Rheumatic Fever

Dr. Sadewantoro. Sp.JP

Cardiologist
Medical Faculty, Hang Tuah University.

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 RHEUMATIC FEVER

Cause Rheumatic Heart Disease (RHD)

Systemic disease, non supuratif

Febris attack with intermitten remision, at

Beta Haemolitikus group A,

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 RHEUMATIC FEVER

Group of disease :Colagen Hypersensitif

Joint
Heart Important
Skin
Serebral

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 RHEUMATIC FEVER

 INSIDENS

 Asll ages  Low Sosio Economic

 90 % 5-15 years  High population
 Rare < 4 th.  Claimed
 Male » female  Gizi

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 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

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RHEUMATIC FEVER DEFINITION

Autoimmune disease occurring as

consequence of infection with group A
beta hemolytic streptococcus

Mainly affects children ages 6- 15

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ETIOLOGY

Antigen of outer
protein cell wall of
Capsule GABHS induces
antibody response in
Cell wall
victim which result
Protein antigens in autoimmune
Group carbohydrate damage to heart
Peptidoglycan valves, sub
cutaneous tissue,
Cyto.membrane
tendons, joints &
Cytoplasm basal ganglia of
brain
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 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. 8
 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

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 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.

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 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.

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 Signs and Symptoms

General symptoms—fatigue, malaise, fever,anorexia

Specific symptoms (depends on organ system affected)

Carditis—systolic murmur, abnormal EKG, CHF

Polyarthritis—joint symptoms and subcutaneous nodules over
joints
Chorea—abnormal involuntary movements caused byCNS
damage (St. Vitus Dance)
Erythema marginatum—pink, macular rash
Subcutan nodule

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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 14
 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.

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 Infeksi akibat
ß hemolitikus Streptokokus Grup A

Infeksi Kuman  Hemolitikus Streptokokus

Group A

Infeksi Tenggorokan

Periode silent
(2mgg)
Rheumatic
Fever

Carditis Polyarthritis Chorea Erythema Sub Kutan

marginatum
Modul

Rheumatic
Heart Disease
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Electrocardiogram
Persistent sinus tachycardia
Sinus bradycardia
Prolonged PR interval
Transient complete heart block
Atrial fibrillation or flutter
Bundle branch block
Low QRS voltage

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 Diagnosis

Evidence of recent strep. infection:

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

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 Diagnosis
Major criteria:

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

[SPECS]

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 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

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 Erythema Marginatum

Erythematous lesions
with pale centers and
rounded or serpiginous
margins. 21
 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]

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 The Jones Criteria for Rheumatic Fever,
Updated 1992
• Major Criteria
– Carditis • Minor Criteria
– Migratory polyarthritis – Clinical
– Sydenham's chore • fever
– Subcutaneous nodules • Arthralgia
– Erythema marginatum – Laboratory
– Elevated acute phase
reactants
plus – 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). 23
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 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).

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 Prophylaxis

after RF prophylaxis involves

Penicillin V until aged 25, and then
antibiotics before dental surgery
etc.

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