- Acute rheumatic fever is a multi system disease.
- Occur as a result of reaction to infection with group A streptococci.
- Almost all the manifestations of rheumatic fever resolve completely except cardiac valvular damage.
- This is mainly a disease of children aged 5 - 14 years.
- Females are more commonly affected.
Jones criteria for diagnosis of rheumatic fever
Major criteria
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor criteria
Fever
Arthralgia
Previous rheumatic fever
Raised ESR
Leucocytosis
1st/2nd degree av block
Plus
Evidence for recent streptococcal infections infection
Recent scarlet fever
Raised antistreptolysin O
Positive throat culture
Major criterias
1.Carditis
Valvular damage occur in carditis
Mitral valve is most commonly affected followed by aortic valve
Early valvular damage produce regurgitation
Later the leaf thickening, scarring and calcification result in valvular stenosis.
Patient will present with breathlessness,palpitation,chest pain,pleuritic central chest pain,pericardial rub, tachycardia, murmur,cardiac enlargement
Auscultation in carditis give the following findings
Soft systolic murmur in mitral area
Soft mid diastolic murmur(CARY COOMBS MURMUR) in mitral area
Pericardial friction rub due to pericarditis
Softening of the first heart sound(soft S1)
ECG will show evidence of ST or T wave changes. P-R interval prolongation.
2.Joint involvement
Knee, ankle, hip, and elbow are most commonly involved - asymmetric joint involvement is seen..
Acute painful inflammation of joint produce pain in rheumatic fever.
Typical joint involvent is migratory, moving from one joint to another over a period of hours.
Joint pain is severe and usually disabling.
If the joint involvement persists more than 1 or 2 days after starting salicylates it is unlikely to be due to acute rheumatic fever.
Most of the time sore throat is seen 2-4 weeks prior to the onset of joint symptoms.
Joint involvement is more prominent in adults and carditis in children.
3.Sydenhams chorea
Manifest late after initial infection with streptococcus(6 months or so).
Sidenham chorea manifest as spasmodic unintentional movements & possibly altered speech.
Spontaneous recovery is seen within 6 weeks.
4. Erythema marginatum
They are red macules which fade in the centre, but remain red in the periphery.Never seen on the face.
5.Subcutaneous nodules
Painless, small (0.5-2 cm), mobile lumps seen beneath the skin overlying the bony prominences, particularly of the hands, feet, elbows and occiput.
It is a delayed manifestation of rheumatic fever
Usually seen 2-3 weeks after the onset of disease.
Significance of subcutaneous nodule is that if they are present associated carditis will be there.
Other clinical features
Pleurisy
Pleural effusion
Pneumonia
High-grade fever (39°C) is the rule.
C-reactive protein (CRP) is elevated..
Elevated Erythrocyte sedimentation rate (ESR)
Investigations in Rheumatic fever
Evidence of systemic illness manifested as
Lleucocytosis,raised ESR, raised C reactive protein.
Evidence of preceeding streptococcal infection detected by the following tests
Throat swab culture: group A streptococcus.
Anti streptolysin o antibodies: > 200(adults), > 300(children
