Rheumatic Fever

Dr. Sadewantoro. Sp.JP

Cardiologist
Medical Faculty, Hang Tuah
University.

Demam Rheuma Akut (DRA)

Suatu keradangan
komplikasi
lambat
tenggorokan
non
streptokokus grup A

difus sebagai
dari
radang
supuratif
o.k.

Penyakit Jantung Reumatik

Suatu penyakit jantung akibat dari
Demam
Rheuma
Akut
yang
meninggalkan gejala sisa berupa
kerusakan katub jantung

Dx berdasarkan Kriteria Jones 2 Mayor / 2 Minor + 1

Mayor

Manifestasi Mayor
Karditis
Poliartritis
Chorea
Eritema
marginatum
Nodul subkutan

Manifestasi Minor
Demam
Rheuma
sebelumnya
Artralgia
Febris
Lab:
LED,
leukositosis
EKG:
interval
PR
memanjang

Gejala sisa pada katub tidak terjadi bila DRA

ditangani awal dengan penatalaksanaan yang
benar.

Kelainan Katub Jantung akibat DRA

sering mengenai:

Katub
Katub
Katub
Katub

Kelainan bisa berupa stenosis atau

regurgitasi (insufisiensi) yang akan
memberi suara bising

Mitral 75-80%
Aorta 30%
Tricuspid 5%
Pulmonal

RHEUMATIC FEVER
Cause Rheumatic Heart Disease
(RHD)
Systemic disease, non supuratif

Febris attack with intermitten

remision, at Beta Haemolitikus group
A,

RHEUMATIC FEVER
Group of disease :Colagen
Hypersensitif

Joint
Heart
Skin
Serebral

Important

RHEUMATIC FEVER
INSIDENS

Asll ages
90 % 5-15 years
Rare < 4 th.
Male female

Low Sosio
Economic
High population
Claimed
Gizi

EPIDEMIOLOGY
Infection of the skin - younger than
6 yr
Streptococcal pharyngitis - between
5 and 15 yr of age
Scarlet fever - common in children
> 3 yr of age

RHEUMATIC FEVER
DEFINITION
Autoimmune disease occurring as
consequence of infection with group
A beta hemolytic streptococcus
Mainly affects children ages 6- 15

ETIOLOGY

Capsule
Cell wall
Protein antigens
Group carbohydrate
Peptidoglycan
Cyto.membrane
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

AETHIOPATHOGENESIS
A. Only infections
GABHS of the
pharynx initiate or
reactivate RF.
B. Rheumatogenic strains of
GABHS M types l, 3, 5, 6,18
& 24 have antigenic domains
similar to antigens in
components of the human
heart
C. Anti-M antibodies against the streptococci
may cross-react with heart tissue, causing
the pancarditis that is observed in RF.

Pathophysiology
Occurs 2- 3 weeks after infection with group A beta
hemotytic strep (strep throat).
The strep organism stimulates an autoimmune
response in which autoantibodies attack:
Myocardium
Pericardium
Mitral valve
Joints
Central nervous system

Histologically
Focal collections of inflammatory
cells (Aschoff bodies) thru'out
heart,esp. LA. These comprise
macrophages, plasma cells & some
lymphocytes.
Valve leaflets are thickened & fused.

Clinical Features:
Acute Rheumatic Fever
Acute Inflammatory Phase
Heart Pancarditis (40-50%)
Skin Erythema Marginatum/
S.nodule (10%)
CNS Sydenham Chorea (15%)
Migratory polyarthritis (75%)

Chronic Rheumatic Fever

Deforming fibrotic valvular disease.

Signs and Symptoms

General symptomsfatigue, malaise, fever,anorexia
Specific symptoms (depends on organ system
affected)
Carditissystolic murmur, abnormal EKG, CHF
Polyarthritisjoint symptoms and subcutaneous
nodules over joints
Choreaabnormal involuntary movements caused
byCNS damage (St. Vitus Dance)
Erythema marginatumpink, macular rash
Subcutan nodule

Symptoms (acute RF)

Heart symptoms (60%):

Sleeping tachycardia
changing murmurs
pericardial rub
heart failure
cardiomegaly
conduction defects (45-70%)
apical systolic murmur
Carey Coomb's murmur (mid-diastolic)
due to thickening of mitral valve leaflets
Esp. causes stenosis in mitral (70%), aortic
(40%), tricuspid (10%) and pulmonary (2%).
Myocarditis
Arrhythmias

Other symptoms:
Migratory (flitting) large joint polyarthritis = red and v.
tender joints (75%)
Subcutaneous nodules (2-20%)
Erythema marginatum = trunk, thighs and arms =
'bathing suit distrib.' (2-10%)
Sydenham's chorea = odd darting movements in

late RF, often preceded by emotional lability &

uncharacteristic behaviour. Commoner in women

and aka St Vitus' dance.

Infeksi akibat
Infeksi Kuman Hemolitikus
hemolitikus Streptokokus
Streptokokus
Grup
A
Group A
Infeksi
Tenggorokan
Periode silent
(2mgg)
Rheumatic
Fever

Carditi
s

Rheumatic
Heart
Disease

Polyarthri
tis

Chorea

Erythema
marginatum

Sub
Kutan
Modul

Electrocardiogram

Persistent sinus tachycardia

Sinus bradycardia
Prolonged PR interval
Transient complete heart block
Atrial fibrillation or flutter
Bundle branch block
Low QRS voltage

Diagnosis

Evidence of recent strep. infection:

Recent scarlet fever
Positive growth from throat swab
Increase in antistreptolysin O titre
(ASOT) >200u/ml.

Diagnosis
Major criteria:

Sydenham's' chorea
Polyarthritis signs
Erythema marginatum
Carditis - (Endo/myo/pericarditis)
Subcutaneous nodules

[SPECS]

Subcutaneous nodules
Rarely seen and when
present
Usually associated with
severe carditis.
Painless, firm, movable,
measuring around 0.5 to
2 cm.
Located over extensor
surfaces of the joints,
particularly knees, wrists
and elbows

Erythema Marginatum

Erythematous
lesions with pale
centers and rounded
or serpiginous

Diagnosis
Minor criteria:
Pyrexia
ECG changes - prolonged PR interval (not if
carditis is a major criterion)
Arthralgia not if arthritis is a major criteria factor)
Raised ESR or CRP
Hx of previous RF or rheumatic heart disease
[PEACH]

The Jones Criteria for Rheumatic

Fever,
1992
MajorUpdated
Criteria

Carditis
Migratory polyarthritis
Sydenham's chore
Subcutaneous nodules
Erythema marginatum

plus

Minor Criteria
Clinical

fever
Arthralgia
Laboratory
Elevated acute phase
reactants
Prolonged PR interval

Supporting evidence of a recent group A streptococcal infection

positive throat culture or

rapid antigen detection test; and/ or elevated or

increasing streptococcal antibody test

(e.g., anti-streptolysin O, anti-deoxyribonuclease B, anti-hyaluronidase).

Management
Bed-rest until normal CRP for 2 weeks (may
take several months)
Benzylpenicillin 600mg IM stat

Then penicillin V 250 mg/6h p.o.

Analgesia for carditis & arthralgia - NSAID
e.g. aspirin 90 mg/kg/day
Immobilise joints in severe arthritis
Haliperidol 0.5mg/8h p.o. for the chorea
(Steroids are not thought to have major
benefit., but may improve symptoms).

Prophylaxis
after RF prophylaxis involves
Penicillin V until aged 25, and then
antibiotics before dental surgery etc.