Rheumatic Fever

Introduction

Rheumatic Fever is a result of abnormal reaction of antibodies developed against antigens of group A B-haemolytic streptococcus.
Infection is usually of the throat; occasionally the skin in a sensitized individual.
Antigen-Antibody complex damages the heart (endocardium, myocardium and pericardium)
The commonest streptococcal strains in Africa are C and G

Clinical features

Duckett-Jones’ diagnostic criteria
Major:

  • Carditis.
  • Sydenham’s chorea
  • Erythema marginatum
  • Subcuoeous nodules.
  • Arthritis (migratory polyarthritis)

Minor:

  • Fever
  • Leucocytosis
  • Arthralgia
  • Raised ESR
  • Raised ASO titre (>200 IU)
  • Prolonged PR interval
  • Supporting evidence of antecedent group A streptococcal infection:
  • Positive throat culture or rapid streptococcal antigen

Diagnosis

2 major criteria
Or:
1 major plus 2 (or more) minor criteria

Differential diagnoses

  • Malaria
  • Viral infection
  • Pyrexia of undetermined origin
  • Connective tissue disease

Complications

  • Rheumatic heart disease
  • Arrhythmias
  • Cardiac failure

Investigations

  • ASO titre
  • ESR
  • Electrocardiograph
  • Full Blood Count and differentials
  • Throat swab for microscopy, culture and Echocardiography
  • Chest radiograph sensitivity

Treatment objectives

  • Relieve symptoms
  • Treat the bacterial throat infection
  • Reduce or abolish inflammatory process
  • Treat cardiac failure if present

Non-drug treatment

  • Bed rest

Drug treatment

Antibiotics
Penicillin V

  • Adult: 500 mg orally every 6 hours, increased up to 1g6hourly in severe infections
  • Child:
    • 1 month – 1 year: 62.5 mg orally every 6 hours increased in severe infection to ensure at least 12.5mg/kg/dose
    • 1-6 years: 125 mg every 6 hours increased in severe infection to ensure at least 12.5 mg/kg/dose
    • 6-12 years: 250 mg every 6 hours, increased in severe infection to ensure at least 12.5 mg/kg/dose
    • 12-18 years 500 mg every 6 hours, increased in severe infection up to 1 g/dose

Or

Erythromycin

  • Adult and child over 8 years: 250-500 mg orally every 6 hours or 500 mg – 1 g every 12 hours; up to 4 g daily in severe infections
  • Child: up to 2 years, 125 orally mg every 6 hours; 2-8 years 250 mg every 6 hours; doses
  • Salicylates – Aspirin (acetylsalicylic acid) doubled for severe infections
  • Adult: 300 mg-1 g orally every 4 hours after food; maximum dose in acute conditions 8 g daily
  • Child: not recommended for use
    Steroids (if salicylates are ineffective)

Prednisolone

  • Initially, up to 10-20 mg orally daily; up to 60 mg daily in severe disease
    (preferably taken in the morning after breakfast); dose can often be reduced within a few days, but may need to be continued for several weeks or months
  • Maintenance 2.5-15 mg orally daily

Prophylaxis against rheumatic fever

Benzathine penicillin 720 mg (1.2 million
units) intramuscularly 3-4 weekly until the age of 25 years or for life

Notable adverse drug reactions

  • Penicillin: anaphylactic reaction
  • Salicylates; steroids: peptic ulceration, Cushingnoid effects are increasingly likely with doses of prednisolone above 7.5 mg
    daily

Prevention

  • Good sanitation
  • School surveys – identify carriers of
    streptococcus and treat
  • Secondary prevention and prophylaxis against endocarditis