Acute rheumatic fever ppt final copy

ARF

1. ACUTE RHEUMATIC FEVER NINAMA JAYDIP LECTURER SCON,ZUNDAL

2. INTRODUCTION Occurs as a result of complex interaction between GROUP A STRAPTOCOCCUS a susceptible host and environment. An abnormal immune response to a GAS infection leads to an acute inflammatory illness that most commonly affects the joints , heart, brain or skin. Major public health problem among children and young adults in developing countries. Most imPortant acquired heart disease in children.

3. CONTD….. IT is most important acquired heart disease in children and commonly found in 4 to 15 years of age with incidence rate 5.0 / 1000 approximately .

4. EPIDEMIOLOGY The incidence of rheumatic fever is closely related the incidence of group A STREPTOCOCCAL PHARYNGITIS. AGES: 5-15 YEARS ARE MOST SUSCEPTIBLE RARE: <3 YEARS GIRLS/ BOYS :BOTH SEXES ARE EQUALLY AFFECTED. COMMON:3 WORLD COUNTRIES ENVIRONMENTAL FACTORS: OVERCROWDING, POOR SANITATION, POVERTY,….. INCIDENCE MORE DRING: WINTER SEASON, FALL,TMPERATURE .

5. DEFINITION “ ACUTE RHEUMATIC FEVER IS AN ACUTE AUTOIMMUNE COLLAGEN DISEASE OCCURS AS A HYPERSENSITIVITY REACTION TO GROUP A BETA HEMOLYTIC STREPTOCOCCAL INFECTION. IT IS CARACTERIZED BY INFLAMMATORY IESIONS OF CONNECTIVE TISUE AND ENDOTHELIAL TISSUE. IT AEECECTS THE HEART,JOINT,BLOOD VESSELS AND OTHER CONNECTINE TISSU E”.

6. ETIOLOGY The etiology of rheumatic fever is not clear. GROUP A BETA HEMOLYTIC STREPTOCOCCAL INFECTION. Delayed non- suppurative Squeal URTI with GAB STREPTOCOCCI. Diffuse inflamatory disease of connective tissue. Primalily involving heart,, blood vessels, joints ,subcutaneous tissue and CN S .

7. RISK FACTORS Most common age group involved in 5 to 15 years. Both sexes are equally affected. PREDISPOSING FACTORS : low socio economic status overcrowding poor nutrition poor hygiene low immunological status increasing susceptibility MANDELIAN RECESSIVE PATTERN HAS ALSO BEEN SUUGGESTED AS A GENETIC PREDISPOSITION .

8. PATHOPHYSIOLOGY The exact etiopathogenesis or ARF is not well understood. Preceding streptococcal infection may not always critically manifest. It is considered as a sort o f hypersensitivity reaction. There is an antigen antibody reaction usually following streptococcal sore throat. Ant streptococcal antibody titer elevated in majority of the patients ,although the streptococci have never been isolated from rheumatic lesions in joints, heart or in the blood –stream. The auto antibodies attack the myocardium, pericardium and cardiac valves.

9. Patho … contd Asch offs bodies develop on the valve, especially on the mitral valve and leading t permanent valve dysfunction. Severe myocarditis may result dilation of the heart and hear failure. The antibodies may react with striated muscle, vascular smooth muscle and nervous tissue resulting joint inflammation,invluntary movements as chorea and lesions in blood vessels and other connective tissue

10. Preceding eventinfection with a strain of group a straptococcus carrying specific virulence factor Repeated group astraptococcus infection Susceotible Host First episode Of ARF

11. First episode Of ARF Repeated or on going infections possybly diving The valvular inflammatory response RHD Episode of recurrent ARF Molecular mimicry between Group a streptococcus and host Exaggerated T- cell mediated immune responce Genetically Determined Host facters

12. CLINICAL MANIFESTATIONS

13. MAJOR MANIFESTATIONS CARDITIS: EARLY MANIFESTATION EXAMPLE: PERICARDITIS , ENDOCARDITIS, MYOCARDITIS EVIDENCED AS PRESENCE OF SIGNIFICANT- MURMU R,ECG CHAGES, CARDIAC ENLARGEMENT,, FRICTION RUB,

14. POLYARTHRITIS Migratory type of joint inflammation s/s- pain, decrease ac tive movements, warm tenderness, redness and swelling. Two or more joints are affected. Commonly knees, ankles and elbow are involved, but .smaller joint may also be affected.

15. CHOERA PURPOSELESS INVOLUNTARY, RAPID MOVEMENTS USUALLY ASSOCIATED WITH MUSCLE WEAKNESS,INCORDINATION,INVILUNTARY FACIAL GRIMACE, SPEECH DISTURBANCE, AWKWARD GAIT AND EMOTIONAL DISTURBANCES.

16. SUBCUTANEOUS NODULES Ii is found as firm painless movements nodule over the extensor surface of certain joints. Joints- elbow, knee, wrists. Occiput and vertebral column .

17. ERYTHEMA MARGINATUM Pink macular non-itching rash Found mainly over the trunk, sometimes on the extremities but never on face It is transient and brought out only by heat and migrates from place to place.

18. MINOR MANIFESTATIONS

19. FEVER Increase in body temperature is common findings. It rarely goes above 39.5 c.

20. ARTHRALGIA Pain in the joints occurs in about 90 percent of cases. It present along with arthritis.

21. PREVIOUS ATTACK OF ARF Previous attack of rheumatic fever or rheumatic heart disease. Applicable for a second attack of rheumatic fever.

22. ECG CHANGES ECG CHANGES WITH PROLONGED P-R INTERVAL IS CONSIDERED AS MINOR CRITERION. IT IS NOT DIAGNOSTIC OF CARDITIS.

23. ELEVATED ESR ELEVATED ESR OR PRESENCE OF C- REACTIVE PROTEIN MAY BE CONSIDERED AS MINOR CRITERIA .

24. ESSENTIAL CRITERIA Elevated antistreptolysin-o –titer indicates previous streptococcal infection. NORMAL= 200 IU /ML Positive throat swab culture may show streptococcal infection.( sore throat, scarlet fever etc..)

25. OTHER MANIFESTATIONS PRECORDIAL PAIN

26. ABDOMINAL PAIN

27. HEADACHE

28. EASY FATIGABILITY

29. GENERAL WEAKNESS

30. TACHYCARDIA

31. MALAISE

32. SWEATING

33. VOMITING

34. SKIN RASH

35. ERYTHEMA NODOSUM

36. EPISTAXIS

37. ANEMIA

38. PLEURITIS

39. WEIGHT LOSS

40. DIAGNOSTIC EVALUATION Artificial subcutaneous nodule Doppler echocardiography Endomyocardial biopsy Chest x-ray Electrocardiography Blood test for ESR,WBC counts.

41. DIFFERENTIAL DIAGNOSIS JUVENILE RHEUMATOID ARTHRITIS OTHER COLLAGEN DISORDERS- SYSTEMIV=C LUPUS ARTHRITIS,INFECTIONS ARTHRITIS, SERUM SICKNESS. ACUTE ARTHRITIS DUE TO VIRUS- EX-RUBELLA,HEPATITIS B, VIRUS. HEMATOLOGIC DISORDERS- SICKLE CELL ANEMIA,LEUKEMIA

42. COMPLICATIONS CHRONIC RHEUMATIC HEART DISEASE- MOST COMMON COMPLICATIONS HEART FAILURE ENDOCARDITIS PERICARDIAL EFFUSION PERMANENT CARDIAC DAMAGE

43. CONTD…… AORTIC IVOLVEMENT MAY BE OBSERVED AS AORTIC INCOMPETENCE. PERMANENT CARDIAC DAMAGE

44. MANAGEMENT INVESTIGATIONS –History collection - physical examination complete blood count Acute phase reactants Throat swab culture Antistreptolysino titer Chest radiograph Electrocardiogram echocardiography

45. TREATMENT BED REST DIET ANTIBIOTIC THERAPHY, PENICILLIN COUNSELLING ANTIINFLAMMATORY THERAPY- Aspirin, Steroid

46. MANAGEMENT OF CHOREA Physical and emotional stress should be reduced. Injection of benzathine penicillin Anti inflammatory drugs not needed in isolated chorea. Severe cases- phenobarbitone Haloperidol Chlorpromazine, diazepam carbamazine

47. NURSING MANAGEMENT NURSING ASSESSMENT - VITAL SIGNS, CARDIAC MONOTORING, PAIN ASSEESSMENT AND OTHER ASSOSIATED PROBLEMS.

48. NURSING DIAGNOSES Decreased cardiac output related to carditis. Pain related to polyarthritis Risk for injury related to involuntary movements in chorea. Anxiety related to disease process Knowledge deficit related to long term treatment and prognosis o f the acquired heart disease .

49. NURSING INTERVENTIONS IMPROVING CARDIAC OUTPUT- Provide rest Nursing care Maintain normal body temperature Provide bland diet Administering medication Monitoring cardiac output

50. RELIVING PAIN anti-inflammatory analgesics Providing comfortable position Arranging divisional activities Play materials

51. PROTECTING THE CHILD FROM INJURY Removing hard and sharp objects Assisting the child in feeding, ambulation and other fine motor activities Administration of drug- to control chorea Explaining about self limiting course of the condition and Importance about physical and mental rest .

52. HEALTH TEACHING FOR MAINTENANCE OF HEALTH AND PREVENTION OF COMPLICATIONS Explaining the duration of treatment Follow up Continuation of school performance Instructing about preventive measures .

53. PREVENTION PRIMARY PREVENTION - health education the people to avoid streptococcal sore throat and elimination of predisposing factors of the disease. Treatment of streptococcal pharyngitis with penicillin or other medications .

54. SECONDARY PREVENTION Patient with documented histories of rheumatic fever, heart disease and also isolated cases of chorea must receive prophylaxis. DURATION: every 3 weeks till the age of 25 to 30 years. After the age of 30years fever is not known to occur.

55. METHOD Long acting BENZATHINE PENICILLIN given to 6,00,000 units to be given to patient weighing 27 KG. Less 1.2 million units for patients weight- more than 27 kg. Route: intramuscularly DURATION: every 21 days.

56. DRUGS ERYTHROMYCIN- 40 MG / KG/ 24 HOURS TO BE GIVEN ONCE A DAY ORAL SULFADIAZINE- 0.59 ONCE A DAY FOR LESS THAN 27 KG AND 1 G ONCE A DAY FOR those more than 27 kg .

57. PROGNOSIS Prognosis of rheumatic fever depend upon the age, presence of heart lesions, stage of detection of the disease, available treatment facilities and number of previous disease. Prognosis is worst in patients with carditis is an early childhood.