجهه‬
                                                                                   ‫الكريم.‬
 ‫أخوكم أويس‬