RHEUMATIC FEVER

A systemic connective tissue disease which follows a streptococcal upper respiratory tract infection. It may involve the heart, joints, skin, subcutaneous tissue, and CNS.
The first attack usually occurs between ages of 3–15 years.

Causes

  • Hypersensitivity reaction to group A streptococcal throat infection

Clinical features

  • Arthritis (migrating asymmetric polyarthritis)
  • Acute rheumatic carditis, signs of cardiac failure, murmurs and pericarditis
  • Subcutaneous nodules
  • Chorea (involuntary movements of limbs)
  • Skin rash
  • Other minor signs/symptoms: fever, arthralgia, laboratory findings

Differential diagnosis

  • Any form of arthralgia/arthritis including sickle cell disease, haemophilia
  • Pyrexia with cardiac failure

Investigations

  • Blood: Haemogram (raised ESR)
  • Chest X-ray
  • ECG
  • Echocardiography
  • Antistreptolysin O titre (ASOT)

Diagnostic criteria (revised Jones criteria)

  • Evidence of recent streptococcal infection
    • Elevated ASO-titer or other streptococcal Ab titres or positive throat swab for group A beta-hemolyticus streptococcus
      PLUS
    • Two major manifestations or one major and two minor manifestations
MAJOR MANIFESTATIONS MINOR MANIFESTATIONS
  • Polyarthritis
  • Carditis
  • Erythema marginatum
  • Subcutaneous nodules
  • Sydehnam’s chorea
  • Polyarthralgia
  • Fever
  • Acute phase reactants
    (increased ESR/CRP)
  • ECG: prolonged PR in the
    absence of carditis

Management

  • Bed rest

To eradicate any streptococci:

  • Phenoxymethylpenicillin (Pen V) 250 mg every 6 hours for 10 days
    Child: 125 mg per dose
  • Or Benzathine benzylpenicillin dose 1.2 MU IM
    stat
    Child < 30 kg: 0.6 MU
    Child > 30 kg: 1.2 MU

To treat the inflammation

  • Acetylsalicylic acid 4-8 g/day untill signs of inflammation subside (usually 4-8 weeks)
    Child: 80-100 mg/kg/day in 3 doses
  • Plus magnesium trisilicate compound 2-4 tablets every 8 hours
    Taken 30 minutes after the acetylsalicylic acid tablets

If allergic to aspirin

  • Low dose steroid

If carditis/heart failure symptoms

  • Treat as per heart failure guidelines
  • Consider high dose steroids (specialist only)

If chorea:

  • Valproate 10-20 mg/kg/day

Prophylaxis

To prevent further episodes

  • Pen V 500 mg 12 hourly
    Child: 125-250 mg 12 hourly
  • Or Benzathine benzylpenicillin 1.2 MU IM every 4 weeks
    Child <30 kg: 0.6 MU

If allergic to penicillin:

  • Erythromycin 250 mg 12 hourly
  • Child: 10 mg/kg twice a day

Duration of prophylaxis depends on severity of disease:

  • Rheumatic fever without carditis: for 5 years or until age 18 or 21 years old
  • Carditis but no residual heart disease: for 10 years or until age 25 years old
  • Carditis with residual heart disease: untill age 40- 45 years or for life

Prevention

  • Early diagnosis and treatment of group A Streptococcus throat infection
  • Avoid overcrowding, good housing
  • Good nutrition