ACUTE RHEUMATIC FEVER

This is an acute, systemic connective tissue disease in children related to an immune reaction to untreated group A beta haemolytic streptococcus infection of the upper respiratory tract . The significance of this disease is the rheumatic
heart disease complication that may result from it, which may cause severe heart valve damage. Rheumatic heart disease is the commonest form of heart disease in children.

The initial attack of acute rheumatic fever occurs in most cases between the ages of 3 and 15 years.

Clinical Features

For the sake of diagnosis, clinical features related to rheumatic heart disease are categorized into major and minor criteria.

  1. The major criteria
    • Migrating polyarthritis
    • Carditis (manifested by signs of cardiac failure, persistent tachycardia, pericardial rub or heart murmurs)
    • Sydenham’s Chorea
    • Erythemamarginatum
    • Subcutaneous nodules.
  2. The minor criteria
    • Past history of rheumatic fever
    • Raised ESR
    • Fever,
    • Arthralgia.

Diagnosis of rheumatic fever occurs when 2 major criteria and 1 minor criteria are present, or 1 major criteria and 2 minor criteria.

Complications

The main complication of rheumatic fever is rheumatic heart disease.

Investigations

  • Anti-streptolysin-0-titre (ASOT) – Titre of 1:300
  • Throat swab for culture
  • ESR
  • Chest x-ray – Features of cardiomegaly
  • ECG if available
  • Electrocardiography
  • Echocardiography

Management

  • Eradicate streptococcal infection from the throat:
    • Amoxicillin 250–500mg (children 25–50mg/kg in divided doses) TDS for 10 days
    • If allergic to penicillin or amoxicillin, erythromycin 12.5mg/kg QDS for 10 days
  • Control fever and inflammation: Aspirin: 75–100mg/kg/day in 4–6 divided doses. Treatment continued until fever and joint inflammation are controlled and then gradually reduced over a 2-week period.
  • Treat failure if present (see Section 3.2, on heart failure).
  • Treat chorea if present with haloperidol 25mcg/kg (0.025mg/kg) TDS.
  • Admit for strict bed rest until symptoms resolve.

Prevention

  • Avoid overcrowding.
  • Early treatment of streptococcal sore throat with benzathine penicillin 1.2 mega units STAT dose OR Phenoxymethyl penicillin 125–250mg TDS for 10 days.

Prophylaxis

  • If there has been previous acute rheumatic fever without carditis, give benzathine penicillin 1.2 mega units monthly for 5 years or up to the age of 18 years, whichever is longer. OR
  • Erythromycin 125–250mg BD for 5 years for those sensitive to penicillin.
  • If there has been previous acute rheumatic fever with carditis give benzathine penicillin 1.2 mega units OR Erythromycin 125–250mg BD for those sensitive to penicillin for life.
  • For patient education:
    • Emphasize need for follow up for prophylaxis.
    • Advise that rheumatic heart disease is a known complication.