Rheumatic Fever

Сентябрь 12, 2022

Содержание

2. Rheumatic fever is an inflammatory disease involving the joints, the heart, the CNS, the skin and
3. Etiology Non-suppurative complications of upper respiratory infections by group A-β hemolytic streptococcal (GAS) Skin infections by
4. Pathogenesis *Autoimmune theory, abnormal immune response by human host to some component of GAS. * The
5. Epidemiology Rheumatic fever occurs at all ages peaks between 5-15 ys A high incidence in tropical
6. Epidemiology Low-Risk populations: Those with incidence ≤2 per 100,000 school-age children per year or all-age rheumatic
7. Epidemiology High-Risk populations: Those with incidence >2 per 100,000 school-age children per year or all-age rheumatic
8. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
9. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
10. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
11. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever Subclinical carditis indicates
12. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
13. Clinical manifestations and diagnosis: 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
14. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever CRP value must
15. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever Prolonged P-R interval
16. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
17. Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
18. Guidelines for the diagnosis of initial or recurrent attack of RF Revised Jones criteria, Updated 2015
20. Major Jones criteria
21. Minor Jones criteria
22. Rheumatic Carditis Most serious manifestations of ARF Occurs in about 50-60% of all cases of ARF
23. Endocarditis (valvulitis) * Numerous small rheumatic sterile vegetation on the line of closure of the valves
24. Murmurs in patients with endocarditis soft - musical - not associated with thrill 1- Apical pansystolic
25. Myocarditis Cardiac dilatation Congestive heart failure Tachycardia disproportionate to fever Arrhythmias Muffled Heart sounds
26. Pericarditis Dry pericarditis precordial pain and friction rub Wet Pericarditis mild to moderate effusion
27. Pericarditis with massive pericardial effusion: Weak pulse. Pulsus paradoxus is an abnormally large decrease in systolic
29. DD of rheumatic carditis: Other causes of myocarditis such as viral myocarditis. Other causes of pericarditis.
30. Treatment of carditis * Mild cases without HF or cardiomegaly Salicylates 50-70mg/kg/day orally after meal divided
31. Rheumatic Polyarthritis -Migratory (from one joint to another)& affects several joints. -Involves large joints. -Mainly symmetrical.
32. Differential diagnosis: Other causes of arthritis - Juvenile rheumatoid arthritis & other collagen diseases. - Infective
33. Treatment of arthritis Salicylates 50-70mg/kg/day orally after meal divided into 4 doses for 3-5 days, then
34. Rheumatic Chorea (Sydenham chorea) Has long latent period (2-6 months), the onset is usually insidious. May
35. Clinical manifestation: - Characterized by involuntary movements, emotional liability & hypotonia. - Purposeless, irregular, rapid, jerking
36. Sydenhams chorea watch please
37. Clinical tests for detection of chorea Marked fluctuation in muscle tone (felt by asking the patient
38. In pure chorea the ESR and ASOT are normal. This is attributed to the long latent
39. Prognosis Chorea is a self limited condition. Mild cases subside within few weeks - 3 months
40. Treatment of rheumatic chorea - Anti inflamatory - Phenobarbital - Haloperidol - Chlorpromazine
41. Subcutaneous nodules Bilaterally symmetrical firm nodules varying in diameter from few millimeters to centimeter. Movable painless
42. Erythema marginatum Red, raised, non pruritic macules extend to form wavy lines or rings with pale
43. Complications of Acute Rheumatic fever Chronic valvular heart disease (RHD) after an attack of rheumatic carditis.
44. Prevention of rheumatic fever can be divided into three approaches General measures Primary prevention Secondary orevention
45. 1. Treatment (eradication ) of GAS infection Treatment of streptococcal upper respiratory tract infection must be
46. Primary prevention eradication of GAS all patients with ARF should receive
47. Secondary prevention (for recurrences of acute rheumatic fever)
48. Duration of Secondary prevention
50. Скачать презентацию

Слайд 2

Rheumatic fever
is an inflammatory disease involving the joints, the

heart, the CNS, the skin and subcutaneous tissue.
It is:
Serious → as it leads to
permanent cardiac damage
(chronic valvular disease)
Important cause →
of acquired heart disease
in children in developing
countries.

Слайд 3

Etiology

Non-suppurative complications of upper respiratory infections by
group A-β hemolytic

streptococcal (GAS)
Skin infections by GAS → acute glomerulonephritis but rarely, if ever to acute RF.

Слайд 4

Pathogenesis
*Autoimmune theory, abnormal immune response by human host to some component

of GAS.
* The resulting antibodies → immunologic damage.
Latent period is 1-3 weeks

Слайд 5

Epidemiology
Rheumatic fever occurs at all ages peaks between 5-15 ys
A

high incidence in tropical and subtropical climates.
Over crowding, poor housing, lack of adequate treatment and genetic predisposition
are predisposing factors

Слайд 6

Epidemiology
Low-Risk populations:
Those with incidence ≤2 per 100,000 school-age children per

year or all-age rheumatic heart disease
prevalence of ≤1 per thousand population.
Include virtually all of the United States, Canada, and Western Europe.

Слайд 7

Epidemiology
High-Risk populations:
Those with incidence >2 per 100,000 school-age children per

year or all-age rheumatic heart disease
prevalence of >1 per thousand population.
Include Maoris in New Zealand, aborigines in Australia, Pacific Islanders, and most developing countries.

Слайд 8

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 9

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 10

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 11

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Subclinical carditis indicates echocardiographic valvulitis.
Erythema marginatum and subcutaneous nodules are rarely “standalone” major criteria.
Joint manifestations can only be considered in either the major or minor categories but not both in the same patient.

Слайд 12

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 13

Clinical manifestations and diagnosis: 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 14

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

CRP value must be greater than upper limit of normal for laboratory.
Because ESR may evolve during the course of ARF, peak ESR values should be used.

Слайд 15

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Prolonged P-R interval [in the ECG] should not be counted as a minor manifestation in patients in whom carditis is counted as a major manifestation.
A prolonged P-R interval alone does not constitute evidence of carditis or predict long-term cardiac sequelae.

Слайд 16

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 17

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Fever

Слайд 18

Guidelines for the diagnosis of initial or recurrent attack of RF

Revised Jones criteria, Updated 2015

Слайд 19

Слайд 20

Major
Jones
criteria

Слайд 21

Minor
Jones
criteria

Слайд 22

Rheumatic Carditis
Most serious manifestations of ARF
Occurs in about 50-60% of all

cases of ARF
Pancarditis involves endocardium, myocardium and pericardium
Result in residual chronic valvular lesion
Rheumatic Subclinical Carditis is carditis without a murmur of valvulitis but with echocardiographic evidence of valvulitis.

Слайд 23

Endocarditis (valvulitis)
* Numerous small rheumatic
sterile vegetation on the line

of closure of the valves
* Mitral valve is commonly
affected followed by the
Aortic valve
* Valvular regurge is characteristic of ARF
* Valvular stenosis usually appears several years after
the ARF

Слайд 24

Murmurs in patients with endocarditis
soft - musical - not associated with

thrill
1- Apical pansystolic murmur, musical
soft, radiating to axilla, changeable, not associated with thrill, caused by mitral valvitis → (MR)
disappears within 6 months if not associated with chronic MR
2- Apical low-pitched mid-diastolic murmur → (MS)
(Carey Coombs murmur).
3- Early diastolic murmur over the aortic area → (AR)
4- Appearance of new murmurs.
5- Change in character of previous murmurs.

Слайд 25

Myocarditis
Cardiac dilatation
Congestive heart failure
Tachycardia disproportionate to fever
Arrhythmias
Muffled Heart sounds

Слайд 26

Pericarditis
Dry pericarditis
precordial pain and friction rub
Wet Pericarditis
mild to moderate

effusion

Слайд 27

Pericarditis with massive pericardial effusion:
Weak pulse.
Pulsus paradoxus
is an abnormally large

decrease in systolic BP during inspiration. The normal fall in systolic BP is <10 mmHg. When the drop is >10mmHg, it is referred to as pulsus paradoxus.
Congested non pulsating neck veins.
Weak apical pulsation
Heart sounds are distant and muffled.
Dullness outside the apex
Ewart’s sign
compression of the left lung produces
dullness and bronchial breathing at the
lung base posteriorly.

Слайд 28

Слайд 29

DD of rheumatic carditis:
Other causes of myocarditis such as viral myocarditis.
Other

causes of pericarditis.
Infective endocarditis.
Congenital heart disease.

Слайд 30

Treatment of carditis
* Mild cases without HF or cardiomegaly
Salicylates

50-70mg/kg/day orally after meal divided into 4 doses for 3-5 days, then 50 mg/kg/day divided into 4 doses for 3 weeks, then 25 mg/kg/day for 3 weeks
* Moderate and severe cases with cardiomegaly and/or HF:
Bed rest
- Prednisone 2 mg/kg/day divided in 4 doses for 2-3 wk., then half the dose for 2-3 weeks
When the patient responds clinically & on lab tests (ESR, CRP), the dose should be tapered by reducing 5 mg/day every 2-3 days.
-Salicylates 50mg/kg/day in 4 divided doses for 6 weeks at the beginning of tapering steroid dose to prevent rebound
-Supportive therapies include digoxin, fluid, salt restriction, diuretics and O2.

Слайд 31

Rheumatic Polyarthritis
-Migratory (from one joint to
another)& affects several joints.
-Involves large

joints.
-Mainly symmetrical.
-The joints are tender, red, warm and swollen.
-Effusion may be present.
-Does not result in chronic joint disease.
-Aspirin or NSAI give dramatic response
in 12-24 hours.
-Arthralgia may occur in some joints
and frank arthritis in others.

Слайд 32

Differential diagnosis:
Other causes of arthritis
- Juvenile rheumatoid arthritis & other collagen

diseases.
- Infective endocarditis.
- Arthritis. Of infection
- Malignancy as Leukemia.
- Sickle cell disease.

Слайд 33

Treatment of arthritis
Salicylates 50-70mg/kg/day orally after meal divided into

4 doses for 3-5 days, then 50 mg/kg/day divided into 4 doses for 3 weeks, and 25 mg/kg/day for 3 weeks.
Early administration of salicylates to a patient before diagnosis is established may obscure the diagnosis.

Слайд 34

Rheumatic Chorea (Sydenham chorea)
Has long latent period (2-6 months), the

onset is usually insidious.
May be the only sign of rheumatic fever (pure chorea) or it may be associated with carditis.

Слайд 35

Clinical manifestation:
- Characterized by involuntary movements, emotional liability & hypotonia.
-

Purposeless, irregular, rapid, jerking movements of the limbs and grimacing of the face
- Exaggerated by emotional stress and disappear during sleep.
- Drop things, spill from a cup and handwriting deteriorates.
- Speech is commonly slurred.
- May affects one side of the body (hemichorea).

Слайд 36

Sydenhams chorea watch please

Слайд 37

Clinical tests for detection of chorea
Marked fluctuation in muscle tone

(felt by asking the patient to squeeze the examiner’s hand).
Spooning:
When the tongue is protruded
it is rapidly withdrawn to prevent being bitten by involuntary jaw movements.
The knee jerk:
either of pendulum type(due to hypotonia) or more commonly is sustained or “hung up”.
Pronation sign:
on elevation of the upper limbs above the level of the head with the palms of hands facing each other, there is pronation in the forearms and the limbs fall down gradually.
Examination of hand writing for fine motor movement

Слайд 38

In pure chorea the ESR and ASOT are normal. This is

attributed to the long latent period (2-6 months), when elevated loog for carditis
DD
Postencephalitic chorea
Cerebral palsy

Слайд 39

Prognosis
Chorea is a self limited condition.
Mild cases subside within few weeks

- 3 months
Severe cases may progress and require a padded cot.

Слайд 40

Treatment of rheumatic chorea
- Anti inflamatory
- Phenobarbital
-

Haloperidol
- Chlorpromazine

Слайд 41

Subcutaneous nodules
Bilaterally symmetrical firm
nodules varying in diameter from

few millimeters to centimeter.
Movable painless and not tender.
Occur over the bony prominences.
Best demonstrated by fully flexing
the joint and stretching the skin over
the extensor surface.
When occurs, usually severe carditis
is present.

Слайд 42

Erythema marginatum
Red, raised, non pruritic macules extend to form wavy lines

or rings with pale centers .
Coalesce forming irregular patterns, which vary in shape, and site from hour to hour.
Usually seen over the trunk.

Слайд 43

Complications of Acute Rheumatic fever
Chronic valvular heart disease (RHD) after

an attack of rheumatic carditis.
Severe acute carditis is the commonest cause of death of rheumatic fever.

Слайд 44

Prevention of rheumatic fever can be divided into three approaches
General measures
Primary prevention
Secondary

orevention

Слайд 45

1. Treatment (eradication ) of GAS infection
Treatment of streptococcal upper respiratory

tract infection must be within 9 days to prevent an initial attack of rheumatic fever.

Слайд 46

Primary prevention eradication of GAS all patients with ARF should receive

Слайд 47

Secondary prevention (for recurrences of acute rheumatic fever)

Слайд 48

Rheumatic Fever

Содержание

Rheumatic fever is an inflammatory disease involving the joints, the

Etiology Non-suppurative complications of upper respiratory infections by group A-β hemolytic

Pathogenesis*Autoimmune theory, abnormal immune response by human host to some component

EpidemiologyRheumatic fever occurs at all ages peaks between 5-15 ys A

EpidemiologyLow-Risk populations: Those with incidence ≤2 per 100,000 school-age children per

EpidemiologyHigh-Risk populations: Those with incidence >2 per 100,000 school-age children per

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis: 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Clinical manifestations and diagnosis 2015 Revised Jones Criteria for diagnosis of Rheumatic

Guidelines for the diagnosis of initial or recurrent attack of RF

Major Jones criteria

Minor Jones criteria

Rheumatic CarditisMost serious manifestations of ARFOccurs in about 50-60% of all

Endocarditis (valvulitis) * Numerous small rheumatic sterile vegetation on the line

Murmurs in patients with endocarditissoft - musical - not associated with

MyocarditisCardiac dilatation Congestive heart failureTachycardia disproportionate to feverArrhythmiasMuffled Heart sounds

PericarditisDry pericarditisprecordial pain and friction rubWet Pericarditis mild to moderate

Pericarditis with massive pericardial effusion:Weak pulse.Pulsus paradoxus is an abnormally large

DD of rheumatic carditis:Other causes of myocarditis such as viral myocarditis.Other

Treatment of carditis * Mild cases without HF or cardiomegaly Salicylates

Rheumatic Polyarthritis-Migratory (from one joint to another)& affects several joints.-Involves large

Differential diagnosis:Other causes of arthritis- Juvenile rheumatoid arthritis & other collagen

Treatment of arthritis Salicylates 50-70mg/kg/day orally after meal divided into

Rheumatic Chorea (Sydenham chorea) Has long latent period (2-6 months), the

Clinical manifestation:- Characterized by involuntary movements, emotional liability & hypotonia.-

Sydenhams chorea watch please

Clinical tests for detection of chorea Marked fluctuation in muscle tone

In pure chorea the ESR and ASOT are normal. This is

PrognosisChorea is a self limited condition.Mild cases subside within few weeks

Treatment of rheumatic chorea - Anti inflamatory- Phenobarbital -

Subcutaneous nodules Bilaterally symmetrical firm nodules varying in diameter from

Erythema marginatumRed, raised, non pruritic macules extend to form wavy lines

Complications of Acute Rheumatic feverChronic valvular heart disease (RHD) after

Prevention of rheumatic fever can be divided into three approachesGeneral measuresPrimary preventionSecondary

1. Treatment (eradication ) of GAS infection Treatment of streptococcal upper respiratory

Primary prevention eradication of GAS all patients with ARF should receive

Secondary prevention (for recurrences of acute rheumatic fever)

Duration of Secondary prevention

Похожие презентации

Rheumatic fever
is an inflammatory disease involving the joints, the

Etiology

Non-suppurative complications of upper respiratory infections by
group A-β hemolytic

Pathogenesis
*Autoimmune theory, abnormal immune response by human host to some component

Epidemiology
Rheumatic fever occurs at all ages peaks between 5-15 ys
A

Epidemiology
Low-Risk populations:
Those with incidence ≤2 per 100,000 school-age children per

Epidemiology
High-Risk populations:
Those with incidence >2 per 100,000 school-age children per

Major
Jones
criteria

Minor
Jones
criteria

Rheumatic Carditis
Most serious manifestations of ARF
Occurs in about 50-60% of all

Endocarditis (valvulitis)
* Numerous small rheumatic
sterile vegetation on the line

Murmurs in patients with endocarditis
soft - musical - not associated with

Myocarditis
Cardiac dilatation
Congestive heart failure
Tachycardia disproportionate to fever
Arrhythmias
Muffled Heart sounds

Pericarditis
Dry pericarditis
precordial pain and friction rub
Wet Pericarditis
mild to moderate

Pericarditis with massive pericardial effusion:
Weak pulse.
Pulsus paradoxus
is an abnormally large

DD of rheumatic carditis:
Other causes of myocarditis such as viral myocarditis.
Other

Treatment of carditis
* Mild cases without HF or cardiomegaly
Salicylates

Rheumatic Polyarthritis
-Migratory (from one joint to
another)& affects several joints.
-Involves large

Differential diagnosis:
Other causes of arthritis
- Juvenile rheumatoid arthritis & other collagen

Treatment of arthritis
Salicylates 50-70mg/kg/day orally after meal divided into

Rheumatic Chorea (Sydenham chorea)
Has long latent period (2-6 months), the

Clinical manifestation:
- Characterized by involuntary movements, emotional liability & hypotonia.
-

Clinical tests for detection of chorea
Marked fluctuation in muscle tone

Prognosis
Chorea is a self limited condition.
Mild cases subside within few weeks

Treatment of rheumatic chorea
- Anti inflamatory
- Phenobarbital
-

Subcutaneous nodules
Bilaterally symmetrical firm
nodules varying in diameter from

Erythema marginatum
Red, raised, non pruritic macules extend to form wavy lines

Complications of Acute Rheumatic fever
Chronic valvular heart disease (RHD) after

Prevention of rheumatic fever can be divided into three approaches
General measures
Primary prevention
Secondary

1. Treatment (eradication ) of GAS infection
Treatment of streptococcal upper respiratory