Patient
Information
Acute Rheumatic Fever
Guidelines of diagnosis used by the American
Heart Association include major and minor criteria (i.e.,
Jones
criteria). In addition to evidence of a previous streptococcal
infection, the diagnosis requires 2 major Jones criteria or 1
major plus 2 minor Jones criteria.
Major criteria
- Carditis
occurs in as many as 40% of patients and may include
cardiomegaly, new murmur, congestive heart failure, and
pericarditis, with or without a rub and valvular disease.
- Arthritis
occurs in 75% of cases and is polyarticular, fleeting, and
involves large joints, particularly the knees, ankles, elbows
and wrists. Characteristically the arthritis migrates
from joint to joint over a period of days. Generally the
pain is very severe, out of proportion to the degree of
objective inflammation of the joint itself.
- Subcutaneous
nodules (i.e., Aschoff bodies) occur in 10% of patients and
are edematous fragmented collagen fibers. They are firm
painless nodules on the extensor surfaces of wrists, elbows,
and knees. They
generally occur several weeks after the onset of fever, and
usually take weeks to resolve.
- Erythema
marginatum occurs in about 5% of cases. The rash is
serpiginous and long lasting.
- Sydenham
chorea (i.e.,
St.
Vitus dance) is a characteristic movement disorder that occurs
in 5-10% of cases. Sydenham chorea consists of rapid
purposeless movements of the face and upper extremities. Onset
may be delayed for several months and may cease when the
patient is asleep.
Minor criteria
- Clinical
findings include arthralgia and fever.
- Laboratory findings include elevated acute phase
reactants (e.g., erythrocyte sedimentation rate, C reactive
protein), a prolonged PR interval, and supporting evidence of
antecedent group A streptococcal infections (i.e., positive
throat culture or rapid streptococcal screen and an elevated
or rising streptococcal antibody titer).
Antistreptococcal prophylaxis
Antistreptococcal prophylaxis should be maintained continuously after an attack of acute RF (or chorea) to prevent recurrences. Benzathine penicillin G in a monthly IM injection of 1.2 million U is most effective, but the injections are painful and require monthly medical attention. Sulfadiazine, in a single oral dose of 1 g/day (500 mg/day in patients <= 27 kg [<= 60 lb]), is as effective as other oral regimens, including penicillin G 400,000 U divided bid or penicillin V 250 mg divided bid.
The optimum duration of antistreptococcal prophylaxis is uncertain. Some authorities believe prophylaxis should be lifelong in all RF or chorea patients, or as long as they have close contact with children, who have higher rates of carriage of group A streptococci. Others recommend prophylaxis only for the first few years after an acute attack in all patients < 18 yr, and for life only in patients with severe cardiac damage.
In patients with mild cardiac damage (i.e., murmurs but no cardiomegaly or decompensation), prophylaxis can be maintained; if it is discontinued, early treatment of streptococcal infections is required.
Web Links:
American Heart Association -
http://www.americanheart.org/presenter.jhtml?identifier=4709
http://www.americanheart.org/presenter.jhtml?identifier=1244
eMedicine - http://www.emedicine.com/emerg/topic509.htm
|
