Rheumatic fever

Heart diseases

1. RHEUMATIC FEVER Prepared by Raveen Ismael Abdullah B.CS.in Nursing Hawler medical university Supervised by : Dr.Shokir Saleem.I College of nursing 2016-2017

2. Outline Rheumatic fever definition Causes Risk factors and complications major and minor manifestations RF Diagnosis and differential diagnosis Medical and nursing Management

3. Objectives By end of seminar audiences will be able to : Identify the child with RF symptoms Understand the steps of medical management for treating cases with rheumatic fever .

4. Introduction Rheumatic fever (RF) is a poorly understood inflammatory disease that occurs after infection with group A β- hemolytic streptococcal(GABHS) pharyngitis . Rheumatic fever is most common in 5- to 15-year-old children, though it can develop in younger children and adults.

5. It is a self-limited illness that involves the joints, skin, brain, serous surfaces, and heart. Cardiac valve damage (referred to as rheumatic heart disease) is the most significant complication of RF. The mitral valve is most often affected. Introduction Cont

6. causes Strong evidence supports a relationship between upper respiratory tract infection with GABHS and subsequent development of RF (usually within 2–6 weeks).

7. Risk factors Family history . Some people carry a gene or genes that might make them more likely to develop rheumatic fever. Type of strep bacteria. Certain strains of strep bacteria are more likely to contribute to rheumatic fever than are other strains. Environmental factors. A greater risk of rheumatic fever is associated with overcrowding, poor sanitation and other conditions that can easily result in the rapid transmission or multiple exposures to strep bacteria

8. Complications Rheumatic heart disease is permanent damage to the heart caused by rheumatic fever. It usually occurs 10 to 20 years after the original illness. Problems are most common with the valve between the two left chambers of the heart (mitral valve) , but the other valves can be affected.

9. Complications The damage can result in: Valve stenosis . This narrowing of the valve decreases blood flow . Valve regurgitation. This leak in the valve allows blood to flow in the wrong direction . Damage to heart muscle. The inflammation associated with rheumatic fever can weaken the heart muscle, affecting its ability to pump.

10. Major manifestations Carditis Tachycardia out of proportion to degree of fever Cardiomegaly New murmurs or change in preexisting murmurs Muffled heart sounds Chest pain Changes in ECG (especially prolonged PR interval)

11. Polyarthritis Swollen, hot, red, painful joint(s) After 1 to 2 days, different joint(s) affected Favors large joints—knees, elbows, hips, shoulders, wrists Erythema Marginatum Erythematous macules with clear center and wavy, well-demarcated border Transitory Nonpruritic Primarily affects trunk and extremities (inner surfaces) Major manifestations

12. Erythema Marginatum

13. Chorea (St. Vitus Dance, Sydenham Chorea) Sudden aimless, irregular movements of extremities Involuntary facial grimaces Speech disturbances Emotional lability Muscle weakness (can be profound) Muscle movements exaggerated by anxiety and attempts at fine motor activity; relieved by rest Major manifestations

14. Chorea

15. Subcutaneous Nodes Non tender swelling Located over bony prominences May persist for some time and then gradually resolve Major manifestations

16. Minor Manifestations Clinical Findings Arthralgia Fever Laboratory Findings Elevated acute-phase reactants • ESR • CRP • Prolonged PR interval Supporting Evidence of Antecedent Group A Streptococcal Infection Positive throat culture or rapid streptococcal antigen test result Elevated or rising streptococcal antibody titer

17. Diagnosis Laboratory Studies No single specific laboratory test can confirm the diagnosis of acute rheumatic fever (ARF). Throat culture Throat culture remains the criterion standard for confirmation of group A streptococcal infection. Blood cultures Blood cultures are obtained to help rule out infective endocarditis , bacteremia , and disseminated gonococcal infection.

18. Diagnosis Antibody titer tests The antibody titer is a test that detects the presence and measures the amount of antibodies within a person’s blood. The amount and diversity of antibodies correlates to the strength of the body’s immune response. Acute-phase reactants, erythrocyte sedimentation rate, and C-reactive protein These tests are nonspecific, but they may be useful in monitoring disease activity.

19. Imaging Studies Chest radiography Chest radiography can reveal cardiomegaly and CHF in patients with carditis . Echocardiography  Echocardiography may demonstrate valvular regurgitant lesions in patients with ARF who do not have clinical manifestations of carditisin rheumatic heart disease.  In patients with chronic rheumatic heart disease, electrocardiography may show left atrial enlargement secondary to mitral stenosis . Other common tests rheumatoid factor, antinuclear antibody (ANA), Lyme serology, blood cultures, and evaluation for gonorrhea. Diagnosis

20. Differential Diagnoses Gonococcal Arthritis Juvenile Idiopathic Arthritis Lyme Disease Mixed Connective-Tissue Disease Physical Medicine and Rehabilitation for Systemic Lupus Erythematosus Reactive Arthritis Rheumatoid Arthritis Septic Arthritis Sickle Cell Anemia

21. goals of medical management eradication of hemolytic streptococci. prevention of permanent cardiac damage. (3) palliation of the other symptoms. (4) prevention of recurrences of RF. Penicillin is the drug of choice or an alternative in penicillin-sensitive children Salicylates are used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended during the acute febrile phase but need not be strict.

22. Treatments Treatments include: Antibiotics. penicillin or another antibiotic to eliminate remaining strep bacteria. Anti-inflammatory treatment. pain reliever, such as aspirin or naproxen ( Naprosyn ), to reduceinflammation , fever and pain. If symptoms are severe or child isn't responding to the anti-inflammatory drugs, doctor might prescribe a corticosteroid.

23. Anticonvulsant medications. For severe involuntary movements caused by Sydenham chorea such as: valproic acid ( Depakene ) or carbamazepine ( Carbatrol , Tegretol , others). Prophylactic treatment against recurrence of RF (secondary prevention) is started after the acute therapy and involves monthly intramuscular injection s of benzathine penicillin G (1.2 million units), two daily oral doses of penicillin (200,000 units), or one daily dose of sulfadiazine (1 g) Treatments

24. In RF with carditis , prophylaxis is recommended for 5 years or until age 21 years. In the setting of carditis ,prophylaxis is recommended for 10 years or until 21 years old. In the setting of RF with carditis and residual heart disease, prophylaxis can continue until the age of 40 years Treatments

25. The objectives of nursing care for the child with RF Encourage compliance with drug regimens. facilitate recovery from the illness. provide emotional support. prevent the disease.

26. Nursing goals during treatment sessions Treatment of endocarditis requires long-term parenteral drug therapy. (1) preparation of the child for IV infusion , usually with an intermittent infusion device and several veni punctures for blood cultures. (2) observation for side effects of antibiotics, especially inflammation along veni puncture sites. (3) observation for complications , including embolism and HF. (4) education regarding the importance of follow-up visits for cardiac evaluation, echocardiographic monitoring, and blood cultures.

27. 1. Rheumatic Fever: Background, Pathophysiology , Epidemiology. 2017 Jun 29 [cited 2017 Jul 4]; Available from: http://emedicine.medscape.com/article/236582-overview