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Rheumatic fever

Rheumatic fever definition, etiology, pathophysiology, clinical manifestations, diagnostics, management

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Rheumatic fever

  1. 1. Presented by : Ms. Avelin D’Souza
  2. 2. DEFINITION: 2  Acute rheumatic fever is a systemic disease of childhood ,often recurrent that follows group A beta hemolytic streptococcal infection  It is a diffuse inflammatory disease of connective tissue primarily involving heart, blood vessels, joints, subcut.tissue and CNS 5/30/2016
  3. 3. Incidence 3  In developing areas of the world, severe disease caused by group A Streptococcus (e.g., ARF, rheumatic heart disease, glomerulonephritis, and invasive infections) is estimated to affect nearly 20 million people and is the leading cause of cardiovascular death during the first five decades of life. ARF can occur at any age, although most cases occur in children 5 to 15 years of age. Worldwide, there are 470,000 new cases of ARF and 233,000 deaths attributable to ARF or rheumatic heart disease each year. Most cases occur in developing countries and among 5/30/2016
  4. 4. Etiology 5/30/20164  Group A Beta hemolytic Streptococcus pyogenes  Malnutrition  Poverty  overcrowding.  Incidence more during fall ,winter & early spring
  5. 5. Pathophysiology 5  Rheumatic fever is a sequela to group A beta- hemolytic streptococcal infection that occurs in about 3% of untreated infections. It is a preventable disease through detection and adequate treatment of streptococcal pharyngitis.  Connective tissue of the heart, blood vessels, joints and subcutaneous tissues can be affected.  Lesions in connective tissue are known as Aschoff bodies, which are localized areas of tissue 5/30/2016
  6. 6. Cont.… 5/30/20166  Heart valves, mainly the mitral valve, are affected resulting in valve leakage and narrowing.  Compensatory changes in the chamber sizes and thickness of chamber walls occur.  Heart involvement (pancarditis) also includes pericarditis, myocarditis, epicarditis and endocarditis.
  7. 7. Pathologic Lesions 7  Fibrinoid degeneration of connective tissue, inflammatory edema, inflammatory cell infiltration & proliferation of specific cells resulting in formation of Ashcoff nodules, resulting in-  Pancarditis in the heart  Arthritis in the joints  Ashcoff nodules in the subcutaneous tissue  Basal gangliar lesions resulting in chorea 5/30/2016
  8. 8. Clinical manifestations 8 Criteria was established by T.D. Jones in 1944 revised by the American Heart Association and modified by WHO to provide a basis for diagnosis, the presence of two major criteria or one major and two minor criteria plus evidence of a preceding group A streptococcal infection indicates a high probability of ARF. 5/30/2016
  9. 9. Cont.… 9 Major criteria  Carditis  Mono or polyarthritis  Chorea  Erythema Marginatum lesion  Subcutaneous nodules 5/30/2016
  10. 10. Cont.… 5/30/201610 Minor criteria  Fever  Polyarthralgia Joint pain without swelling  Raised erythrocyte sedimentation rate or C reactive protein  Leukocytosis  ECG showing features of heart block, such as a prolonged PR interval  Previous episode of rheumatic fever or inactive heart disease
  11. 11. Cont.… 11 Evidence of infection  Fever (38.9 to 40 C [101 to 104 F])  Chills  Sore throat (sudden in onset)  Diffuse redness of throat with exudate on oropharynx (may not appear until after the first day)  Enlarged and tender lymph nodes  Abdominal pain (more common in children)  Acute sinusitis and acute otitis media  Increased antistreptolysin O titre  Positive throat culture  Positive rapid antigen test for group A streptococci 5/30/2016
  12. 12. 12 Jones Criteria (Revised) for Guidance in the Diagnosis of Rheumatic Fever* Major Manifestation Minor Manifestations Supporting Evidence of Streptococal Infection Carditis Polyarthritis Chorea Erythema Marginatum Subcutaneous Nodules Clinical Laboratory Increased Titer of Anti-Streptococcal Antibodies ASO (anti-streptolysin O), others Positive Throat Culture for Group A Streptococcus Recent Scarlet Fever Previous rheumatic fever or rheumatic heart disease Arthralgia Fever Acute phase reactants: Erythrocyte sedimentation rate, C-reactive protein, leukocytosis Prolonged P-R interval *The presence of two major criteria, or of one major and two minor criteria, indicates a high probability of acute rheumatic fever, if supported by evidence of Group A streptococcal nfection. Recommendations of the American Heart Association 5/30/2016
  13. 13. Complications 5/30/201613  Chronic rheumatic carditis.  Valvular heart disease  Cardiomyopathy  Heart failure  Atrial arrhythmias  Pulmonary and systemic embolism
  14. 14. Medical management 5/30/201614  Anti-microbial therapy—penicillin is the drug of choice  Rest to maintain optimal cardiac function.  Salicylates or NSAIDS or corticosteroids  Periodic prophylaxis throughout life  Beta blockers, ACE inhibitors, digoxin, diuretics, supplemental oxygen, rest, sodium and fluid restrictions to manage heart failure  Phenobarbital and diazepam to manage chorea
  15. 15. Treatment 15  Step I - primary prevention (eradication of streptococci)  Step II - anti inflammatory treatment (aspirin, steroids, NSAIDS)  Step III- supportive management & management of complications  Step IV- secondary prevention (prevention of recurrent attacks) 5/30/2016
  16. 16. 16 STEP I: Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis) Agent Dose Mode Duration Benzathine penicillin G 600 000 U for patients Intramuscular Once 27 kg (60 lb) 1 200 000 U for patients >27 kg or Penicillin V Children: 250 mg 2-3 times daily Oral 10 d (phenoxymethyl penicillin) Adolescents and adults: 500 mg 2-3 times daily For individuals allergic to penicillin Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d Estolate (maximum 1 g/d) or Ethylsuccinate 40 mg/kg/d 2-4 times daily Oral 10 d (maximum 1 g/d) Recommendations of American Heart Association 5/30/2016
  17. 17. 17 Arthritis only Aspirin 75-100 mg/kg/day,give as 4 divided doses for 6 weeks (Attain a blood level 20- 30 mg/dl) Carditis Prednisolone 2-2.5 mg/kg/day, give as two divided doses for 2 weeks Taper over 2 weeks & while tapering add Aspirin 75 mg/kg/day for 2 weeks. Continue aspirin alone 100 mg/kg/day for another 4 weeks Step II: Anti inflammatory treatment Clinical condition Drugs 5/30/2016
  18. 18. 18  Bed rest  Treatment of congestive cardiac failure: -digitalis, diuretics  Treatment of chorea: -diazepam or haloperidol  Rest to joints & supportive splinting 3.Step III: Supportive management & management of complications 5/30/2016
  19. 19. 19 STEP IV : Secondary Prevention of Rheumatic fever (Prevention of Recurrent Attacks) Agent Dose Mode Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular or Penicillin V 250 mg twice daily Oral or Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral 1.0 g once daily for patients >27 kg (60 lb) For individuals allergic to penicillin and sulfadiazine Erythromycin 250 mg twice daily Oral *In high-risk situations, administration every 3 weeks is justified and recommended Recommendations of American Heart Association 5/30/2016
  20. 20. 20 Duration of Secondary Rheumatic Fever Prophylaxis Category Duration Rheumatic fever with carditis and At least 10 y since last residual heart disease episode and at least until (persistent valvar disease*) age 40 y, sometimes lifelong prophylaxis Rheumatic fever with carditis 10 y or well into adulthood, but no residual heart disease whichever is longer Rheumatic fever without carditis 5 y or until age 21 y, whichever is longer *Clinical or echocardiographic evidence. Recommendations of American Heart Association 5/30/2016
  21. 21. Nursing management 5/30/201621 Nursing assessment Subjective data:  Important health information  Functional health patterns Objective data:  General  Integumentary  Cardiovascular  Neurologic  Musculoskeletal
  22. 22. Cont.… 5/30/201622 Nursing diagnosis:  Hyperthermia related to disease process  Decreased cardiac output related to decreased cardiac contractility  Activity intolerance related to joint pain and easy fatigability
  23. 23. Nursing interventions 5/30/201623 Reducing fever  Administer penicillin therapy to eradicate the hemolytic streptococcus.  Give salicylates or NSAIDS as prescribed to suppress the rheumatic activity controlling toxic manifestations to reduce fever and relieve joint pain.  Assess for effectiveness of drug therapy
  24. 24. Cont.… 5/30/201624 Maintaining adequate cardiac output  Assess for signs and symtoms of ARF  Auscultate the heart sounds every 4 hours document the presence of murmur or pericardial effusion  Monitor for development of chronic rheumatic endocarditis which may include valvular disease and heart failure
  25. 25. Cont.… 5/30/201625 Maintaining activity  Maintains bed rest for duration of fever or if signs of active carditis is present  Provide ROM exercise program  Provide diversional activities that prevent exertion
  26. 26. Patient education and health maintenance 5/30/201626  Counsel about need for good nutrition,  Counsel on hygiene practices ( hand washing)  Counsel about importance of adequate rest  Instruct patient to seek treatment immediately should sore throat or fever occur  Support patient in long term antibiotic therapy to prevent relapse  Instruct patient with valvular disease to use prophylaxis penicillin therapy before certain procedures and surgery  Patient with previous history of ARF should be taught about the disease process, possible sequelae and continues need for prophylactic therapy.  Teach about monthly injections of penicillin or
  27. 27. Summary 5/30/201627
  28. 28. Reference 5/30/201628  Brunner & Siddharth, ‘Textbook of Medical surgical nursing’, Volume 1, 11th edition, Wolters Kluwer publication, New Delhi 2009, pg. 794 - 796.  Lewis et al, ‘Medical Surgical Nursing’,7th edition, Elsevier publication 2007 New Delhi, pg. 875- 878  Linda et al, ‘Understanding Medical Surgical Nursing’, 4th edition, Jaypee brothers’ publication, pg. 740 - 742  Lippincott, ‘Manual of Nursing Practise’, 10th edition, Wolters Kluwer publication, New Delhi 2010, pg. 405- 406.  www.mayoclinic.org/diseases-conditions/rheumatic fever/basics/.../con-20031399
  29. 29. Cont.… 5/30/201629  www.uptodate.com/.../acute-rheumatic-fever- clinical-manifestations-and-diagnosis  emedicine.medscape.com/article/333103- overview  https://en.wikipedia.org/wiki/Rheumatic_fever  www.healthline.com › Reference Library  www.medicinenet.com/rheumatic_fever/article.ht m
  30. 30. 5/30/201630
  31. 31. 31 THANK YOU 5/30/2016