Rheumatic fever .pdf

5. A 5 years old boy presents with fever & swelling of knee and ankle joint for 3 weeks. Write down 3 important D/D. Discuss the treatment of acute rheumatic fever with carditis. (DU-09Ju)

Three important differential diagnoses of a 5-year-old boy presenting with fever and joint swelling for 3 weeks include:

Septic arthritis: This is an acute bacterial infection of a joint that causes similar symptoms to rheumatic fever but is usually monoarticular and associated with more severe pain, redness, and tenderness of the affected joint. Septic arthritis requires urgent drainage and antibiotics.

Juvenile idiopathic arthritis: This is a group of chronic autoimmune disorders that can present with fever, joint swelling, and stiffness. The diagnosis is based on clinical features, laboratory tests, and imaging studies. The treatment may include nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, and biologic agents.

Reactive arthritis: This is an inflammatory joint disease that can occur after an infection, especially with certain bacteria such as Chlamydia, Salmonella, or Shigella. Reactive arthritis usually affects the lower limb joints, such as knees, ankles, and feet, and may be associated with skin rash, eye inflammation, or urethritis. The treatment may include antibiotics, nonsteroidal anti-inflammatory drugs, and corticosteroids.

Assuming the diagnosis of acute rheumatic fever with carditis, the treatment usually involves a combination of antibiotics and anti-inflammatory drugs. The antibiotics aim to eradicate the streptococcal infection and prevent further rheumatic fever recurrences, while the anti-inflammatory drugs aim to reduce the inflammation and symptoms of carditis. The specific regimen may vary depending on the severity of carditis, the presence of other complications, and the patient's age and weight. In general, the following principles apply:

Antibiotics: A 10-day course of oral or intramuscular penicillin is the first-line antibiotic for acute rheumatic fever, as it is effective against most strains of streptococci and has low toxicity. Alternative antibiotics may be used for patients who are allergic to penicillin or have recurrent rheumatic fever despite adequate penicillin therapy. Long-term prophylaxis with penicillin is recommended to prevent recurrences, usually until the age of 21 years or for 10 years after the last episode of rheumatic fever, whichever is longer.

Anti-inflammatory drugs: High-dose aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are usually given for the first 2-3 weeks of acute rheumatic fever to control fever, pain, and inflammation. Corticosteroids such as prednisone or methylprednisolone may be used in severe cases of carditis or when other therapies are not effective or contraindicated. The duration and dose of anti-inflammatory drugs should be tailored to the patient's response and adverse effects, such as gastric

1. "Unlocking the Mysteries of
Rheumatic Fever: Understanding,
Diagnosing and Conquering a Silent
Threat"

2. Introduction
●Brief definition of rheumatic
fever
● its connection to streptococcal
infections

3. ●Rheumatic Fever: An Autoimmune Response
●Rheumatic fever is a complex inflammatory condition that primarily
affects the heart, joints, skin, and brain.
●It occurs as a result of an abnormal immune response to a previous
infection with Streptococcus pyogenes, commonly known as group A
streptococcus.
●Connection to Streptococcal Infections
●Streptococcus pyogenes: A Common Bacterium
●Streptococcus pyogenes is a bacterial pathogen responsible for
various infections, including strep throat and skin infections.
●It possesses specific antigens that resemble molecules found in
human tissues.
Introduction

4. ●Acute rheumatic fever is a systemic disease of
childhood ,often recurrent that follows group A beta
hemolytic streptococcal infection
●It is a diffuse inflammatory disease of connective tissue
primarily involving heart, blood vessels, joints,
subcutaneous tissue and CNS
Rheumatic fever
Definition
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5. ●Molecular Mimicry: Triggering an Immune Response
●After a streptococcal infection (such as strep throat), the body's immune
system may mistake its own tissues, particularly heart and joint tissues, for
the bacterial antigens due to molecular mimicry.
●This confusion leads to an autoimmune response, where the immune
system attacks and damages these tissues.
●Historical Context
●Historically, rheumatic fever was a significant cause of morbidity and mortality,
especially in children and young adults.
●Improved hygiene and antibiotics have reduced its incidence in developed
countries, but it remains a concern in certain regions with limited access to
healthcare.
Introduction

6. Scope of the Presentation
●This presentation will delve into the epidemiology, etiology,
pathogenesis, clinical manifestations, diagnosis, treatment,
prevention,and ongoing research related to rheumatic fever.
●By understanding the intricate interplay between streptococcal
infections and the immune system, we can better grasp the
complexities of rheumatic fever and work towards its
prevention and management.
Introduction

7. ●Prevalence and incidence rates
●Age and gender distribution
●Geographical trends
Epidemiology

8. Epidemiology
•Ages 5-15 yrs are most susceptible
•Rare <3 yrs
•Girls>boys
•Common in 3rd world countries
•Environmental factors-- over crowding, poor sanitation,
poverty,
•Incidence more during fall ,winter & early spring
Rheumatic fever
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9. ●Prevalence and Incidence Rates
●Rheumatic fever was more prevalent in the past, but its incidence has
decreased significantly in developed countries due to improved living
conditions and antibiotic treatment.
●It continues to be a concern in certain developing regions with limited
access to healthcare.
●Age and Gender Distribution
●Rheumatic fever primarily affects children and young adults, typically
between 5 and 15 years of age.
●However, it can also occur in adults, particularly those with ongoing
heart valve damage from previous episodes.
Epidemiology

10. Geographical Trends
●Higher Incidence in Developing Regions
●Rheumatic fever remains a significant public health issue in parts of Africa, Asia, and
Oceania.
●Limited access to healthcare, inadequate treatment of streptococcal infections, and
crowded living conditions contribute to its persistence.
●Decline in Developed Countries
●The incidence of rheumatic fever has significantly decreased in developed nations due to
improved sanitation, living standards, and the availability of antibiotics.
●Clusters and Outbreaks
●Even in areas with low overall incidence, localized outbreaks can occur, often linked to
community or school settings where streptococcal infections spread easily.
Epidemiology

11. ●Socioeconomic Factors
●Impact of Poverty
●Low socioeconomic status is a risk factor for rheumatic fever due to reduced access to
healthcare and crowded living conditions that facilitate the spread of streptococcal infections.
●Healthcare Disparities
●Disparities in healthcare infrastructure can lead to delayed diagnosis and inadequate treatment,
increasing the risk of complications.
●Importance of Awareness and Education
●Raising awareness about the connection between streptococcal infections and
rheumatic fever is crucial for early diagnosis and prompt treatment, especially in regions
with higher prevalence.
●Public health campaigns and educational programs can help reduce the burden of
rheumatic fever by promoting hygiene, proper medical care, and antibiotic treatment of
streptococcal infections.
Epidemiology

12. ●Streptococcus pyogenes (group A
streptococcus) as the causative agent
●Explanation of the immune response
triggering rheumatic fever
Aetiology

13. Etiology
•Acute rheumatic fever is a systemic disease of childhood, often
recurrent that follows group A beta hemolytic streptococcal
infection
•It is a delayed non-suppurative sequelae to URTI with GABH
streptococci.
•It is a diffuse inflammatory disease of connective tissue,
primarily involving heart, blood vessels, joints, subcutaneous
tissue and CNS
Rheumatic fever
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14. 14
Diagrammatic structure of the
group A beta hemolytic
streptococcus
Capsule
Cell wall
Protein antigens
Group carbohydrate
Peptidoglycan
Cyto.membrane
Cytoplasm
cytoplasm
……………………………………………
……...
Antigen of outer protein cell
wall of GABHS induces
antibody response in victim
which result in autoimmune
damage to heart valves,
sub cutaneous tissue,tendons,
joints & basal ganglia of brain

15. Aetiology
●Streptococcus Pyogenes (Group A Streptococcus) as the Causative Agent
●Streptococcus pyogenes, commonly known as group A streptococcus, is a bacteria
responsible for various infections, including strep throat and skin infections.
●It possesses specific cell wall components and antigens that help it evade the immune
system and adhere to human tissues.
●Certain strains of group A streptococcus are associated with a higher risk of rheumatic fever.
●Immune Response Triggering Rheumatic Fever
●Molecular Mimicry: Cross-Reactive Antigens
●After a streptococcal infection, the body's immune system produces antibodies to
fight the bacteria.
●In some individuals, the antibodies mistakenly recognize antigens on the surface of
streptococci that resemble proteins found in human tissues, particularly heart and
joint tissues.

16. Autoimmune Reaction
●The antibodies and immune cells that were initially targeting
the bacteria may start attacking the body's own tissues due
to the resemblance between bacterial and human antigens.
●This autoimmune response leads to inflammation, tissue
damage, and the characteristic symptoms of rheumatic
fever.
Aetiology

17. Pathogenesis: Immune-Mediated Inflammation
●Cardiac Involvement
●The immune response primarily targets the heart, leading to inflammation of the heart's
lining (endocardium), valves (valvulitis), and other structures.
●Repeated episodes of inflammation can cause scarring and deformities of heart valves,
leading to rheumatic heart disease.
●Joint Involvement
●The immune response can also affect the synovium (lining) of joints, causing joint
inflammation and pain.
●Skin Manifestations
●Immune complexes deposited in the skin can lead to the development of characteristic
skin rashes.
Neurological Symptoms
●In some cases, the immune response affects the brain, causing Sydenham's chorea, a movement disorder.
Aetiology

18. ●Genetic and Environmental Factors
●Genetic susceptibility plays a role in determining who is more prone to
developing rheumatic fever after a streptococcal infection.
●Environmental factors such as the specific strain of streptococcus, host
immune response, and overall health also contribute to the likelihood of
developing the condition.
●Clinical Significance
●Understanding the immune response underlying rheumatic fever highlights the
importance of early and effective treatment of streptococcal infections to
prevent its occurrence.
●Ongoing research aims to uncover the specific mechanisms driving the
autoimmune reaction, leading to potential new treatment strategies and
preventive measures.
Aetiology

19. ●Autoimmune reaction and molecular
mimicry
●Inflammatory processes affecting
various organs
Pathogenesis

20. Pathophysiology
Rheumatic fever
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21. Pathogenetic pathway for ARF & RHD
strong correlation between progression
to RHD & HLA-DR class II alleles &
the inflammatory protein-encoding genes
MBL2 and TNFA
Common antigenic determinants are
shared between components of
GAS (M protein, protoplast
membrane, cell wall group A
carbohydrate, capsular
hyaluronate) & specific mammalian
tissues (e.g., heart, brain, joint)
certain M
proteins (M1, M5,
M6, and M19)
share epitopes
with human
tropomyosin &
myosin

22. Rheumatic fever
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23. Autoimmune Reaction and Molecular Mimicry
●Immune System's Role
●After a streptococcal infection, the immune system produces antibodies (proteins) to
target the bacteria.
●These antibodies are designed to recognize specific antigens on the surface of the
bacteria.
●Molecular Mimicry
●Some streptococcal antigens resemble proteins found in human tissues, particularly
heart and joint tissues.
●Antibodies produced against the streptococcal antigens can mistakenly bind to similar
antigens in the host tissues due to their structural resemblance.
●This cross-reactivity leads to the immune system attacking and damaging the host
tissues.
Pathogenesis

24. Inflammatory Processes Affecting Various Organs
●Cardiac Involvement: Carditis and Valvular Damage
●Inflammatory response targets the heart, leading to inflammation of the heart's
lining (endocarditis) and valves (valvulitis).
●The inflammation can cause swelling, pain, and dysfunction of the heart,
impacting its ability to pump blood efficiently.
●Repeated episodes of inflammation can lead to scarring and deformities of
heart valves, contributing to rheumatic heart disease.
●Joint Involvement: Arthritis
●Inflammation affects the synovium (lining) of joints, causing arthritis
characterized by joint pain, swelling, and limited movement.
●The immune response triggers an accumulation of immune cells and
inflammatory molecules within the affected joints.
Pathogenesis

25. ●Skin Manifestations: Subcutaneous Nodules and
Rash
●Immune complexes deposited in the skin lead to the development of
small, firm nodules beneath the skin's surface.
●Skin rashes, such as erythema marginatum, can occur due to immune-
mediated vasculitis (inflammation of blood vessels).
●Neurological Involvement: Sydenham's Chorea
●Inflammation affecting the brain can result in Sydenham's chorea, a
disorder characterized by rapid, involuntary movements.
●The exact mechanism linking the immune response to neurological
symptoms is not fully understood.
Pathogenesis

26. Rheumatic fever
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Pathogenesis

27. ●Systemic Impact
●The autoimmune reaction and resulting inflammation can have systemic effects on various organs
and tissues beyond the heart, joints, skin, and brain.
●Elevated levels of inflammatory markers in the blood, such as C-reactive protein and erythrocyte
sedimentation rate, indicate the extent of inflammation and help guide diagnosis and treatment.
●Treatment Implications
●Understanding the inflammatory processes and the organs affected is crucial for tailoring treatment
approaches.
●Anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and
corticosteroids, are used to manage the inflammation and symptoms associated with rheumatic fever.
●Ongoing Research
●Researchers continue to investigate the molecular and cellular mechanisms underlying the
autoimmune reaction in rheumatic fever, aiming to identify novel therapeutic targets and interventions
to prevent tissue damage.
Pathogenesis

28. Key morphologic
features of acute
rheumatic heart
disease.
Pathogenesis

29. Pathogenesis

30. ●Major and minor criteria for diagnosis
●Cardiac symptoms: Carditis, valvular damage
●Extra-cardiac symptoms: Arthritis, skin rash,
chorea, subcutaneous nodules
Clinical Manifestations

31. Major and Minor Criteria for Diagnosis
●Jones Criteria
●The Jones criteria are used to diagnose rheumatic fever based on clinical and
laboratory findings.
●Major Criteria: Significant evidence of cardiac involvement, such as carditis,
valvulitis, or valvular damage.
●Minor Criteria: Other clinical manifestations, including arthritis, skin rash, fever,
elevated inflammatory markers, and previous streptococcal infection.
●Diagnosis requires the presence of either two major criteria or one major and
two minor criteria, along with evidence of a recent streptococcal infection.
Clinical Manifestations

32. MODIFIED JONES CRITERIA 1956
Rheumatic fever
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MAJOR MANIFESTATION
1.CARDITIS
2.POLYARTHRITIS
3. CHOREA
4.SUBCUTANEOUS NODULES
5.ERYTHEMA MARGINATUM
1.FEVER
2.ARTHRALGIA
3.PROLONGED PR INTERVAL
4.INCREASED ESR,CRP OR
LEUKOCYTOSIS
5.PREVIOUS H/O OF RF OR RHD
6.EVIDENCE OF PRECEEDING BETA
HEMOLYTIC STREPTOCOCCAL
INFECTION

33. Cardiac Symptoms: Carditis and Valvular Damage
●Carditis (Inflammation of the Heart)
●Presents as chest pain, breathlessness, and an abnormal heart rhythm.
●Due to inflammation of the heart muscle and lining.
●Can lead to heart enlargement and impaired function.
●Valvular Damage (Valvulitis)
●Inflammation can cause scarring and deformities of heart valves.
●Most commonly affects the mitral valve, followed by the aortic valve.
●Valve damage can lead to murmurs, regurgitation, and heart failure.
Clinical Manifestations

34. Carditis
Rheumatic fever
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•Incidence varies from 50%-60%
•The clinical diagnosis of carditis in an index attack of RF is based on
•1) Presence of significant murmurs (MR/AR)
•2)Pericardial rub
•3) Unexplained cardiomegaly with CHF.
• Common in young
•80% of patients develop it within first 2 weeks of RF

35. Endocarditis/ Valvulitis
•Almost always associated with a murmur of valvulitis
• An universal finding in rheumatic carditis, whereas the presence of pericarditis
or myocarditis is variable.
•Valve involvments-
•92 – 95% mitral valve involvement ( 70 – 75 % isolated MV)
• 20 – 25% aortic valve involvement( 5-8% isolated AV)
•MR – PSM in apex radiating to axilla > with grade 2 (MC FINDING IN CARDITIS)
•AR in the absence of MR is uncommon
Rheumatic fever
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36. Rheumatic fever
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•First attack of RF- apical holosystolic murmur of mitral regurgitation (with or without apical
MDM, Carey Coombs), or basal EDM
•Pt. with previous RHD- a definite change in the character of any of these murmurs or the
appearance of a new significant murmur
•Severe MR
• Associated with worst prognosis - fatal HF
• Incidence of chronic RHD 90%.
•Linear relationship between the severity of MR during the first episode of RF and subsequent RHD.
Endocarditis/ Valvulitis

37. Pathogenesis of severe MR
• Valvulitis
•Mitral annular dilatation
• Leaflet prolapse with or without chordal elongation
• Chordal rupture
• Carey Coombs murmur
•MDM without presystolic accentuation
•Associated with severe MR
•Due to increased flow through diseased mitral valve
Rheumatic fever
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Endocarditis/ Valvulitis

38. During an episode of
ARF, valve changes can
be minor and are still
able to regress
After recurrent
episodes of ARF,
thickening of subvalvar
apparatus, chordal
thickening and
shortening and
progression to
permanent valve damage
is evident

41. myocarditis
•Myocarditis is always associated with valvulitis
• New onset CMGLY and recent change in cardiac size - most specific sign
•No definite evidence of myocarditis!!
- No consistent elevation of cardiac biomarkers
- No evidence of systolic dysfunction
- CHF does not occur without significant valvular lesions
- Radionuclide studies failed to demonstrate significant myocardial staining
- Biopsy in acute RF failed to show cellular necrosis -inflammation was subepicardial, subendocardial and
perivascular
- Surgical valve replacement during RF and AHF reverted features of HF
- Aschoff nodules do not contain myocardial cells
Rheumatic fever
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42. Pericarditis
Rheumatic fever
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•6 -15 % OF RF
•Diagnosed by typical pain & friction rub
•Always associated with rheumatic valvulitis
•May be associated with normal ECG
•May be associated with effusion but rarely causes constriction and tamponade
•Its presence denote severe carditis

43. Extra-cardiac Symptoms
●Arthritis
●Joint inflammation, typically affecting larger joints.
●Causes pain, swelling, and limited range of motion.
●Skin Rash: Erythema Marginatum
●A rare rash characterized by reddish, non-itchy, and spreading lesions with clear
centers.
●Chorea (Sydenham's Chorea)
●Involuntary, purposeless movements, often affecting the limbs and face.
●Can be accompanied by emotional disturbances and difficulty concentrating.
●Subcutaneous Nodules
●Small, painless lumps beneath the skin, usually over bony prominences.
●Composed of immune cells and fibrin deposits.
Clinical Manifestations

44. Poly arthritis
•66-75% of patients
•MC & most earliest manifestation
•Typically involves larger joints – knee, ankle, wrist, & elbow
•Involved joints - hot, red, swollen, and tender
• Migratory in nature
•Not deforming
• A dramatic response to small doses of salicylates
Rheumatic fever
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45. •Synovial fluid in ARF usually has 10,000-100,000 WBC/mm
3
•Exudative with normal glucose & neutrophil predominance
•Self limiting & normalizes by 2 – 4 wks
•Polyarthritis & sydenham’s chorea never occurs simultaneously
•Inverse relationship b/w the severity of arthritis & cardiac
involvement
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Poly arthritis

46. Subcutaneous nodule
Rheumatic fever
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•Rare
• 2-20%
• Freely mobile, painless
• 0.5 - 2 cm
•Occur in crops over bony prominences or
extensor tendons
•Common locations - elbow, wrist, knee,
ankle & achilles tendon

47. Erythema marginatum
Rheumatic fever
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• 3-15%
• Erythematous, serpiginous, macular lesions with
pale centers that are not pruritic
• Multiple lesions primarily on the trunk or
proximal extremities,rarely on distal extremities &
never on face
•It occurs early in course of RF

48. Rheumatic fever
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• Nonpainful , nonpruritic, blanches on pressure
• Accentuated by warming the skin.
•Not influenced by antiinflammatory therapy
•It is associated with carditis
•Nodules & marginatum can occur simultaneously
•It is also seen in sepsis, drug reactions , glomerulonephritis
Erythema marginatum

49. Chorea
Rheumatic fever
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•Sydenham chorea , St.Vitus dance
• 5 - 36% of ARF
•Mc in females, rare > 20 yrs
• Isolated, frequently subtle, neurologic behavior disorder
• Emotional lability, incoordination, poor school performance, uncontrollable movements,
and facial grimacing
• Exacerbated by stress and disappears with sleep
• Seen occasionally unilateral

50. Rheumatic fever
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•Long latent period
• Clinical maneuvers to elicit features of chorea include
• (1) demonstration of milkmaid’s grip (irregular contractions of the muscles of the hands
while squeezing the examiner’s fingers)
• (2) spooning & pronation of the hands when the patient’s arms are extended
• (3) wormian darting movements of the tongue upon protrusion
• (4) examination of handwriting to evaluate fine motor movements
• Do not cause permanent neurologic sequelae
Chorea

51. Sydenham’s Chorea
Rheumatic fever

52. Rheumatic fever
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•Rheumatic chorea –marker of future carditis
•23% pure rheumatic chorea developed MS in 20 yr follow up
& 27% in 30 yr period
•Chorea is rarely associated with polyarthritis
•Inflammatory markers & ASO titres may be normal
Chorea

53. Minor manifestations
Rheumatic fever
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•Arthralgia
•constitutes pain in one or more joints without evidence of inflammation, tenderness to touch, or limitation of motion.
•Arthralgia + monoarticular arthritis – suggestive of RF
•Fever
•Temperature >100.40 F rectally-diurnal variations are seen
•Children with mild carditis and pateints with chorea are afebrile
•Epistaxis seen in 4% of cases
•Abdominal pain
•5% 0f cases - occurs before the appearance of major manifestation
•Pain usually epigastric or periumbilical & may mimic appendicitis

54. ●Varied Presentation
●Clinical manifestations of rheumatic fever can vary widely among individuals.
●Some patients may experience only minor symptoms, while others may have
more severe cardiac and extra-cardiac involvement.
●Importance of Early Diagnosis
●Prompt recognition of clinical manifestations is essential to initiate appropriate
treatment and prevent further damage to the heart and other affected organs.
●Clinicians must be vigilant, especially in regions with higher prevalence, and
consider the possibility of rheumatic fever in patients presenting with
compatible symptoms.
Clinical Manifestations

55. Rheumatic fever
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•Those patients who develop extracardiac manifestation in the initial
attack , there is a less chance for carditis during recurrence whereas if
the initial attack is carditis there is a high chance of recurrent carditis
MIMETIC FEATURE OF RHEUMATIC FEVER

56. Rheumatic fever
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POST STREPTOCOCCAL REACTIVE ARTHRITIS
•Relatively shorter latent period
( 7 to 10) days
•May be persistent or relapsing
•Slower response to aspirin
•Not associated with other
major manifestations
•Symmetric invlnt. of large , small
joints & axial skeleton
•Occ . causation by non GABHS
•Secondary prophylaxis for up to 1
year after the onset of their
symptoms (Class IIb,LOE C)

57. Rheumatic Pneumonia
Rheumatic fever
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•An acute inflammatory pneumonitis has been described in patients with RF
•Presents as sudden onset respiaratory distress
•Associated with carditis
•CXR shows a hilar or patchy distribution
•Difficult to differentiate clinically with CHF
•Responds to steroids
•Uncertainity of its frequency and its existence as a distinct entity

58. Rheumatic fever
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JACCOUD’S ARTHRITIS

59. JACCOUD’S ARTHRITIS
•Chronic postrheumatic fever arthritis
•Seen in patients with severe RHD & not associated with evidence of RF
•Recovery delayed & assoc. with stiffness of metacarpophalyngeal joints
•Characteristic deformity due to periarticular , fascial and tendon fibrosis
•Joint disease is inactive with normal ESR & negative RA factor
•Deformity characterized by flexion at the metcarpophalangeal joint with ulnar deviation
of 4
th
and 5
th
fingers & hyperextn of PIP
• Initially the deformity is correctable & not assoc with bone destruction
Rheumatic fever
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60. PANDAS
•Pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections
•Autoimmune responses that cross-react with brain
tissue in response to a GAS infection
• Obsessive-compulsive & tic disorders
•No need of secondary prophylaxis (Class III, LOE B).
Rheumatic fever
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61. ●Jones criteria for diagnosing rheumatic
fever
●Importance of clinical and laboratory
findings
●Differential diagnosis from other
conditions
Diagnosis

62. Jones Criteria for Diagnosing Rheumatic Fever
●Developed to standardize the diagnosis of rheumatic fever based on clinical and
laboratory criteria.
●Used to confirm the link between a recent streptococcal infection and the
development of rheumatic fever.
●Major Criteria: Carditis, polyarthritis, chorea, erythema marginatum, subcutaneous
nodules.
●Minor Criteria: Fever, arthralgia (joint pain), elevated acute phase reactants (e.g., C-
reactive protein), prolonged PR interval on ECG, evidence of previous streptococcal
infection.
●Diagnosis requires either two major criteria or one major and two minor criteria,
along with evidence of a recent streptococcal infection.
Diagnosis

63. Importance of Clinical and Laboratory Findings
●Clinical Assessment:
●Thorough physical examination to identify major and minor criteria.
●Assessment of cardiac function, joint involvement, skin changes, and
neurological symptoms.
●Laboratory Investigations:
●Streptococcal throat culture or rapid strep test to confirm recent streptococcal
infection.
●Blood tests to measure inflammatory markers (e.g., C-reactive protein,
erythrocyte sedimentation rate).
●Electrocardiogram (ECG) to evaluate heart rhythm and PR interval.
●Echocardiogram to assess heart structure and function.
Diagnosis

64. Differential Diagnosis from Other Conditions
●Lupus (Systemic Lupus Erythematosus)
●Shares some clinical features with rheumatic fever, such as joint pain, skin
rash, and cardiac involvement.
●Specific antibodies and diagnostic criteria help differentiate between the
two.
●Infective Endocarditis
●Can present with fever, cardiac symptoms, and inflammatory markers.
●Blood cultures and echocardiogram help distinguish it from rheumatic
fever.
●Post-Streptococcal Reactive Arthritis
●Presents with joint pain and inflammation after streptococcal infections.
●Distinguished by the absence of major criteria and unique clinical features.
Diagnosis

65. ●Challenges in Diagnosis
●Clinical manifestations can be subtle or overlap with other conditions,
leading to misdiagnosis or delayed diagnosis.
●Diagnostic criteria may not be fully met in some cases, particularly in
patients with less severe or atypical presentations.
●Role of Healthcare Providers
●Healthcare professionals must have a high index of suspicion,
especially in regions with a higher prevalence of rheumatic fever.
●Collaboration between clinicians, cardiologists, rheumatologists, and
other specialists is important for accurate diagnosis and management.
Diagnosis

66. ●Chronic rheumatic heart disease
●Risk factors for progression
●Importance of early intervention
Complications

67. Chronic Rheumatic Heart Disease
●Definition: Chronic damage to heart valves due to repeated
episodes of rheumatic fever.
●Mechanism: Inflammation and scarring of heart valves lead to
stenosis (narrowing) or regurgitation (leakage) of blood
through the valves.
●Impact: Impaired heart function, risk of heart failure, and
increased vulnerability to infective endocarditis.
Complications

68. Risk Factors for Progression
●Frequency of Rheumatic Fever Episodes: Repeated episodes increase the risk of
valve damage.
●Severity of Initial Episode: Severe initial episode may result in more extensive valve
damage.
●Type of Valve Affected: Mitral valve is commonly affected, and its damage has
greater clinical implications.
●Age of First Episode: Rheumatic fever at a younger age increases the risk of chronic
heart disease.
●Genetic Predisposition: Genetic factors may influence the severity and progression
of valve damage.
Complications

69. Importance of Early Intervention
●Prevention of Rheumatic Heart Disease: Timely and effective
treatment of streptococcal infections can prevent the occurrence of
rheumatic fever and subsequent heart valve damage.
●Prompt Treatment of Rheumatic Fever: Early diagnosis and
appropriate management can reduce inflammation and minimize
tissue damage.
●Regular Follow-Up: Individuals with a history of rheumatic fever
require long-term monitoring to detect and manage valve damage.
Complications

70. Secondary Prophylaxis (Preventive Antibiotics)
●Administering antibiotics (usually penicillin) to
individuals with a history of rheumatic fever.
●Prevents streptococcal infections and reduces the
risk of recurrent rheumatic fever episodes.
●Important to adhere to recommended antibiotic
schedule to ensure effectiveness.
Complications

71. ●Surgical Intervention
●In cases of severe valve damage and heart failure, surgical
procedures such as valve repair or replacement may be
necessary.
●Timely intervention can improve quality of life and overall
prognosis.
●Patient Education and Empowerment
●Educating patients and their families about the risks,
complications, and preventive measures is crucial.
●Encouraging adherence to antibiotic prophylaxis, regular follow-
up appointments, and healthy lifestyle practices.
Complications

72. ●Public Health Strategies
●Developing and implementing public health programs to
improve access to healthcare, raise awareness, and provide
preventive measures, especially in regions with higher
prevalence of rheumatic fever.
●Collaborative Efforts
●Collaborative approach involving healthcare providers,
public health agencies, policymakers, and communities is
essential to effectively address and mitigate the complications of
rheumatic fever and rheumatic heart disease.
Complications

73. ●Antibiotic therapy for streptococcal
infections
●Anti-inflammatory treatment
●Management of cardiac involvement
Treatment

74. Treatment
•Step I - primary prevention (eradication of streptococci)
•Step II - anti inflammatory treatment (aspirin,steroids)
•Step III- supportive management & management of complications
•Step IV- secondary prevention (prevention of recurrent attacks)
Rheumatic fever
25.08.2019 [email protected]

75. STEP I: Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis)
Agent Dose Mode Duration
Benzathine penicillin G600 000 U for patients Intramuscular Once
27 kg (60 lb)
1 200 000 U for patients >27 kg
or
Penicillin V Children: 250 mg 2-3 times daily Oral 10 d
(phenoxymethyl penicillin) Adolescents and adults: 500 mg 2-3 times daily
For individuals allergic to penicillin
Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d
Estolate (maximum 1 g/d)
or
Ethylsuccinate 40 mg/kg/d 2-4 times daily Oral 10 d
(maximum 1 g/d)
TREATMENT OF RF

76. Step II: Anti inflammatory treatment

77. TREATMENT OF RF
Rheumatic fever
[email protected]

78. TREATMENT OF RF
Rheumatic fever
[email protected]
1)TREATMENT OF GABHS1) ORAL PENCILLIN V 500MG B.D -10DAYS
2) INJ BENZATHINE PENCILLIN 12LAKH UNITS
3)ERYTHROMYCIN 250MG Q.I.D - 10 DAYS
2)TREATMENT OF ARTHRITIS1)ASPIRIN ONCE DIAGNOSIS IS CONFIRMED WITH
100MG/KG FOR 2 WEEKS AND THEN GRADUALLY
TAPERED TO 60 -80 MG/KG FOR ANOTHER 4 WKS
2) NAPROXEN ALTERNATIVE
3) TREATMENT OF CARDITIS1)NO CHF- ONLY ASPIRIN
2) CHF- STEROIDS AT A DOSE 2MG/KG FOR 4 WEEKS
TO BE OVERLAPPED WITH ASPIRIN WHEN IT IS TAPERED
3) ANTIFAILURE eg. Diuretics ,Ace, beta blockers,digoxin

79. TREATMENT OF RF
Rheumatic fever
[email protected]
TREATMENT OF SKIN LESIONS NO SPECIFIC TREATMENT
TREATMENT OF CHOREA 1)REASSURANCE & SEDATION
2)NSAID & STEROID HAVE NO ROLE
3)HALOPERIDOL
4)CARBAMZEPINE & VALPROATE –REFRACTORY CASES
5)IVIG & PLASMAPHERESIS-NO BENEFIT
SURGERY
1) PT WITH REFRACTORY CARDITIS
2)IDEAL AFTER THE ACUTE INFLAMMATION SETTLES
3) VALVE REPLACEMENT BETTER THAN VALVE REPAIR
4)IF MORPHOLOGIC EVIDENCE OF INFLAMMATION
REPAIR MAY CAUSE INCREASED REOPERATION

80. TREATMENT OF RF
Rheumatic fever
[email protected]

81. Antibiotic Therapy for Streptococcal Infections
●Primary Prevention: Prompt treatment of streptococcal infections,
particularly strep throat, with antibiotics (usually penicillin or amoxicillin).
●Secondary Prevention (Prophylaxis): Administering antibiotics regularly to
individuals with a history of rheumatic fever to prevent recurrence.
●Importance: Antibiotics prevent further streptococcal infections, reducing
the risk of recurrent rheumatic fever episodes and subsequent heart valve
damage.
●Adherence: Ensuring consistent and proper use of antibiotics is crucial for
effectiveness.
Treatment

82. Anti-inflammatory Treatment
●Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Used to
manage inflammation, reduce pain, and improve joint
symptoms.
●Corticosteroids: Sometimes prescribed for severe
inflammation, particularly in cases of carditis or severe
arthritis.
●Monitoring: Regular assessment of inflammatory markers and
symptoms to guide the duration and dosage of anti-inflammatory
treatment.
Treatment

83. Management of Cardiac Involvement
●Heart Failure Management: Diuretics, medications to improve
heart function (e.g., ACE inhibitors, beta-blockers), and lifestyle
modifications.
●Valve Repair or Replacement: Surgical intervention to repair
damaged heart valves or replace severely affected valves.
●Endocarditis Prevention: Antibiotic prophylaxis before dental
or surgical procedures to prevent infective endocarditis in
individuals with damaged heart valves.
Treatment

84. ●Multidisciplinary Approach
●Cardiologist Involvement: Collaboration between cardiologists, rheumatologists, and
other specialists to tailor treatment based on the severity and type of cardiac
involvement.
●Individualized Treatment Plans: Treatment plans should consider the patient's age,
overall health, severity of symptoms, and response to therapy.
●Monitoring and Follow-Up
●Clinical Assessment: Regular evaluation of symptoms, joint function, cardiac status, and
other manifestations.
●Echocardiograms: Periodic imaging to assess heart valve function and detect changes in
structure.
●Medication Adjustments: Adjustments to medication doses and types based on clinical
response and potential side effects.
Treatment

85. ●Patient Education
●Importance of Medication Adherence: Emphasizing the need to follow
prescribed antibiotic regimens and anti-inflammatory medications.
●Symptom Recognition: Educating patients about the signs of recurrent
rheumatic fever and the importance of seeking medical attention promptly.
●Future Directions
●Research and Innovation: Ongoing research aims to develop targeted therapies
that modulate the immune response and prevent tissue damage.
●Global Initiatives: Collaborative efforts to improve access to healthcare,
especially in regions with higher prevalence of rheumatic fever, can lead to
better diagnosis and treatment outcomes.
Treatment

86. ●Strategies for preventing streptococcal
infections
●Importance of prompt treatment of
streptococcal infections
●Public health measures to reduce rheumatic
fever incidence
Prevention

87. Strategies for Preventing Streptococcal Infections
●Good Hygiene Practices: Regular handwashing and maintaining personal
hygiene to reduce the spread of bacteria.
●Avoiding Close Contact: Minimizing contact with individuals who have
streptococcal infections, such as strep throat.
●Respiratory Hygiene: Covering the mouth and nose when coughing or
sneezing to prevent the release of infectious droplets.
●Educational Campaigns: Promoting awareness about streptococcal
infections and their prevention in communities, schools, and healthcare
settings.
Prevention

88. ●Importance of Prompt Treatment of Streptococcal Infections
●Antibiotic Treatment: Early and appropriate antibiotic therapy for streptococcal infections can prevent
the development of rheumatic fever.
●Reduced Transmission: Treating infected individuals reduces the spread of bacteria to others,
lowering the overall incidence of streptococcal infections.
●Educational Efforts: Healthcare providers should educate patients and their families about the
importance of completing prescribed antibiotic courses.
●Public Health Measures to Reduce Rheumatic Fever Incidence
●Access to Healthcare: Improving healthcare infrastructure and access to medical services in regions
with limited resources.
●Early Diagnosis and Treatment: Training healthcare providers to recognize symptoms of
streptococcal infections and rheumatic fever for early intervention.
●Community Outreach: Conducting health camps, workshops, and awareness programs to educate
communities about streptococcal infections and their consequences.
●Vaccination Development: Researching and developing vaccines against streptococcal infections to
prevent their occurrence and subsequent development of rheumatic fever.
●Surveillance Systems: Establishing surveillance systems to monitor the incidence of streptococcal
infections and rheumatic fever, enabling timely response and intervention.
Prevention

89. ●School and Community Initiatives
●Promoting Hygiene: Educating students about proper handwashing, respiratory
hygiene, and personal cleanliness.
●Identifying Cases: Encouraging teachers to recognize and report signs of
streptococcal infections among students.
●Timely Referral: Facilitating access to healthcare for affected students and
their families.
●Global Efforts and Collaborations
●Research and Funding: Supporting research on streptococcal infections,
rheumatic fever, and potential vaccines.
●Capacity Building: Collaborating with international organizations to strengthen
healthcare systems and training programs in regions with higher prevalence.
Prevention

90. Advocacy and Policy
●Policy Implementation: Encouraging governments to
implement policies that prioritize healthcare
infrastructure, disease awareness and preventive
measures.
●Raising Awareness: Advocating for rheumatic fever
prevention as a public health priority, highlighting its
impact on communities and future generations.
Prevention

91. ●Current research on understanding the
pathogenesis
●Advances in diagnostic techniques
●Novel treatment approaches
Research and Advancements

92. ●Current Research on Understanding the Pathogenesis
●Immunological Mechanisms: Investigating the intricate immune response and molecular mimicry
underlying rheumatic fever to identify potential therapeutic targets.
●Genetic Susceptibility: Exploring genetic factors that influence an individual's susceptibility to
developing rheumatic fever after streptococcal infections.
●Bacterial Factors: Studying specific strains of Streptococcus pyogenes that are more likely to trigger rheumatic fever.
●Microbiome Influence: Exploring the role of the microbiome in modifying the immune response and influencing disease
development.
●Advances in Diagnostic Techniques
●Biomarkers: Identifying specific biomarkers that could aid in diagnosing and predicting the severity of
rheumatic fever.
●Genomic Studies: Using genomics to uncover genetic markers associated with increased
susceptibility to rheumatic fever.
●Imaging Modalities: Developing more advanced imaging techniques to assess heart valve damage
and inflammation with higher precision.
●Point-of-Care Tests: Creating rapid and accurate diagnostic tests that can quickly identify
streptococcal infections and assess risk of rheumatic fever.
Research and Advancements

93. ●Novel Treatment Approaches
●Immunomodulatory Therapies: Developing therapies that modulate the immune response
to prevent autoimmune reactions without compromising overall immunity.
●Targeted Biologics: Investigating the potential of biologic drugs that specifically target
components of the immune system responsible for tissue damage.
●Anti-inflammatory Agents: Exploring new anti-inflammatory medications with improved
efficacy and fewer side effects.
●Personalized Medicine: Tailoring treatment approaches based on individual genetic,
immunological, and clinical factors for optimal outcomes.
●Vaccine Development
●Streptococcal Vaccines: Researching and developing vaccines against Streptococcus
pyogenes to prevent streptococcal infections and subsequent rheumatic fever episodes.
●Challenges: Overcoming challenges related to bacterial diversity, antigen variability, and
the need for long-lasting immunity.
Research and Advancements

94. ●Collaborative Initiatives
●International Research Networks: Collaborating across borders to pool
resources, expertise, and data to accelerate advancements in rheumatic fever
research.
●Public-Private Partnerships: Encouraging partnerships between academia,
pharmaceutical companies, and governmental agencies to support research
funding and drug development.
●Patient Involvement and Advocacy
●Patient-Centric Research: Involving patients and their families in research
design, prioritization, and decision-making.
●Advocacy Groups: Supporting organizations that raise awareness, promote
research, and advocate for improved care for individuals with rheumatic fever.
Research and Advancements

95. ●Clinical Trials
●Evaluating New Therapies: Participating in well-designed clinical trials
to assess the safety and efficacy of novel treatment approaches.
●Contributing to Knowledge: Clinical trial data contribute to a better
understanding of the disease and help refine treatment strategies.
●Future Outlook
●Advances in research and technology hold the promise of improving
diagnosis, treatment, and prevention of rheumatic fever, moving us
closer to reducing its global burden.
Research and Advancements

96. ●Real-life cases highlighting
different aspects of rheumatic
fever
●Clinical challenges and lessons
learned
Case Studies

97. ●Case 1: Carditis and Valvular Damage
●Presentation: A 12-year-old patient with a history of strep throat presents with chest pain, fever, and
shortness of breath.
●Diagnosis: Fulfilling major Jones criteria with carditis and minor criteria with fever and elevated
inflammatory markers.
●Challenge: Determining the optimal management strategy for heart inflammation and preventing
further valve damage.
●Lesson: Early detection, prompt antibiotic treatment, and close cardiac monitoring can prevent severe
valvular complications.
●Case 2: Atypical Presentation
●Presentation: A 25-year-old individual presents with unexplained joint pain, skin rash, and chorea.
●Diagnosis: Fulfilling major Jones criteria with chorea and minor criteria with joint pain and skin rash.
●Challenge: Recognizing and diagnosing rheumatic fever in an atypical presentation, as chorea is a less
common manifestation.
●Lesson: Rheumatic fever can manifest with a wide range of symptoms, emphasizing the importance of
thorough evaluation and considering less common presentations.
Case Studies

98. Case 3: Long-Term Management
●Presentation: A 30-year-old patient with a history of rheumatic fever presents with recurrent joint pain
and valvular dysfunction.
●Diagnosis: Fulfilling minor Jones criteria with joint pain and previous history of rheumatic fever.
●Challenge: Managing chronic rheumatic heart disease and preventing further complications.
●Lesson: Long-term follow-up and secondary prophylaxis are essential to monitor disease progression
and prevent recurrent episodes.
●Case 4: Streptococcal Outbreak in a Community
●Presentation: A community reports an unusual increase in streptococcal infections and cases of
rheumatic fever among children.
●Response: Public health officials initiate a rapid response, providing antibiotics, educating the
community, and promoting hygiene.
●Challenge: Controlling the outbreak, ensuring access to treatment, and preventing its recurrence.
●Lesson: Strengthening public health measures and community engagement are crucial in controlling
outbreaks and reducing disease burden.
Case Studies

99. ●Case 5: Genetic Predisposition
●Presentation: A 16-year-old patient with a family history of rheumatic fever develops carditis after a
strep throat infection.
●Diagnosis: Fulfilling major Jones criteria with carditis and minor criteria with elevated inflammatory
markers.
●Challenge: Addressing the genetic predisposition and managing the increased risk of severe disease.
●Lesson: Genetic factors play a role in disease susceptibility, emphasizing the importance of tailored
treatment and preventive strategies.
●Case 6: Challenges in Resource-Limited Settings
●Presentation: A 9-year-old child from a rural area presents with joint pain and fever, followed by a skin
rash.
●Diagnosis: Fulfilling major Jones criteria with skin rash and minor criteria with joint pain and fever.
●Challenge: Limited access to healthcare, delayed diagnosis, and lack of awareness about rheumatic
fever.
●Lesson: Addressing healthcare disparities and improving awareness are critical in preventing
complications, especially in resource-limited settings.
Case Studies

100. Lessons Learned
●Clinical Variability: Rheumatic fever can present with diverse symptoms,
requiring clinicians to maintain a high index of suspicion.
●Early Intervention: Prompt diagnosis and appropriate treatment are crucial
to prevent complications and long-term sequelae.
●Holistic Approach: Collaboration among different medical specialties,
public health authorities, and communities is essential for comprehensive
care and prevention.
●Patient Education: Educating patients, families, and communities about
streptococcal infections, rheumatic fever, and preventive measures can
have a significant impact on disease outcomes.
Case Studies

101. ●Promising areas of research
●Potential vaccines for streptococcal
infections
●Collaborative efforts to eradicate
rheumatic fever
Future Directions

102. ●Promising Areas of Research
●Immunogenetics: Understanding the interplay between genetics and immune response in rheumatic
fever susceptibility and severity.
●Immunomodulation: Developing targeted therapies to regulate immune responses and prevent
autoimmune reactions.
●Microbiome Studies: Exploring the role of the microbiome in modifying disease progression and
immune interactions.
●Biomarker Discovery: Identifying specific biomarkers for early diagnosis, disease monitoring, and
treatment response assessment.
●Potential Vaccines for Streptococcal Infections
●Streptococcal Vaccines: Researching and developing vaccines to prevent streptococcal infections,
reducing the incidence of rheumatic fever.
●Challenges: Addressing bacterial diversity, antigen variability, and ensuring long-lasting immunity.
●Impact: Successful vaccines could significantly reduce the global burden of rheumatic fever and its
complications.
Future Directions

103. ●Collaborative Efforts to Eradicate Rheumatic Fever
●Global Initiatives: Collaborating across nations to pool resources, expertise, and knowledge to
combat rheumatic fever.
●International Research Networks: Sharing data, best practices, and research findings to accelerate
advancements.
●Community Engagement: Involving communities in awareness campaigns, preventive measures, and
advocacy.
●Multidisciplinary Teams: Bringing together clinicians, researchers, policymakers, and patients to
develop comprehensive strategies.
●Advancements in Technology
●Diagnostic Tools: Continued development of rapid, accurate, and accessible diagnostic tests for
streptococcal infections and rheumatic fever.
●Telemedicine: Utilizing telehealth solutions to improve access to healthcare and follow-up care,
particularly in remote areas.
Future Directions

104. ●Education and Awareness
●Health Literacy: Promoting health education to empower individuals
and communities with knowledge about streptococcal infections and
rheumatic fever.
●School Programs: Integrating rheumatic fever awareness and
prevention into school curricula to educate children from a young age.
●Policy Changes
●Governmental Support: Advocating for policies that prioritize
healthcare infrastructure, research funding, and disease prevention.
●Public Health Campaigns: Launching national and international
campaigns to raise awareness about the importance of preventing
streptococcal infections and rheumatic fever.
Future Directions

105. ●Patient-Centered Care
●Patient Involvement: Incorporating patients' perspectives and
experiences in research, treatment planning, and policy-making.
●Supportive Networks: Establishing patient support groups and
resources to empower individuals living with rheumatic fever.
●Closing Remarks
●Collaborative efforts, innovative research, and a holistic approach are
key to eradicating rheumatic fever and its devastating impact on
individuals and communities.
●Together, we can strive for a future where rheumatic fever is no longer
a public health concern.
Future Directions

106. ●Recap of key points
●Emphasis on the importance of
awareness, diagnosis, and
treatment
Conclusion

107. Recap of Key Points
●Rheumatic fever is an autoimmune inflammatory disease triggered by
streptococcal infections, particularly group A streptococcus.
●It can affect the heart, joints, skin, brain, and other organs, leading to
complications such as chronic rheumatic heart disease.
●Diagnosis relies on the Jones criteria, which consider clinical and
laboratory findings, especially cardiac involvement.
●Prompt and appropriate treatment of streptococcal infections is vital to
prevent the development of rheumatic fever.
●Multidisciplinary care, patient education, and public health measures are
essential to control the disease's prevalence and impact.
Conclusion

108. ●Emphasis on the Importance of Awareness, Diagnosis, and Treatment
●Awareness: Educating individuals, families, communities, and healthcare providers about
streptococcal infections, rheumatic fever, and preventive strategies.
●Diagnosis: Recognizing the diverse clinical manifestations and understanding the
diagnostic criteria to ensure early and accurate identification.
●Treatment: Promoting prompt antibiotic therapy, anti-inflammatory treatment, and long-
term management to prevent complications and improve outcomes.
●Parting Message
●By working together, fostering research advancements, implementing effective public
health measures, and prioritizing patient-centered care, we can make substantial
progress in eradicating rheumatic fever and minimizing its impact on global health.
Knowledge, awareness, and collaborative efforts are our tools for a brighter, healthier
future.
Conclusion

109. 1.World Health Organization. (2018). Rheumatic fever and rheumatic heart disease. Retrieved from https://www.who.int/news-room/fact-
sheets/detail/rheumatic-fever-and-rheumatic-heart-disease
2.Carapetis, J. R., Beaton, A., Cunningham, M. W., & Guilherme, L. (2016). Acute rheumatic fever and rheumatic heart disease. Nature
Reviews Disease Primers, 2, 15084.
3.Gewitz, M. H., Baltimore, R. S., Tani, L. Y., Sable, C. A., Shulman, S. T., Carapetis, J., ... & Hoke, T. R. (2015). Revision of the Jones criteria
for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart
Association. Circulation, 131(20), 1806-1818.
4.Kumar, R. K., Tandon, R., & Iyengar, S. D. (2018). Rheumatic heart disease: current status of diagnosis and therapy. Nature Reviews
Cardiology, 15(3), 137-149.
5.Marijon, E., Mirabel, M., Celermajer, D. S., Jouven, X., & Rheumatic Heart Disease. (2018). Rheumatic heart disease. The Lancet,
392(10146), 1019-1032.
6.Oliver, J. M., Kronzon, I., & Tunick, P. A. (2019). Prophylaxis against infective endocarditis. Progress in Cardiovascular Diseases, 62(4),
291-295.
7.Engel, M. E., Stander, R., Vogel, J., Adeyemo, A. A., Mayosi, B. M., & Genetic Contributors to Rheumatic Heart Disease Consortium. (2017).
Genetic susceptibility to acute rheumatic fever: a systematic review and meta-analysis of twin studies. PLoS One, 12(3), e0173098.
8.Watkins, D. A., Johnson, C. O., Colquhoun, S. M., Karthikeyan, G., Beaton, A., Bukhman, G., ... & Zuhlke, L. J. (2017). Global, regional, and
national burden of rheumatic heart disease, 1990–2015. New England Journal of Medicine, 377(8), 713-722.
9.Parks, T., & Smeesters, P. R. (2019). Streptococcal skin infection and rheumatic heart disease. Current Opinion in Infectious Diseases,
32(2), 122-128.
10.World Heart Federation. (2021). Rheumatic heart disease. Retrieved from https://www.world-heart-federation.org/what-we-
do/awareness/rheumatic-heart-disease/
11.Beaudoin, A., & Edison, L. (2017). Rheumatic fever in children and adolescents. Journal of Pediatric Health Care, 31(5), 648-657.
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References

110. MCQ – Rheumatic fever
1.10-year-old child presents with joint pain and swelling in multiple joints,
fever, and a history of recent strep throat infection. On examination, you
notice red, swollen joints. Which criterion of the Jones criteria does this case
fulfill?
A) Major criterion: Carditis
B) Major criterion: Polyarthritis
C) Minor criterion: Elevated inflammatory markers
D) Minor criterion: Skin rash
E) Minor criterion: Chorea
Answer: B) Major criterion: Polyarthritis

111. 2. A 15-year-old patient presents with involuntary,
purposeless movements of the limbs and face,
emotional disturbances, and difficulty concentrating.
Which manifestation is most likely present in this case?
A) Carditis
B) Polyarthritis
C) Erythema marginatum
D) Chorea
E) Subcutaneous nodules
Answer: D) Chorea

112. 3.A 20-year-old patient with a history of rheumatic fever
develops shortness of breath, chest pain, and an abnormal heart
rhythm. Which complication is most likely occurring?
A) Joint pain
B) Skin rash
C) Carditis
D) Erythema marginatum
E) Subcutaneous nodules
Answer: C) Carditis

113. 4.A 12-year-old child is diagnosed with rheumatic fever
based on the Jones criteria. Which combination of
criteria is necessary for the diagnosis?
A) Two major criteria
B) One major and one minor criterion
C) Two minor criteria
D) Three minor criteria
E) One major criterion
Answer: A) Two major criteria

114. 5.A 30-year-old patient with a history of rheumatic fever presents with chest
pain, shortness of breath, and heart palpitations. Echocardiography reveals
scarring and deformities of the heart valves. What complication is likely
present in this case?
A) Polyarthritis
B) Chorea
C) Carditis
D) Subcutaneous nodules
E) Chronic rheumatic heart disease
Answer: E) Chronic rheumatic heart disease

115. 6.A 8-year-old child is diagnosed with strep throat and receives appropriate
antibiotic treatment. What is the primary goal of treating streptococcal
infections promptly in this case?
A) Preventing joint pain
B) Treating skin rash
C) Preventing rheumatic fever
D) Preventing subcutaneous nodules
E) Preventing chorea
Answer: C) Preventing rheumatic fever

116. 7.A 25-year-old patient presents with joint pain, fever, and skin
rash. Laboratory tests show elevated inflammatory markers.
Which criterion of the Jones criteria does this case fulfill?
A) Major criterion: Carditis
B) Minor criterion: Joint pain
C) Minor criterion: Skin rash
D) Minor criterion: Elevated inflammatory markers
E) Major criterion: Chorea
Answer: D) Minor criterion: Elevated inflammatory markers

117. 8.A community reports an increase in streptococcal infections
and cases of rheumatic fever among children. What public health
measure is crucial to control the outbreak and prevent its
recurrence?
A) Treating individual cases with antibiotics
B) Implementing quarantine measures
C) Promoting hand hygiene only
D) Educating communities and providing antibiotics
E) Isolating affected individuals
Answer: D) Educating communities and providing antibiotics

118. 9.A 16-year-old patient with a family history of rheumatic fever
develops fever and joint pain after a strep throat infection. What
additional consideration is important for managing this case?
A) Cardiac involvement
B) Skin rash assessment
C) Chorea evaluation
D) Genetic predisposition
E) Subcutaneous nodules
Answer: D) Genetic predisposition

119. 10.A 40-year-old patient with a history of rheumatic fever presents with chest
pain, breathlessness, and an abnormal heart murmur. What diagnostic test is
essential to assess the extent of valvular damage?
A) Blood culture
B) X-ray of the chest
C) Electrocardiogram (ECG)
D) Echocardiogram
E) Magnetic resonance imaging (MRI)
Answer: D) Echocardiogram

120. 11.A 12-year-old child presents with fever, sore throat, and joint pain. Physical
examination reveals a new-onset heart murmur. Which major and minor
criteria for the diagnosis of rheumatic fever are likely met in this case?
A) Major: Polyarthritis, Minor: Elevated ESR
B) Major: Chorea, Minor: Elevated CRP
C) Major: Carditis, Minor: Arthralgia
D) Major: Subcutaneous nodules, Minor: Fever
E) Major: Erythema marginatum, Minor: Anemia
Answer: C) Major: Carditis, Minor: Arthralgia

121. 12.A 25-year-old patient presents with shortness of breath, fatigue, and chest
pain. On auscultation, a mid-diastolic rumbling murmur is heard at the apex.
Echocardiography shows mitral valve stenosis. What is the likely underlying
cause of these findings?
A) Atherosclerosis
B) Rheumatic fever
C) Hypertension
D) Myocardial infarction
E) Congenital heart defect
Answer: B) Rheumatic fever

122. 13. A 40-year-old patient with a history of rheumatic fever presents with
palpitations and irregular heartbeat. ECG reveals atrial fibrillation. Which heart
chamber is most commonly associated with atrial fibrillation in the context of
rheumatic heart disease?
A) Left ventricle
B) Right atrium
C) Right ventricle
D) Left atrium
E) Ventricular septum
Answer: D) Left atrium

123. A 16-year-old patient presents with fever, joint pain, and evidence of recent
streptococcal infection. The patient's joint pain is mild, and there is no
evidence of carditis. Which condition should be considered in the differential
diagnosis?
A) Juvenile idiopathic arthritis
B) Kawasaki disease
C) Infective endocarditis
D) Tuberculosis
E) Systemic lupus erythematosus (SLE)
Answer: A) Juvenile idiopathic arthritis
Explanation: Juvenile idiopathic arthritis (JIA) can present with joint pain and inflammation. The differential diagnosis should
consider the history of recent streptococcal infection and the presence of other diagnostic criteria to differentiate rheumatic fever
from JIA.

124. A 13-year-old patient presents with fever, joint pain, and a skin rash following a
streptococcal throat infection. The patient has a history of allergies and is currently
experiencing shortness of breath. Which condition should be included in the
differential diagnosis?
A) Kawasaki disease
B) Type 1 diabetes mellitus
C) Tuberculosis
D) Asthma exacerbation
E) Systemic lupus erythematosus (SLE)
Answer: D) Asthma exacerbation
Explanation: Asthma exacerbation can cause shortness of breath and may be associated with allergies. However, the combination of fever,
joint pain, skin rash, and a history of streptococcal infection should raise suspicion for rheumatic fever.

125. A 15-year-old patient presents with fever, joint pain, and a new heart murmur.
On examination, the patient has erythema marginatum and subcutaneous
nodules. Which condition should be considered in the differential diagnosis?
A) Lyme disease
B) Kawasaki disease
C) Infective endocarditis
D) Systemic lupus erythematosus (SLE)
E) Rheumatoid arthritis
Answer: E) Rheumatoid arthritis
Explanation: Rheumatoid arthritis can present with joint pain, and in some cases, subcutaneous nodules. However, the presence of
erythema marginatum and a new heart murmur with elevated ASO titers points towards rheumatic fever.

126. A 12-year-old patient presents with fever, joint pain, and evidence of recent
streptococcal infection. The patient has a new heart murmur and elevated
anti-streptolysin O (ASO) titers. Which condition should be considered in the
differential diagnosis?
A) Kawasaki disease
B) Infective endocarditis
C) Tuberculosis
D) Juvenile idiopathic arthritis
E) Asthma
Answer: B) Infective endocarditis
Explanation: Infective endocarditis can present with similar symptoms, including fever, new heart murmur, and elevated inflammatory
markers. However, in rheumatic fever, the presence of recent streptococcal infection and elevated ASO titers is a key differentiating
factor.

127. A 14-year-old patient presents with fever, joint pain, and a skin rash following a recent
streptococcal throat infection. On examination, the patient has polyarthritis, elevated
erythrocyte sedimentation rate (ESR), and elevated C-reactive protein (CRP) levels.
Which condition should be included in the differential diagnosis?
A) Systemic lupus erythematosus (SLE)
B) Type 1 diabetes mellitus
C) Tuberculosis
D) Leukemia
E) Crohn's disease
Answer: A) Systemic lupus erythematosus (SLE)
Explanation: Systemic lupus erythematosus (SLE) can present with similar clinical manifestations, such as fever, joint pain, and
elevated inflammatory markers. Both conditions may show polyarthritis. The differential diagnosis should consider distinguishing
features between the two conditions.

128. A 13-year-old patient presents with fever, joint pain, and evidence of recent streptococcal
infection. On examination, you observe transient, pink, non-pruritic, macular rashes over the trunk
and limbs. What term best describes these skin findings, and what condition are they associated
with?
A) Petechiae; Leukemia
B) Erythema marginatum; Rheumatic fever
C) Chorea; Streptococcal infection
D) Rheumatoid nodules; Juvenile idiopathic arthritis
E) Tics; Neurological disorder
Answer: B) Erythema marginatum; Rheumatic fever
Explanation: The described transient, pink, non-pruritic, macular rashes over the trunk and limbs are characteristic
of erythema marginatum, an extracardiac manifestation of rheumatic fever.

129. A 16-year-old patient with a history of untreated streptococcal infection presents with
fever, joint pain, and carditis. On cardiac examination, you hear a diastolic murmur
heard best at the left lower sternal border. What valvular lesion is likely responsible for
this murmur, and what is its significance?
A)Aortic stenosis; Benign finding
B) Mitral regurgitation; Indicative of myocardial infarction
C)Tricuspid regurgitation; Associated with pulmonary hypertension
D) Aortic regurgitation; Indicates valvular damage
E) Pulmonary stenosis; Suggests congenital heart defect
Answer: D) Aortic regurgitation; Indicates valvular damage
Explanation: The diastolic murmur heard best at the left lower sternal border is characteristic of aortic regurgitation. It indicates
valvular damage, likely caused by the inflammatory processes associated with rheumatic fever.

130. A 15-year-old patient presents with fever, joint pain, and a skin rash following
an episode of Streptococcus pyogenes throat infection. On examination, you
note subcutaneous swellings over the extensor surfaces of the elbows and
knees. What term describes these findings?
A) Erythema marginatum
B) Chorea
C) Rheumatoid nodules
D) Petechiae
E) Macular rash
Answer: C) Rheumatoid nodules
Explanation: The subcutaneous swellings over the extensor surfaces of the elbows and knees are
characteristic of rheumatoid nodules, which are a less common extracardiac manifestation of
rheumatic fever.

131. A 12-year-old patient presents with fever, joint pain, and a new heart murmur. On
physical examination, you notice irregular, jerky, purposeless movements of the
patient's hands and face. What term best describes these movements, and what
condition are they indicative of?
A) Tremors; Hypertension
B) Myoclonus; Valvular stenosis
C) Tics; Rheumatic fever
D) Chorea; Rheumatic fever
E) Rigidity; Myocardial infarction
Answer: D) Chorea; Rheumatic fever
Explanation: The described irregular, jerky, purposeless movements of the hands and
face are characteristic of chorea, which is an extrapyramidal manifestation often seen in
rheumatic fever. Chorea is caused by inflammation of the basal ganglia.

132. A 15-year-old patient is diagnosed with rheumatic fever and is receiving
treatment for carditis. What lifestyle modification is advisable to prevent
further complications and progression of the condition?
A) Reducing physical activity to minimize strain on the heart
B) Maintaining a high-sodium diet to manage fluid balance
C) Ensuring adequate rest and sleep
D) Avoiding all forms of physical activity
E) Increasing caffeine consumption for better cardiac function
Answer: C) Ensuring adequate rest and sleep
Explanation: Ensuring adequate rest and sleep is advisable for patients with rheumatic fever,
especially those with carditis. Rest helps the heart recover and reduces the strain on the
cardiovascular system. It is important to balance physical activity with rest to promote healing and
prevent complications.

133. A 13-year-old patient with a history of rheumatic fever is
scheduled for a dental procedure. What preventive measure is
recommended to reduce the risk of recurrent episodes?
A)Administering angiotensin-converting enzyme (ACE) inhibitors
B) Providing intravenous antibiotics
C) Initiating corticosteroid therapy
D) Regularly monitoring blood pressure
E) Administering antipyretic medications
Answer: B) Providing intravenous antibiotics Explanation: Patients with a history of rheumatic fever are at risk of
recurrent episodes triggered by Streptococcus pyogenes infections. Before certain medical or dental procedures,
prophylactic intravenous antibiotics are often recommended to prevent the introduction of bacteria and reduce
the risk of recurrence.

134. A 14-year-old patient is diagnosed with rheumatic fever and receives
antibiotic treatment. The patient's siblings also had streptococcal throat
infections recently. What preventive measure should be taken for the patient's
siblings?
A)Administering antipyretic medications
B) Initiating corticosteroid therapy
C) Providing angiotensin-converting enzyme (ACE) inhibitors
D) Completing the full course of antibiotic treatment
E) Administering intravenous antibiotics
Answer: D) Completing the full course of antibiotic treatment
Explanation: If siblings of a patient with rheumatic fever have had recent streptococcal throat infections, they
should also receive the full course of antibiotic treatment. This helps prevent the development of rheumatic fever
and its complications.

135. A 12-year-old patient is diagnosed with rheumatic fever and is undergoing
treatment. What additional measure can help prevent the recurrence of
rheumatic fever?
A) Bed rest for an extended period
B) Long-term corticosteroid therapy
C) Continuous use of nonsteroidal anti-inflammatory drugs (NSAIDs)
D) Regular echocardiographic monitoring
E) Secondary antibiotic prophylaxis
Answer: E) Secondary antibiotic prophylaxis
Explanation: Secondary antibiotic prophylaxis (long-term antibiotic therapy) is recommended for patients with a history of rheumatic
fever to prevent recurrence after the initial episode. This is especially important for preventing subsequent Streptococcus pyogenes
infections that could trigger more episodes.

136. A 10-year-old patient is diagnosed with streptococcal throat infection and
receives appropriate antibiotic treatment. What is the primary preventive
measure for reducing the risk of rheumatic fever in this case?
A)Initiating corticosteroid therapy
B) Administration of angiotensin-converting enzyme (ACE) inhibitors
C) Administering antipyretic medications
D) Ensuring proper hand hygiene
E) Completing the full course of antibiotic treatment
Answer: E) Completing the full course of antibiotic treatment
Explanation: The primary preventive measure after a streptococcal throat infection is completing the full course of
antibiotic treatment to eradicate the bacteria. Properly treated streptococcal infections significantly reduce the
risk of developing rheumatic fever.

137. A 16-year-old patient presents with fever, joint pain, and evidence of recent
streptococcal infection. Carditis is suspected, but the patient's condition is stable.
Which medication is commonly used to manage inflammation and prevent further
cardiac damage in this case?
A) Intravenous antibiotics
B) Immunosuppressive therapy
C) Corticosteroids
D) Nonsteroidal anti-inflammatory drugs (NSAIDs)
E) Angiotensin-converting enzyme (ACE) inhibitors
Answer: D) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Explanation: In cases of stable carditis in rheumatic fever, treatment with NSAIDs is often used to manage inflammation and prevent
further cardiac damage. Corticosteroids and immunosuppressive therapy are reserved for more severe cases.

138. A) Intravenous antibiotics
B) Bed rest for several weeks
C) Immunosuppressive therapy
D) Corticosteroids
E) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer: E) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Explanation: For managing mild joint pain in cases of rheumatic fever, treatment with NSAIDs is the recommended approach.
NSAIDs help alleviate inflammation and reduce pain without the need for corticosteroids or other aggressive interventions.

139. A) Eradicate Streptococcus pyogenes infection
B) Alleviate joint pain
C) Reduce inflammation
D) Prevent recurrence of skin rash
E) Treat valvular stenosis
Answer: A) Eradicate Streptococcus pyogenes infection
Explanation: The primary goal of antibiotic therapy in the treatment of rheumatic fever is to eradicate the
Streptococcus pyogenes infection that triggered the autoimmune response. This helps prevent further
complications and recurrences.

140. A) Surgical intervention
B) Immunosuppressive therapy
C) Corticosteroids
D) Intravenous antibiotics
E) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer: E) Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: For the management of neurological
manifestations such as chorea in rheumatic fever, treatment with NSAIDs is typically recommended. Immunosuppressive therapy
and corticosteroids are not the primary treatment approaches for chorea.

141. A) Long-term antibiotic therapy
B) Complete bed rest for several months
C) Immunosuppressive therapy
D) Corticosteroids
E) Surgical valve repair
Answer: D) Corticosteroids
Explanation: Corticosteroids are used in cases of severe carditis in rheumatic fever to suppress inflammation and
prevent further damage to the heart. However, their use is carefully considered due to potential side effects.

142. A 14-year-old patient is diagnosed with rheumatic fever and has
moderate to severe carditis with valvular regurgitation. What is
the recommended treatment for managing the valvular damage
in this case?
A) Surgical valve replacement
B) Intravenous antibiotics
C) Nonsteroidal anti-inflammatory drugs (NSAIDs)
D) Corticosteroids
E) Angiotensin-converting enzyme (ACE) inhibitors
Answer: A) Surgical valve replacement
Explanation: In cases of significant valvular damage due to rheumatic fever, such as valvular regurgitation,
surgical valve replacement may be necessary to restore proper heart function and prevent long-term
complications.

143. A 12-year-old patient is diagnosed with acute rheumatic fever
with mild carditis. Which treatment approach is most appropriate
for managing the cardiac involvement in this case?
A) Surgical valve replacement
B) Intravenous antibiotics
C) Nonsteroidal anti-inflammatory drugs (NSAIDs)
D) Corticosteroids
E) Angiotensin-converting enzyme (ACE) inhibitors
Answer: C) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Explanation: In cases of mild carditis in rheumatic fever, treatment with NSAIDs is the primary approach. NSAIDs
help reduce inflammation and alleviate symptoms, including carditis, without the need for corticosteroids or
surgical interventions.

144. A 12-year-old child presents with fever, joint pain, and a skin rash following a
recent episode of Streptococcus pyogenes throat infection. The patient meets
the Jones criteria for the diagnosis of rheumatic fever. What is the
significance of the Jones criteria in this context?
A) They determine the genetic predisposition to rheumatic fever
B) They predict the risk of cardiac complications
C) They assess the severity of joint pain
D) They establish the optimal antibiotic treatment
E) They aid in the clinical diagnosis of rheumatic fever
Answer: E) They aid in the clinical diagnosis of rheumatic fever
Explanation: The Jones criteria are clinical criteria used to aid in the diagnosis of rheumatic fever. Meeting
specific combinations of major and minor criteria helps establish the diagnosis and differentiate rheumatic fever
from other conditions with similar clinical manifestations.

145. A 14-year-old patient presents with fever, joint pain, and a new heart murmur.
Laboratory tests show elevated levels of C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR). What is the significance of CRP and ESR
in the diagnosis of rheumatic fever?
A) They directly neutralize streptococcal toxins
B) They differentiate between bacterial and viral infections
C) They measure the severity of joint pain
D) They indicate the presence of immune complexes
E) They are markers of inflammation
Answer: E) They are markers of inflammation
Explanation: Both CRP and ESR are markers of inflammation in the body. In rheumatic fever, the immune
response and inflammatory processes contribute to the clinical manifestations. Elevated CRP and ESR levels are
supportive of the diagnosis by indicating the presence of ongoing inflammation.

146. A 13-year-old patient presents with fever, joint pain, and a skin
rash following an episode of untreated streptococcal throat
infection. Which laboratory test can help confirm the diagnosis of
rheumatic fever in this case?
A) White blood cell count
B) Blood glucose levels
C) Serum cholesterol levels
D) Anti-streptolysin O (ASO) titer
E) Serum vitamin D levels
Answer: D) Anti-streptolysin O (ASO) titer
Explanation: Elevated ASO titers are a marker of recent streptococcal infection. In the context of clinical manifestations suggestive
of rheumatic fever, elevated ASO titers can support the diagnosis, as streptococcal infections are a major trigger for the condition.

147. A 10-year-old patient presents with fever, joint pain, and evidence of recent
Streptococcus pyogenes throat infection. The patient has elevated anti-
streptolysin O (ASO) titers and elevated C-reactive protein (CRP) levels. What is
the most appropriate diagnostic tool to confirm the diagnosis of rheumatic
fever in this case?
A) Echocardiography
B) Skin biopsy
C) Chest X-ray
D) Electrocardiogram (ECG)
E) Blood culture
Answer: A) Echocardiography
Explanation: Echocardiography is an important diagnostic tool for assessing valvular damage and carditis in rheumatic fever. It can
reveal structural changes in the heart valves, such as regurgitation or stenosis, which are common consequences of rheumatic fever.

148. A 15-year-old patient presents with fever, joint pain, and a skin rash characterized by
pink, non-pruritic rings with central clearing. Physical examination reveals
inflammation of multiple joints. Which clinical feature is not typically associated with
this condition?
A) Subcutaneous nodules
B) Carditis
C) Chorea
D) Valvular damage
E) Splenomegaly
Answer: E) Splenomegaly
Explanation: Splenomegaly is not a common clinical feature of rheumatic fever. The other manifestations
mentioned can be associated with rheumatic fever, particularly carditis, chorea, valvular damage, and
subcutaneous nodules.

149. A 12-year-old child presents with fever, joint pain, and a new heart murmur.
Laboratory tests show elevated levels of anti-streptolysin O (ASO) titer.
Physical examination reveals inflammation of a single joint. What additional
clinical manifestation is likely to be present in this case?
A) Erythema marginatum
B) Subcutaneous nodules
C) Chorea
D) Polyarthritis
E) Skin rash with central clearing
Answer: A) Erythema marginatum
Explanation: In this case, with the presence of carditis (new heart murmur), elevated ASO titer, and inflammation of a single joint, the
clinical manifestation of erythema marginatum is likely to be present.

150. A 14-year-old patient presents with fever, joint pain, and a skin
rash following a recent episode of Streptococcus pyogenes
throat infection. Which clinical feature is most likely associated
with this skin rash?
A) Carditis
B) Chorea
C) Valvular damage
D) Erythema marginatum
E) Subcutaneous nodules
Answer: D) Erythema marginatum
Explanation: The skin rash described (pink, non-pruritic rings with central clearing) is characteristic of erythema
marginatum, which is a clinical feature of rheumatic fever. It typically appears on the trunk and limbs.

151. A 13-year-old patient presents with fever, joint pain, and a new heart murmur.
Physical examination reveals inflammation of a single joint. Which set of
clinical manifestations is likely present in this case?
A) Erythema marginatum, chorea
B) Carditis, subcutaneous nodules
C) Polyarthritis, elevated CRP
D) Valvular damage, skin rash
E) Arthralgia, anemia
Answer: B) Carditis, subcutaneous nodules
Explanation: In this case, the patient presents with carditis (new heart murmur) and subcutaneous
nodules. These manifestations fulfill the diagnostic criteria for rheumatic fever.

152. A 10-year-old patient presents with fever, joint pain, and a skin rash
characterized by pink, non-pruritic rings with central clearing. Physical
examination reveals inflammation of multiple joints. Which set of clinical
manifestations is likely present in this case?
A) Carditis, valvular damage
B) Erythema marginatum, subcutaneous nodules
C) Chorea, elevated ESR
D) Polyarthritis, chorea
E) Subcutaneous nodules, heart murmur
Answer: D) Polyarthritis, chorea
Explanation: In this case, the patient presents with polyarthritis (inflammation of multiple joints) and chorea
(involuntary muscle movements). These manifestations fulfill the diagnostic criteria for rheumatic fever.

153. A heart valve excised from a patient with rheumatic fever shows thickening and
deformity of the valve leaflets. On microscopic examination, there is evidence of
chronic inflammation, fibrosis, and neovascularization. What term best describes this
valvular pathology?
A) Valvular endocarditis
B) Vegetations formation
C) Aortic stenosis
D) Rheumatic heart disease
E) Myocardial infarction
Answer: D) Rheumatic heart disease
Explanation: The described valvular pathology of thickening, deformity, chronic inflammation, fibrosis, and
neovascularization is characteristic of rheumatic heart disease. Chronic inflammation and immune responses
triggered by streptococcal infections lead to progressive damage and changes in the heart valves.

154. An autopsy of a patient who succumbed to complications of rheumatic fever
shows the presence of subcutaneous nodules on the skin. Histopathological
examination of these nodules reveals central fibrinoid necrosis surrounded by
histiocytes and lymphocytes. What term describes these nodules?
A) Myxomatous degeneration
B) Atheromatous plaque
C) Aschoff bodies
D) Macrophage granulomas
E) Rheumatoid nodules
Answer: E) Rheumatoid nodules
Explanation: The described subcutaneous nodules with central fibrinoid necrosis and surrounding histiocytes and
lymphocytes are characteristic of rheumatoid nodules. These nodules are an extracardiac manifestation of
rheumatic fever and are often found in the subcutaneous tissue.

155. A patient with a history of untreated streptococcal throat infection presents
with symptoms of rheumatic fever. Echocardiography reveals irregular
thickening of the mitral valve leaflets and fusion of commissures. Which term
best describes this pathological change?
A) Atheromatous plaque formation
B) Valvular calcification
C) Myocardial hypertrophy
D) Vegetations on valve leaflets
E) Macrophage infiltration
Answer: B) Valvular calcification
Explanation: Valvular calcification is not a typical feature of rheumatic fever. The described changes of irregular
thickening and commissural fusion are characteristic of fibrosis and scarring due to the chronic inflammation
associated with rheumatic valvular disease.

156. A cardiac biopsy of a patient with rheumatic fever shows the
presence of Aschoff bodies within the myocardium. What are
Aschoff bodies, and what is their significance in rheumatic fever?
A) Fibrinoid necrosis in the myocardium
B) Accumulation of lipid deposits in myocardial cells
C) Inflammatory nodules containing activated T cells
D) Clusters of bacteria invading cardiac tissue
E) Amyloid deposits in cardiac muscle fibers
Answer: C) Inflammatory nodules containing activated T cells
Explanation: Aschoff bodies are characteristic histopathological findings in rheumatic fever. They are
inflammatory nodules within the myocardium that contain activated T cells, macrophages, and fibrinoid necrosis.
These nodules are indicative of the immune response and inflammation associated with rheumatic fever.

157. 1. How do you diagnose acute rheumatic fever? (DU-16Ja)
2. Write down the diagnostic criteria of acute rheumatic fever. (DU-10Ja, 09Ju)
3. What is modified Jones criteria of rheumatic fever and pathogenesis of rheumatic fever? (DU-
08M)
4. A 13 years old girl presented with history of fever and painful swelling of large joints. What are
the D/Ds? How will you treat if she develops carditis? (DU-07Ja)
5. A 5 years old boy presents with fever & swelling of knee and ankle joint for 3 weeks. Write down
3 important D/D. Discuss the treatment of acute rheumatic fever with carditis.(DU-09Ju)
6. A 15 year old boy presented with oligoarthritis involving large joints for 2 week. He had fever about 3 weeks
back and suffered from sore throat. (DU- 13Ja)
a) What is your provisional diagnosis? Mention the other important physical findings that you will look for in this
case.
b) Name important investigation that can be done to establish the diagnosis.

158. 7. A 13 years old girl presents with migrating polyarthritis for 2 weeks. Her Pulse is 120
beats/min asucultations reveal soft 1st heart sound with pansystolic murmur at apex. (DU-11Ju)
8. A 15 years old boy presents with polyarthritis. (DU-11Ja)
a. What diagnostic criteria would you look for to establish the diagnosis of rheumatic fever?
b. Give an outline of management of rheumatic fever.
9. How will you differertiate rheumatoid arthritis from rheumatic fever? (DU-08Ja)