Acute Rheumatic fever mbbs undergraduate.pptx

Arf

1. Acute Rheumatic Fever MBBS Class

2. What is acute rheumatic fever Non- suppurative , immunological complication of GABHS pharyngitis Affects joints, skin, subcutaneous tissue, brain and heart

3. Annual incidence of RF in developed countries < 1.0 /100 000 The prevalence of RHD in India : 1.0–5.4 per 1000 5-15year; M=F Epidemiology

4. Pathogenesis Occurs after 2-4 weeks following sore throat due to Group A streptococcal infection (GAS phayngitis ) Rheumatogenic serotypes of GAS include M type [1, 3, 5, 6, 14, 18, 19 and 24] Nelson textbook of pediatrics, 20 th edition

5. Sore throat (80%) Viral (3-20%) GABHS Infection (0.3-3%) Acute Rheumatic Fever ( carditis 50%)*RHD ( MR 80% > MS 11%> >AR>> > AS ) Sequence of events leading to ARF and RHD

6. Revised Jones Criteria

7. Arthritis Most common , least specific 75% of patients with first attack of ARF Early in the course Migratory large joints (knee>ankles) >>>mono or additive Excruciating tender, warm swelling Dramatic response to even low dose of salicylates Arthritis and carditis frequently co-exist with inverse relationship b/w severity

8. Carditis Most specific , serious ,~60% of ARF attacks Pancarditis - Endocarditis ( valvulitis ) is a universal finding Endocarditis (valve insufficiency): Mitral valve (65-70% of patients) Aortic valve (25%) Tricuspid valve (10%) almost always associated with mitral and aortic lesions Pulmonary valve is rarely affected Severe valve insufficiency and even death 1% cases Myocardial dysfunction Pericarditis: (rarely affects cardiac function or results in constrictive pericarditis)

9. Sydenham`s chorea st.vitus dance 10 -15%, Primarily in children F>M, rare in postpubertal males Emotional lability ,motor uncoordination (erratic ,abrupt) Wormian darting movements of tongue, spooning and pronation sign, milkmaid`s grip ,change in handwriting, jerky and staccato speech Disappear in sleep , no sensory involvement

10. ERYTHEMA MARGINATUM 5-15% ,early in the course Evanescent, nonpruritic , painless, bright pink macular on trunk spreading in outward fashion (never on face) Smoke rings Can be accentuated by warming the skin

11. Subcutaneous nodules Up to 20% , 0.5-2 cm Painless ,firm , overlying skin not inflamed Extensor surfaces of tendons, bony prominences elbow, wrists, knees Persists <1month(1-2 weeks) Rarely isolated Severe carditis

12. Laboratory Studies CBC, ESR, CRP Throat culture Usually negative Can be isolated in 10-20% of the patients Attempts should be made to isolate the organism before the initiation of antibiotic Rapid antigen detection test ( streptozyme test) Rapid, easy to perform, less standardised and less reproducible

13. Anti streptococcal antibodies Antistreptolysin O (ASO) Antideoxyribonuclease ( DNAse ) B Antihyaluronidase Antistreptokinase Antistreptococcal esterase Anti-DNA Antistreptococcal polysaccharide Antiteichoic acid antibody Anti–M protein antibody Multiple antibody tests should be performed when acute rheumatic fever is suspected

14. Other workup ECG Prolonged PR interval – Not to be used when carditis is a major criteria Chest X Ray – Cardiomegaly, e/o CCF Doppler-echocardiogram Mild carditis Chronic valvulitis Subclinical rheumatic carditis Heart catheterization Only in chronic disease,

15. Treatment General measures (bed rest) and symptomatic relief Antibiotic therapy – eradication of GAS from upper respiratory tract Management of inflammatory process Management of chorea Management of cardiac complications CHF AF INDIAN PEDIATRICS, VOLUME 45:JULY 17: 2008;565

16. TREATMENT ANTIBIOTICS After Pharyngitis: After ARF SUPPORTIVE TREATMENT Bed rest Diet Salt restriction ,inotropes (CCF)

17. SUPPRESIVE THERAPY Aspirin: Polyarthritis , carditis without cardiomegaly, congestive cardiac failure 50-70 mg/kg /day 4 divided doses-3 to 5 days( ghai 90-120mg/kg day – 10 weeks then tapered in 2 weeks.) Followed by 50mg/kg/day 3weeks then half the dose 2-4 weeks . STERIODS: Carditis with cardiomegaly or CCF Dose 2-4mg/kg/day 2-3 week in 4 divided doses, half the dose 2-3 weeks tapering 5mg/24 hr every 3-5 days( total 12 weeks ) When steroid is tapered aspirin is added for remaining 6 weeks.

18. CHOREA Usually self-limiting Phenobarbitone (16-32 mg every 6-8 hr PO) Haloperidol (0.01- 0.03 mg/kg/24 hr divided bid PO)

19. PRIMARY PREVENTION (WHO technical report series ; 923) IM benzathine penicillin is more superior to oral penicillin

20. Recurrence risk of GABHS pharyngitis is lower with I/M penicillin rather than PO Every 4 weeks – Low risk areas Every 3 weeks – Moderate/high risk areas SECONDARY PREVENTION

21. SECONDARY PROPHYLAXIS - DURATION Gerber MA, Baltimore RS, Eaton CB, et al: Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis : a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis , and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, Circulation 119:1541–1551, 2009.

22. Prognosis ARF resolve in 12 weeks in 80% of patients and may extend as long as 15 weeks Following the development of antibiotics, the mortality rate decreased 1-10% 70% of the patients with carditis recover with no residual heart disease; (WHO technical report series ; 923)

23. Thank You