Differentiate aortic regurgitation due to syphilis and rheumatic AR

How will you differentiate between aortic regurgitation due to syphilis and rheumatic fever?

The pathology of AR in syphilis and rheumatic fever are different. In syphilis there is aortic root dilatation and in rheumatic fever there is valve damage.

Features of Rheumatic AR

1.    Usually affect young individuals

2.    Past history of rheumatic fever may be present

3.    Other valves may be affected

4.    Usually there is no diastolic thrill

5.    A₂ diminished 

6.    Murmur is of blowing character

7.    It is best heard on 3^rd left intercostals space

8.    Peripheral signs of AR are present.

Features of syphilitic AR

1.    Older individuals are affected

2.    History of exposure to syphilis present

3.    Syphilitic AR is usually an isolated lesion

4.    Diastolic thrill is more common than rheumatic AR

5.    A_2­ is usually loud tambour like

6.    Murmur is ringing, cooing, or musical in nature

7.    Best heard along the right sternal border.

8.    Peripheral sign are more marked than rheumatic AR.

Jones criteria for diagnosis of rheumatic fever

1. Acute rheumatic fever is a multi system disease.
2. Occur as a result of reaction to infection with group A streptococci.
3. Almost all the manifestations of rheumatic fever resolve completely except cardiac valvular damage.
4. This is mainly a disease of children aged 5 - 14 years. 
5. 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

Screening tests for acute and chronic polyarthritis

Screening tests in arthritis will help you to arrive at a diagnosis.

Screening tests for acute polyarthritis are the following

Blood cultures.

Antistreptolysin O titer.

Parvovirus B-19 immunoglobulin G and immunoglobulin M levels.

Hepatitis B serology.

ANA.

Others
HIV test, a rubella titer, an angiotensin-converting enzyme level . chest radiograph, and ANCA.

Screening tests for chronic polyarthritis are the following

Complete blood cell count.

ESR and CRP level.

ANAs.

Rheumatoid factor and CCP antibody.

Liver function tests, serum creatinine level.

Serum uric acid level.

Urinalysis.

OthersThyroid-stimulating hormone level, a serum ferritin level, and an iron saturation of serum transferrin.

Screening tests for diffuse arthralgias and myalgias

ESR and CRP - elevated in  inflammatory disease, including polymyalgia rheumatica.

Creatine kinase and aldolase level - myositis.

Thyroid test.

Chemistry profile (ie, calcium, phosphorus, electrolyte, glucose, total protein) - metabolic or endocrine disorders.

Others.

25-hydroxy vitamin D level -Osteomalacia.

Sacroiliac joint radiography - Ankylosing spondylitis, especially in woman <45 y with neck, chest wall, and low back pain).

HLA-B27 - In reactive arthritis.

Hepatitis B and C serology testing.

Serum and urine protein electrophoresis -to rule out multiple myeloma.

ANA and rheumatoid factor (if clinical features suggest RA, SLE, or another connective-tissue disease).