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ACUTE RHEUMATIC FEVER (Clinical manifestations & treatment)

Author: Dr. Evans Kemboi
Medical Officer, Reale Hospital & Clinics
Rheumatic fever is an inflammatory process which can involve the joints, heart, skin and brain. It is caused by antibody cross reactivity and occurs 2-3 weeks after a Group A Streptococcal infection. Streptococcal infections are any type of infection caused by the group of bacteria Streptococcus.
CLINICAL MANIFESTATIONS CARDITIS
Usually manifests within the first 3 weeks of Acute Rheumatic Fever with new heart murmur, cardiomegaly, CHF, pericardial friction rub, effusions as the common signs. Chronic inflammatory changes may lead to development of rheumatic heart disease. Characteristic murmur or  Rheumatic heart disease:

a) mitral regurgitation
b) Low-pitched mid diastolic flow murmur at the apex (Carey Coombs murmur
c) Aortic regurgitation
d) Can also get AV conduction delays

JOINTS
This is always identified with arthralgias and arthritis (usually migratory), and warm, swollen, tender joints. The condition usually involves the knees, ankles, elbows and wrists and it lasts for 2-3 weeks. SUBCUTANEOUS NODULES
usually associated with severe carditis and occur several weeks after onset. Firm, painless nodules (up to 2cm) found over bony surfaces and tendons. Occur near elbows, knees, wrists, Achilles tendon, vertebral joints. Usually persist for 1-2 week

ERYTHEMA MARGINATUM
nonpruritic, painless erythematous rash on trunk and/or proximal extremities. Macular lesions with raised margins and central clearing and may last from weeks to months.

SYDENHAM’S CHOREA
neurologic disorder with muscular weakness, emotional lability and involuntary, uncoordinated, purposeless movements which disappear during sleep, mainly occur in hands, feet and face with Sensation intact and lasts for 2-4 months

TREATMENT
Acute Rheumatic Fever is always treated with Anti-inflammatory Agents such as; Aspirin 100mg/kg/day for children, anti-inflammatory therapy until ESR or CRP are normal and this may need steroids if there is cardiac involvement to help prevent sequelae such as mitral stenosis. Corticosteroids, if indicated, are given at prednisone 2mg/kg/day for 2 weeks and then tapered.

Antibiotics such as Benzathine penicillin G 0.6-1.2mu im stat, Oral or crystalline Penicillin for at least 10 days and penicillin 500mg BID-TID. One can also use erythromycin for PCN allergic patients (given at 40mg/kg/day given in 2-4 doses/day.

The condition is also treated with Prophylaxis which is needed to prevent recurrence of Acute Rheumatic Fever by starting after acute episode resolves. One can use penicillin V 250mg BID or, Sulfadiazine 1000mg daily, or Penicillin G 1.2 million units IM q4weeks. For PCN allergic patients: erythromycin 250mg PO BID.

WHO GUIDELINES
At least 5 years of prophylaxis or if child until age 18 if not cardiac involvement
10 years prophylaxis or if child until age 25 if has mild mitral regurgitation
Lifelong prophylaxis if has severe valve disease

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