Acute Rheumatic Fever – Don’t Forget about it!

 

 

 

 

 

 

 

We’ve discussed Strep Pharyngitis (12/3/2010) and how in treating it we are primarily focusing on preventing Rheumatic Heart Disease. It is certainly safe to say that we’ve done a great job of reducing the incidence of this dreaded complication in the United States (although perhaps overdoing it now with the antibiotics); however, Acute Rheumatic Fever (ARF) still occurs in isolated outbreaks and can easily be encountered in those traveling from abroad. Additionally, ~1/3 of ARF cases result from undetected strep infections. Therefore, it is still important that we know how to recognize and diagnose it.

 

Basics of ARF

  •  WorldWide most common cause of acquired heart disease (In developed countries it is now Kawasaki Disease)
  • Peak incidence is 5-15 years
  • Occurs ~3 weeks after initial Strep infection
  • American Heart Association update of the Jones Criteria (1992):
    • Major Criteria
      • Carditis (of any of the layers of the heart)
      • Polyarthritis
      • Subcutaneous Nodules
      • Erythema Marginatum
      • Chorea (Sydenham chorea)
    • Minor Criteria
      • Arthralgia (not a criterion if polyarthritis is present)
      • Fever
      • Elevated acute-phase reactants (ESR, CRP)
      • Prolonged P-R interval
    • Diagnosis made by presence of TWO MAJOR or ONE MAJOR PLUS TWO MINOR.
    • Diagnosis can also be made with presence of chorea and documented strep pharyngitis

Acute Management

  • Treat the Infection
    • Penicillin (Pen V for 10 days or Pen G IM)
  • Alleviate Symptoms
    • Salicylates are particularly effective for migratory arthritis
      • High Dose ASA (80-100mg/kg/Day for several weeks, and then taper)
    • NSAIDs for those who cannot tolerate ASA
    • Steroids reserved for moderate to severe carditis.

Bisno AL, Stevens DL. Streptococcus pyogenes. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 198.

References

Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24;119(11):1541-51. PMID: 19246689. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

Leave a Reply

Your email address will not be published. Required fields are marked *