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.