Investigation

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Acute Rheumatic Fever

Dr Husain Tayib M.R.C.P UK F.R.C.P London
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Acute rheumatic fever

• Definition Acute, immunologically mediated
  multisystemic inflammatory disease following
  group A streptococcal pharyngitis .affecting
  joints, skin, heart and brain
• Occures in 3 of patients with group A
• streptococcal pharyngitis.
• Increase risk of reactivation with new
• pharyngeal infections

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Rheumatic fever
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Diagrammatic structure of the group A beta
hemolytic streptococcus
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
Capsule
Cell wall
Protein antigens
Group carbohydrate
Peptidoglycan
Cyto.membrane
Cytoplasm
...
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Pathogenesis of rheumatic fever
Rheumatic fever

• ARF is a hyper sensitivity reaction induced by
  group A streptococci.
• Antibodies directed against M proteins of
  streptococci cross-react with glycoproteins of
  heart,joints,skin and brain.
• Oncet of symptoms is 2-3 weeks after
  infection,and absence of bacteria in leasions.

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Rheumatic fever
Rheumatic fever
Acute valvulitis AV
Acute valvulitis AV
Acute valvulitis AV
ASCHOFF BODIES
ASCHOFF BODIES
Multinucleated giant cells, macrophages And T
lymphpcytes seen only in the heart Found in
myocardial biopsy
Multinucleated giant cells, macrophages And T
lymphpcytes seen only in the heart Found in
myocardial biopsy
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Clinical features
Rheumatic fevr

• Fever ,anorexia ,Lethargy ,joint pain 2-3 weeks
  after an episode of streptococcal pharingitis
• Arthritis migratory ,asymmetrical affecting
  large joints elbows ,wrists, knees ,ankles
• Skin lesions Erythema marginatum , subcutaneous
  nodules
• Cardites usually pancarditis ,cardiomegaly ,
  murmurs, tachycardia ,chest pain,
• Sydenhams chorea occurs 3 m after acute RF
• Rare manifestations pleurisy ,pleural effusion
  ,pneomonia

Peak incidence 5-15 years
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Rheumatic fevr
arthritis
Migratory asymmetrical non -deforming Polyarthriti
s affects large joints Responds quickly to
aspirin Occurs in 75 Joints are painful, red and
warm For 1-7 days
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Rheumatic fever
Skin
Subcutaneous Nodulle
10-15, painless mobile over joints with normal
skin color, small and transient 0.5-2mm in size,
occures 3w after onset Associated with carditis
Erythema marginatum
Transient skin rash red macules over trunk
proximal part of extremities pale center red
margins which coalesce as snake like
appearance, non pruritic, gt10
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Rheumatic fevr
carditis
Dyspnoea, crdiomegaly, pericarditis, murmers,
tachycardia, chest pain May be pancarditis
incidence decrease with age 30 in adults ECG
changes
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Rheumatic fever
Sydenhams chorea
St.Vituss dance
Occures in 10 of patients, it is late
manifestation of RF 3m Nonpurpossive,
nonrepititive involantory movement of hands,
face, or feet, more in females, Explosive speech
..Emotional liability . last 2-6m ,
spontaneous recovery is usual 25 go on to
develop chronic RVD TR halloperidole,
phenobarbitone, Na-vlproate Carbimezapine
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Rheumatic fever
Jones criteria for diagnosis of RF
Major manifestations Cardtids Polyarthritis
Chorea Erythema marginatum Subcutaneous
nodules Minor manifestations Fever
Arthralgia Previous RF

Raised ESR or
CR-protein Leukocytosis 1st an 2nd AV block
Evidence of preceding streptococcal infection
Raised ASO titer Positive throat swab culture
For diagnosis of RF 2 Major or 1 Major
2 Minor Evidence of recent streptococcal
Infection.
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Rheumatic fever
Investigations
Nonspecific raised ESR, CRP, WBC Evidence
of preceeding strept. Infection _ Throat
swab culture for group A beta haemolytic
strept. _ ASO titer gt 200 u adults , and
gt 300 u children Evidence of carditis
_Chest XR cardiomegaly, pulmonary congestion
_ ECG 1st and 2nd AV block , ST , T , changes
_ ECHO. chamber dilatation , valve
abnormalities
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Treatment of acute rheumatic fever
Rheumatic fever

• Benzathine penicillin 1.2m units i.m to
  eliminate residual
• Strepto. infection
• Bed rest and supportive measures rest till
  symptoms
• improve
• Aspirin 60-120mg /kg b.w in 6 doses for 3-4
  ws
• Corticosteroids in cases of carditis or severe
  arthritis prednisolone 1-2 mg/kg b.w in divided
  doses 2-3 ws tapering 20/w
• Secondary prevention
• _ Benzathine penicillin 1.2 million units i.m
  monthly
• or phenoxymethylpenicillin 250mg b.d or
  erythromycin
• until 21 year at least 5 years after last
  attack of acute RF

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Chronic rheumatic carditis
Rheumatic fever

• occurs in 50 of those affected with RF with
  carditis History of RF or chorea
  elicited only in 5o of
• patients with chronic RVD
• MV is affected in 90 of cases ,AV next most
  frequent
• then TV and least frequently PV
• isolated MS occurs in 25 of all cases
• Symptoms usually delayed for years or decades
  after acute RF
• Predominant pathology is progressive fibrosis
  mainly affecting the valves causing
  thickening ,deformity and
• calcification ending in varying degree of
  stenosis and /or regurgitation
• Clinical features and complications depend on
  valves involved and include
• Cardiac murmurs Cardiac hypertrophy
  and dilatation
• Congestive heart failure Thromboembolic
  incidents
• Infective endocarditis Arrhythmias
  mainly AF

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Rheumatic fevr
ChronicRVD
chronic MS
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Summery
Acute rheumatic Fever
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Thank you