Rheumatic fever clinical features and diagnosis

RHEUMATIC RHEUMATIC
FEVERFEVER
Clinical features Clinical features
and and
diagnosisdiagnosis
DR . SUJIT SAHUDR . SUJIT SAHU
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INTRODUCTION INTRODUCTION
HISTORICAL BACKROUND HISTORICAL BACKROUND
EPIDEMIOLOGYEPIDEMIOLOGY
PATHOGENESISPATHOGENESIS
PATHOLOGY PATHOLOGY
CLINICAL FEATURESCLINICAL FEATURES
DIAGNOSISDIAGNOSIS

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INTRODUCTIONINTRODUCTION
Clinical syndrome Clinical syndrome
Acute , non-suppurative inflammatory disease Acute , non-suppurative inflammatory disease
following Group A Beta Hemolytic following Group A Beta Hemolytic
Streptococcal sore throatStreptococcal sore throat

Classified as Connective tissue disease or Classified as Connective tissue disease or
collagen vascular diseasecollagen vascular disease
affecting the Joints, heart , brain , skin and affecting the Joints, heart , brain , skin and
subcutaneous tissuesubcutaneous tissue

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HISTORICAL HISTORICAL
BACKROUNDBACKROUND
1604 –1604 – Guilleaume (France)Guilleaume (France)
Thomas Syndenham (Eng)Thomas Syndenham (Eng)
--PolyarthritisPolyarthritis
1605 -1605 - SydenhamSydenham - - St. Vitus Dance St. Vitus Dance
1761 -1761 - Morgani Morgani (Italy) – (Italy) – Heart valvesHeart valves
1813 -1813 - W.C.wells W.C.wells – – Subcutaneous NodulesSubcutaneous Nodules
1818 -1818 - LaennecLaennec - - RHD (clinical)RHD (clinical)

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HISTORICAL HISTORICAL
BACKROUNDBACKROUND
1886 -1886 - CheadleCheadle - - Full syndromeFull syndrome
1904 -1904 - Aschoff Aschoff - - Aschoff NoduleAschoff Nodule
1931 -1931 - Coburn Coburn - - Streptococcal assocStreptococcal assoc..
1944 -1944 - Jones Jones - - Criteria Criteria
1951 -1951 - WannamakerWannamaker (penicillin prophylaxis)(penicillin prophylaxis)

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EPIDEMIOLOGYEPIDEMIOLOGY

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IndiaIndia
S PadmavatiS Padmavati
Director, National Heart Institute, New Delhi, Director, National Heart Institute, New Delhi,
IndiaIndia
In 2000, in a school survey involving 3963 In 2000, in a school survey involving 3963
children from the district of Kanpur, the children from the district of Kanpur, the
prevalence of RHD was 4.54 per 1000 prevalence of RHD was 4.54 per 1000
(Urban 2.56 and Rural 7.42). (Urban 2.56 and Rural 7.42).
The prevalence of RF was 0.75 per 1000 The prevalence of RF was 0.75 per 1000
(Rural 1.20, Urban 0.42) (Rural 1.20, Urban 0.42)

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EPIDEMIOLOGYEPIDEMIOLOGY
2000 - 20042000 - 2004
HOSPITAL BASED SURVEYSHOSPITAL BASED SURVEYS : :

Agarwal et al (varanasi) : Decreasing Agarwal et al (varanasi) : Decreasing
(8.4% - RHD & 1.1% RF) (8.4% - RHD & 1.1% RF)
Despande et al (Mumbai): No changeDespande et al (Mumbai): No change
Mishra et al (cuttack) : No changeMishra et al (cuttack) : No change

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EPIDEMIOLOGYEPIDEMIOLOGY
PREVELANCE :PREVELANCE :
2 million at present2 million at present
INCIDENCE :INCIDENCE :
50 000 new cases every year 50 000 new cases every year

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PATHOGENESIPATHOGENESI
SS

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STRUCTURE OF Group –A STRUCTURE OF Group –A
Beta Hemolytic StreptococcusBeta Hemolytic Streptococcus

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Group - A StreptococcusGroup - A Streptococcus
Two highly conserved epitopes within M protein Two highly conserved epitopes within M protein
divide GAS immunologically into divide GAS immunologically into
Class I (throat) Class II (skin) strains.Class I (throat) Class II (skin) strains.
All RF strains fall clearly into Class I throat All RF strains fall clearly into Class I throat
strains strains
The site of infection must be pharyngealThe site of infection must be pharyngeal. .
Regardless of how virulent an invasive strain may be, Regardless of how virulent an invasive strain may be,
ARF does not result when it is introduced extra-ARF does not result when it is introduced extra-
pharyngeally, e.g. through skin lesions or wound pharyngeally, e.g. through skin lesions or wound
infections infections

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CROSS REACTIVITYCROSS REACTIVITY

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CO-PATHOGENSCO-PATHOGENS
Burch et al & Pongpanich et al :Burch et al & Pongpanich et al :
(1970) (1976)(1970) (1976)
Serological evidence of Cox B viruses Serological evidence of Cox B viruses
in patients with rheumatic fever in patients with rheumatic fever

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GENETIC GENETIC
PREDISPOSITIONPREDISPOSITION
Specific B - cell alloantigen Specific B - cell alloantigen
HLA DR 3 - Indians HLA DR 3 - Indians
Moari races in New Zealand & Moari races in New Zealand &
Samoans in Hawaii Samoans in Hawaii
High concordance in twins High concordance in twins
Increased risk in families with H/O RFIncreased risk in families with H/O RF

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ENVIRONMENTENVIRONMENT
Low socio-economic groupLow socio-economic group
Urban slumsUrban slums

Poor accesibility to health carePoor accesibility to health care

Over crowdingOver crowding

Unclean environment Unclean environment
Mostly seen in developing Mostly seen in developing
countriescountries

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INTERACTIONINTERACTION

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PATHOLOGYPATHOLOGY

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INFLAMMATORY RESPONSEINFLAMMATORY RESPONSE
Edematous changeEdematous change

Cellular infiltrateCellular infiltrate
Fibrinoid necrosisFibrinoid necrosis
Aschoff body Aschoff body
(seen only in heart)(seen only in heart)

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Joints : Joints : serositisserositis
PericardiumPericardium

Skin (S/C nodule) : Skin (S/C nodule) : Fibrinoid Fibrinoid
Heart Heart degenerationdegeneration
Erythema Marginatum : Erythema Marginatum : VasculitisVasculitis
Chorea : Chorea : VasculitisVasculitis

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GranulomaGranuloma
Central fibrinoid Central fibrinoid
necrosisnecrosis
Surrounded by Surrounded by
lymphocytes, lymphocytes,
Antischkow cells Antischkow cells
and Plasma cellsand Plasma cells
ASCHOFF BODYASCHOFF BODY

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Initial edemaInitial edema
Hyaline degenerationHyaline degeneration
Verrucae formation at the edge of leafletsVerrucae formation at the edge of leaflets
Prevents approximation Prevents approximation RegurgitationRegurgitation
Fibrosis & calcification Fibrosis & calcification StenosisStenosis

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ORDER OF VALVE ORDER OF VALVE
INVOLVEMENTINVOLVEMENT
MitralMitral
AorticAortic
Tricuspid Tricuspid
PulmonaryPulmonary

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INTERNATIONAL SERIES BY INTERNATIONAL SERIES BY
BONOWBONOW
PURE MS : PURE MS : 25 %25 %
PURE MR : PURE MR : 10 %10 %
MS / MR : MS / MR : 25 %25 %
AORTIC : AORTIC : 8 %8 %
ALL VALVES : ALL VALVES : 7 %7 %

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 CLINICAL FEATURESCLINICAL FEATURES

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PERCENTAGE PERCENTAGE
INVLOVEMENTINVLOVEMENT
(Indian Scenario)(Indian Scenario)
ARTHRITISARTHRITIS : : 70 %70 %

ARTHALGIAARTHALGIA : : 90 %90 %
CARDITISCARDITIS : : 70 %70 %
CHOREACHOREA : : 08 %08 %
S/C NODULES/C NODULE : : 02 02
%%
ERYHTEMA MARGINATUMERYHTEMA MARGINATUM : : 01 01
% %

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LATENCYLATENCY
From onset of sore throat to onset of From onset of sore throat to onset of
initial attack of rheumatic fever isinitial attack of rheumatic fever is
1 – 5 weeks1 – 5 weeks
for recurrent attacksfor recurrent attacks
Median of 19 days & shorterMedian of 19 days & shorter

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LATENCYLATENCY
Joint manifestations are Joint manifestations are firstfirst to occur to occur
- heralding onset of disease- heralding onset of disease
Carditis occurs within Carditis occurs within 2 weeks2 weeks
- is apparent when patient is first seen- is apparent when patient is first seen
Subcutaneous nodules appear Subcutaneous nodules appear 4 weeks4 weeks or more or more
after onset of symptomsafter onset of symptoms
Chorea may appear Chorea may appear 2 to 6 months2 to 6 months later later
Erythema marginatum occurs both early & later Erythema marginatum occurs both early & later

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MODE OF ONSETMODE OF ONSET
VariableVariable
Abrupt onsetAbrupt onset
with fever & acute polyarthritiswith fever & acute polyarthritis
Insidious or sub clinical Insidious or sub clinical
in mild indolent carditisin mild indolent carditis
May present with CCFMay present with CCF

May present atypically with acute abdomen due May present atypically with acute abdomen due
to peritoneal inflammationto peritoneal inflammation

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POLYARTHRITISPOLYARTHRITIS
Most common & Least specificMost common & Least specific
severe in adultssevere in adults
Large joints ; asymetricalLarge joints ; asymetrical
Flitting - Flitting - involves joints after jointsinvolves joints after joints
Fleeting - Fleeting - Lasting for short timeLasting for short time
3 days - 1 week 3 days - 1 week
No residual damage No residual damage

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POLYARTHRITISPOLYARTHRITIS
Responds dramatically to aspirinResponds dramatically to aspirin

Severity inversely related to carditisSeverity inversely related to carditis
(Feinstein & Spagnuola et al – 1962)(Feinstein & Spagnuola et al – 1962)
JACCOUDS ARTHRITISJACCOUDS ARTHRITIS ::
Small joints Small joints
Produces residual damage Produces residual damage
Seems to be related to RFSeems to be related to RF

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PANCARDITISPANCARDITIS
More severe in the youngMore severe in the young
Sub clinical to fulminant Sub clinical to fulminant
ENDOCARDITIS :ENDOCARDITIS :
ARAR : 20 %: 20 %

MRMR : 75 %: 75 %
: due to - Valvulitis: due to - Valvulitis
- MVP (anterior leaflet)- MVP (anterior leaflet)
- Annular dysfunction- Annular dysfunction

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ENDOCARDITISENDOCARDITIS
Clinical Evidence of Clinical Evidence of
Endocaritis :Endocaritis :
 Apical holosystolic murmur Apical holosystolic murmur
 Carey coomb’s murmurCarey coomb’s murmur
 Early diastolic murmurEarly diastolic murmur

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MYOCARDITISMYOCARDITIS
Clinical evidence of Myocarditis :Clinical evidence of Myocarditis :
Cardiomegaly Cardiomegaly
Clinical features of CHFClinical features of CHF
Gallop rhythm Gallop rhythm

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PERICARDITISPERICARDITIS
Clinical evidence of Pericarditis :Clinical evidence of Pericarditis :
Pericardial rubPericardial rub
 Associated with endocarditisAssociated with endocarditis

Indicates severe carditisIndicates severe carditis
(High rheumatic activity)(High rheumatic activity)
No residual constriction No residual constriction

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CHOREA CHOREA
Occurs 3 months later than other RF features Occurs 3 months later than other RF features
- spontaneous resolution- spontaneous resolution
Duration : variable Duration : variable ( upto 6 months) ( upto 6 months)

Often in prepuberal girlsOften in prepuberal girls

Neuropsychiatric disorderNeuropsychiatric disorder

Seen in 5 - 15 % casesSeen in 5 - 15 % cases

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CHOREACHOREA
ST. VITUS DANCE ST. VITUS DANCE
25 - 30 % develop RHD particularly 25 - 30 % develop RHD particularly MSMS
(Bland et al – 20 years follow up)(Bland et al – 20 years follow up)
Multiple purposeless movements of legs and Multiple purposeless movements of legs and
hands hands
(also involves face)(also involves face)
 on exertion & absent during sleepon exertion & absent during sleep

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DD FOR CHOREADD FOR CHOREA
HABITUAL SPASMSHABITUAL SPASMS
WILSONS DISEASEWILSONS DISEASE
POST ENCEPHALITISPOST ENCEPHALITIS
HYSTERESIS HYSTERESIS

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SUBCUTANEOUS SUBCUTANEOUS
NODULENODULE
FIRM FIRM
PAINLESS PAINLESS
0.5 – 3 cm IN SIZE 0.5 – 3 cm IN SIZE
IN CROPS ( OVER EXTENSORS)IN CROPS ( OVER EXTENSORS)
DISAPPEAR IN 12 WEEKS DISAPPEAR IN 12 WEEKS
ALWAYS ASSOCIATED WITH CARDITISALWAYS ASSOCIATED WITH CARDITIS

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SUBCUTANEOUS SUBCUTANEOUS
NODULENODULE

ERYTHEMA ERYTHEMA
MARGINATUMMARGINATUM
Rare (< 1 %)Rare (< 1 %)
Bikini distributionBikini distribution
EvanescentEvanescent
vanishingvanishing
Non pruritic Non pruritic

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OTHER MANIFESTATIONSOTHER MANIFESTATIONS
EPISTAXISEPISTAXIS
ABDOMINAL PAINABDOMINAL PAIN

- - Occurs in 5% cases Occurs in 5% cases
- Clinical importance - Clinical importance

Often appear hours or days before major Often appear hours or days before major
manifestationsmanifestations
Acute abdomen [ appendicitis ] to be excluded Acute abdomen [ appendicitis ] to be excluded

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FEVERFEVER
Relatively common But nonspecificRelatively common But nonspecific
Low grade; subside without treatment in 1-2wkLow grade; subside without treatment in 1-2wk
Associated with constitutional symptoms Associated with constitutional symptoms
Lab indices are high even after fever subsidesLab indices are high even after fever subsides

Remission does not exclude rheumatic activityRemission does not exclude rheumatic activity

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ECG CHANGESECG CHANGES
Seen in 2/5Seen in 2/5
t ht h
patients [ Disciascio(1980)] patients [ Disciascio(1980)]
 PR interval ; PR interval ;
 QT interval ;QT interval ;
 AV blocksAV blocks
Does not correlate with organic murmurs, Does not correlate with organic murmurs,
prognosis or residual heart diseaseprognosis or residual heart disease
Nonspecific & occur in many other infectionNonspecific & occur in many other infection

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LAB INVESTIGATIONSLAB INVESTIGATIONS

Monitoring the Detecting the Monitoring the Detecting the
antecedentantecedent
inflammatory activity infection with inflammatory activity infection with
streptococcusstreptococcus

There is no single diagnostic testThere is no single diagnostic test

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EVIDENCE OF STREPTOCOCAL EVIDENCE OF STREPTOCOCAL
INFECTIONINFECTION
TH ROAT SWAB CULTURETH ROAT SWAB CULTURE : :
Only in Minority of casesOnly in Minority of cases
ASO TITREASO TITRE : :

elevated from 7 - 10 days elevated from 7 - 10 days
rise and fall rapidlyrise and fall rapidly
>240 todd units (adults)>240 todd units (adults)
>330 todd units (children)>330 todd units (children)
Antibiotics/steroids/liver disease Antibiotics/steroids/liver disease
affect the titreaffect the titre

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EVIDENCE OF STREPTOCOCAL EVIDENCE OF STREPTOCOCAL
INFECTIONINFECTION
ANTI-DNAase B TESTANTI-DNAase B TEST : :
## > 120 todd units (adults)> 120 todd units (adults)
# > 240 todd units (children) # > 240 todd units (children)
# used when ASO titre is not conclusive # used when ASO titre is not conclusive
# remains elevated for long time # remains elevated for long time
STREPTOZYME TESTSTREPTOZYME TEST : :
Detects antibodies against streptococcal Detects antibodies against streptococcal
antigen antigen

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RHEUMATIC ACTIVITY RHEUMATIC ACTIVITY
DETECTIONDETECTION
Activity considered ended only when both ESR Activity considered ended only when both ESR
& CRP become normal & CRP become normal
and remain so for 2 weeks after stopping drugsand remain so for 2 weeks after stopping drugs
Fever & tachycardia subside long before lab Fever & tachycardia subside long before lab
reactants declinereactants decline
Joint symptoms & active carditis do not occur Joint symptoms & active carditis do not occur
after ESR & CRP declineafter ESR & CRP decline

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RHEUMATIC ACTIVITY RHEUMATIC ACTIVITY
DETECTIONDETECTION
CRP more specific than ESRCRP more specific than ESR
Usually lasts for 3 monthsUsually lasts for 3 months
Longer in patients with valvular involvementLonger in patients with valvular involvement
In 5% cases rheumatic activity persist longer In 5% cases rheumatic activity persist longer
than than 6 months6 months
termed CHRONIC RHEUMATIC FEVERtermed CHRONIC RHEUMATIC FEVER

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ECHOCARDIOGRAMECHOCARDIOGRAM
Abernathy et al : Abernathy et al :
echo allowed earlier diagnosis of carditisecho allowed earlier diagnosis of carditis
Veasy et al :Veasy et al :
echo increased the sensitivity of detecting echo increased the sensitivity of detecting
carditis from 72% to 91% carditis from 72% to 91%

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ECHOCARDIOGRAMECHOCARDIOGRAM
Differentiates between innocent murmur and Differentiates between innocent murmur and
Rheumatic MRRheumatic MR
Detects MVP due to Rheumatic feverDetects MVP due to Rheumatic fever
(Wu et al – JACC 1994)(Wu et al – JACC 1994)
- AML- AML
- Elongated chordae- Elongated chordae
- No myxomatous thickening- No myxomatous thickening

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ECHOCARDIOGRAMECHOCARDIOGRAM
Cost effectiveness and the additional Cost effectiveness and the additional
workload have to be validatedworkload have to be validated

Vasan et al (Circ . 1994 ):Vasan et al (Circ . 1994 ): showed no showed no
additional detection of carditis by echo additional detection of carditis by echo
than by clinical detection than by clinical detection

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OTHER INVESTIGTIONSOTHER INVESTIGTIONS
Endomyocardial biopsyEndomyocardial biopsy – to establish – to establish
the myocarditisthe myocarditis
not likely to provide additional informationsnot likely to provide additional informations
Radionuclide imaging- Radionuclide imaging-
- - Gallium-67 imaging has better diagnostic Gallium-67 imaging has better diagnostic
characteristics than antimyosin scintigraphycharacteristics than antimyosin scintigraphy
- the results confirm that rheumatic carditis is - the results confirm that rheumatic carditis is
infiltrative rather than degenerative in natureinfiltrative rather than degenerative in nature
- not suitable for routine investigation- not suitable for routine investigation

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DUCKETT JONES DUCKETT JONES
CRITERIACRITERIA
ORIGINAL (JAMA 1944)ORIGINAL (JAMA 1944)
MAJORMAJOR MINOR MINOR
Carditis Carditis erythema mariginatum erythema mariginatum
ChoreaChorea fever / epistaxis / fever / epistaxis /
ArthralgiaArthralgia abdominal pain abdominal pain
S/C NoduleS/C Nodule WBC / ESR / CRP WBC / ESR / CRP
Preexisting RFPreexisting RF

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DUCKETT JONES DUCKETT JONES
CRITERIACRITERIA
MODIFIEDMODIFIED :1956 - AHA :1956 - AHA
Arthritis : Included as – major Arthritis : Included as – major
criteriacriteria
Erythema marginatum: Included as – major criteriaErythema marginatum: Included as – major criteria
REVISEDREVISED : 1965 /84 - AHA : 1965 /84 - AHA
Recent streptococcal infection is included as essential Recent streptococcal infection is included as essential
criteriacriteria
WHO : 1988 WHO : 1988
UPDATEDUPDATED : 1992 - AHA : 1992 - AHA
WHO CRITERIA : 2003WHO CRITERIA : 2003

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DUCKETT JONES DUCKETT JONES
CRITERIACRITERIA
WHO CRITERIA FOR RF AND RHD- 2003WHO CRITERIA FOR RF AND RHD- 2003
MAJORMAJOR MINOR MINOR
CarditisCarditis ClinicalClinical
Polyarthritis - FeverPolyarthritis - Fever
ChoreaChorea - Arthralgia - Arthralgia
S/C NodulesS/C Nodules LaboratoryLaboratory
Ery. MarginatumEry. Marginatum - Leucocytosis - Leucocytosis
- Elevated : ESR /CRP- Elevated : ESR /CRP
ECGECG - Increased - Increased
PR intervalPR interval

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DUCKETT JONES DUCKETT JONES
CRITERIACRITERIA
Supporting evidence of antecedent Supporting evidence of antecedent
streptococcal infection Within the last 45 streptococcal infection Within the last 45
daysdays
- - positive Throat culture positive Throat culture
- Rapid streptococcal antigen test- Rapid streptococcal antigen test
- Elevated or Rising ASO Titer- Elevated or Rising ASO Titer
- Recent scarlet fever- Recent scarlet fever

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Diagnostic categories: WHO 2003Diagnostic categories: WHO 2003
PRIMARY RF :PRIMARY RF :
2 major or 1 major and 2 minor + evidence of preceding Gr-A 2 major or 1 major and 2 minor + evidence of preceding Gr-A
streptococcal infectionstreptococcal infection
RECURRENT ATTACK OF RF WITHOUT RECURRENT ATTACK OF RF WITHOUT
ESTABLISHED RHD ESTABLISHED RHD
2 major or 1 major and 2 minor + evidence of preceding Gr-A 2 major or 1 major and 2 minor + evidence of preceding Gr-A
streptococcal infectionstreptococcal infection
RECURRENT ATTACK OF RF WITHRECURRENT ATTACK OF RF WITH
ESTABLISHED RHDESTABLISHED RHD
2 minor + evidence of preceding Gr-A streptococcal infection2 minor + evidence of preceding Gr-A streptococcal infection

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Diagnostic categories: WHO 2003Diagnostic categories: WHO 2003
Rheumatic chorea Rheumatic chorea
Insidious onset rheumatic carditisInsidious onset rheumatic carditis
Other major manifestations or evidence of Other major manifestations or evidence of
Group-A streptococcal infection not requiredGroup-A streptococcal infection not required

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Diagnostic categories: WHO 2003Diagnostic categories: WHO 2003
Chronic valve lesions of RHDChronic valve lesions of RHD

Patients presenting first time with pure MS Patients presenting first time with pure MS
or mixed mitral valve disease and /or or mixed mitral valve disease and /or
aortic valve diseaseaortic valve disease

Do not require any other criteria for Do not require any other criteria for
diagnosis as having RHDdiagnosis as having RHD

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DUCKETT JONES DUCKETT JONES
CRITERIACRITERIA
Specificity – 97 %Specificity – 97 %
Sensitivity – 77 %Sensitivity – 77 %

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BEYOND JONES BEYOND JONES
CRITERIACRITERIA
Not a substitute for clinical judgmentNot a substitute for clinical judgment
Not meant to predict course or severityNot meant to predict course or severity
Useful for initial diagnosis onlyUseful for initial diagnosis only
Exceptions : Exceptions :
- Chorea- Chorea
- Isolated indolent carditis- Isolated indolent carditis
- Recurrence with RHD- Recurrence with RHD

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APPLYING JONES CRITERIAAPPLYING JONES CRITERIA
2 major criteria is stronger than 2 major criteria is stronger than
One major and 2 minorOne major and 2 minor
Arthalgia cannot be used as minor criteria when Arthalgia cannot be used as minor criteria when
arthritis is presentarthritis is present
Prolonged PR cannot be used as a minor criteria Prolonged PR cannot be used as a minor criteria
when clinical carditis is present when clinical carditis is present

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APPLYING JONES APPLYING JONES
CRITERIACRITERIA
Absence of evidence of an antecedent Absence of evidence of an antecedent
Group-A Beta-hemolyticus Streptococci is a Group-A Beta-hemolyticus Streptococci is a
warning that RF is unlikelywarning that RF is unlikely
Possibility of early suppression of full clinical Possibility of early suppression of full clinical
manifestations by drugs should be sought manifestations by drugs should be sought
during history taking during history taking

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RECURRENCERECURRENCE
Cardiac status deteriorates with each new attackCardiac status deteriorates with each new attack
Younger the patient - higher recurrence rateYounger the patient - higher recurrence rate
Recurrence decreases with passage of time – Recurrence decreases with passage of time –
. . - - 50% within first year 50% within first year
- only 10% after 5 years- only 10% after 5 years
Recurrence more in those with valvular lesionRecurrence more in those with valvular lesion
Increase antibody response associated with high Increase antibody response associated with high
recurrence raterecurrence rate

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RECURRENCERECURRENCE
Clinical manifestations in recurrence tend to Clinical manifestations in recurrence tend to
mimic those in preceding attackmimic those in preceding attack
Recurrence distinguished from rebound or Recurrence distinguished from rebound or
exacerbation if interval of 3 months freedom exacerbation if interval of 3 months freedom
of rheumatic activityof rheumatic activity
Valve stenosis at diagnosis indicates Valve stenosis at diagnosis indicates
recurrencerecurrence

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RHEUMATIC FEVERRHEUMATIC FEVER
 Licks the Joint and Bites the Heart Licks the Joint and Bites the Heart

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 THANK YOUTHANK YOU

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site site
Visit us regularly for updatesVisit us regularly for updates
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Rheumatic fever clinical features and diagnosis

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Rheumatic fever clinical features and diagnosis

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