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d                n Zia      Dr IrfaBy:FEVER&KNEE PAIN
AN 11-YEAR OLDPRESENTED WITHFEVERJOINT PAINAND SWELLINGSOB
O/E : tachypnea and tachycardia             T 38.2             P 160             RR 32           BP 100/60            SaO2...
Lungs clearCVS S1S2, pansystolic murmur 3/6 heard at apex with radiation to              axillaAbdomen Soft, normoactive b...
Left knee is swollen and extremely tender withwarmth & Limited ROM. His right ankle is very swollenand warm. He has limite...
Enlarged, erythematosus tonsils with exudates
CNS : No abnormal   movements of arms,   hands, or tongue arenoted. He is unable to walk        due to pain.
P   R
CARDIOMEGALY
Diffe      r   entia                l   s?
RHEUMATICFEVER       DR IRFAN ZIAD
12 millionare affected by ARF andCRHD globallydeveloping countries are150 timesmore susceptible thanthe developed countrie...
AN INFLAMMATORY DISEASE OFCHILDHOOD RESULTING FROM        UNTREATED    STREPTOCOCCOCCAL  PHARYNGEAL INFECTION
Group Aβ-hemolyticStreptococcusRheumatogenic strain
Group A B-hemolytic                  Streptococcus                  Rheumatogenic strain                   tein           ...
Joints-Athralgia-Migratory polyarthritis
Skin-Subcutaneous nodules-Erythema marginatum
Subcutaneous nodules
Erythema marginatum
CNSBasal Ganglia
syndenhamCHOREAaka San Vitus Dancerapid involuntarymovement affectingthe hands, feet,tongue and face.
HeartMyocardiumPericardiumEndocardium
PericardiumPancarditis   Myocardium              Endocardium
Myocarditis-heart is enlarged-may develop CCF
Pericarditis- Completely resolved- Heal with adhesion  Myocardium Endocardium“Bread and Butter” Pericarditis
MyocardiumEndocardium
In patients with critical stenosis, mitralvalvulotomy, percutaneous balloon valvuloplasty,  or mitral valve replacement ma...
polyarthritiserythema marginatum & nodulesSydenham choreaRheumatic myocarditis & pericarditisRheumatic endocarditis
MODIFIED JONES CRITERIA FOR    ACUTE RHEUMATIC FEVER    MAJOR CRITERIA        MINOR CRITERIACarditis                Fever ...
INVESTIGATIONSFBC: anaemia, leucocytosisThroat swabASOTCXR, ECGEchocardiogram
How to make the diagnosis      Initial episode of ARF          2   MAJOR CRITERIA                     OR1   MAJOR CRITERIA...
How to make the diagnosis     Recurrent attack of ARF          2   MAJOR CRITERIA                     OR1   MAJOR CRITERIA...
Evidence of a preceding group A     streptococcal infectionIncreased antistreptolysin O titre (ASOT)Positive throat cultur...
J oints - artritis       O bvious - cardiac       N odules - rheumatic AJ ORM      E rythema marginatum       S ydenham ch...
TREATMENT  Bedrest
TREATMENT   Anti-Streptococcal Therapy   IV C. Penicillin 50 000U/kg/dose 6H                      or   Oral Penicillin V 2...
TREATMENTAnti-Inflammatory Therapy       mild / no carditis:Oral Aspirin 80-100 mg/kg/day in 4 doses for          2-4 week...
TREATMENTAnti-Inflammatory TherapyPericarditis, or moderate to severe              carditis:Oral Prednisolone 2 mg/kg/day ...
TREATMENTAnti-Inflammatory Therapy    Monitor Aspirin level and LFT
Watch out forREYESSYNDROMEEncephalopathyFatty liver degenerationTransaminase elevation.
TREATMENT  Anti-failure medicationDiuretics, ACE inhibitors, digoxin (to be used                with caution).
TREATMENT      Secondary prophylaxis• IM Benzathine Penicillin 0.6 mega units (<30 kg)   or 1.2 mega units (>30 kg) every ...
TREATMENT    Secondary prophylaxis      Duration of prophylaxis• Until age 21 years or 5 years after last attack of       ...
Summary        Accurate diagnosis is important.       Jones Criteria is a good guidelineManagement include post-strep ther...
In a case of knee swelling..Don’t forget your stethoscope!
References  1.  Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N  (2007), Robbins Basic Pathology (8th ed....
Rheumatic fever
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Rheumatic fever

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Rheumatic fever

  1. 1. d n Zia Dr IrfaBy:FEVER&KNEE PAIN
  2. 2. AN 11-YEAR OLDPRESENTED WITHFEVERJOINT PAINAND SWELLINGSOB
  3. 3. O/E : tachypnea and tachycardia T 38.2 P 160 RR 32 BP 100/60 SaO2 94%
  4. 4. Lungs clearCVS S1S2, pansystolic murmur 3/6 heard at apex with radiation to axillaAbdomen Soft, normoactive bowel sounds
  5. 5. Left knee is swollen and extremely tender withwarmth & Limited ROM. His right ankle is very swollenand warm. He has limited subtalar motion. Both hisknee and ankle are very tender even to touch. 
  6. 6. Enlarged, erythematosus tonsils with exudates
  7. 7. CNS : No abnormal movements of arms, hands, or tongue arenoted. He is unable to walk due to pain.
  8. 8. P R
  9. 9. CARDIOMEGALY
  10. 10. Diffe r entia l s?
  11. 11. RHEUMATICFEVER DR IRFAN ZIAD
  12. 12. 12 millionare affected by ARF andCRHD globallydeveloping countries are150 timesmore susceptible thanthe developed countries5-14 yearsis the most frequent agegroup
  13. 13. AN INFLAMMATORY DISEASE OFCHILDHOOD RESULTING FROM UNTREATED STREPTOCOCCOCCAL PHARYNGEAL INFECTION
  14. 14. Group Aβ-hemolyticStreptococcusRheumatogenic strain
  15. 15. Group A B-hemolytic Streptococcus Rheumatogenic strain tein Pro M- Molecular mimicryImmune Heart Brain Skinresponse Connective tissue
  16. 16. Joints-Athralgia-Migratory polyarthritis
  17. 17. Skin-Subcutaneous nodules-Erythema marginatum
  18. 18. Subcutaneous nodules
  19. 19. Erythema marginatum
  20. 20. CNSBasal Ganglia
  21. 21. syndenhamCHOREAaka San Vitus Dancerapid involuntarymovement affectingthe hands, feet,tongue and face.
  22. 22. HeartMyocardiumPericardiumEndocardium
  23. 23. PericardiumPancarditis Myocardium Endocardium
  24. 24. Myocarditis-heart is enlarged-may develop CCF
  25. 25. Pericarditis- Completely resolved- Heal with adhesion Myocardium Endocardium“Bread and Butter” Pericarditis
  26. 26. MyocardiumEndocardium
  27. 27. In patients with critical stenosis, mitralvalvulotomy, percutaneous balloon valvuloplasty, or mitral valve replacement may be indicated.
  28. 28. polyarthritiserythema marginatum & nodulesSydenham choreaRheumatic myocarditis & pericarditisRheumatic endocarditis
  29. 29. MODIFIED JONES CRITERIA FOR ACUTE RHEUMATIC FEVER MAJOR CRITERIA MINOR CRITERIACarditis Fever (Temp>38oC)Polyarthritis, aseptic ESR > 30 mm/h ormonoarthritis or CRP > 30 mg/LpolyathralgiaChorea Prolonged PR intervalErythema marginatumSubcutaneous nodules
  30. 30. INVESTIGATIONSFBC: anaemia, leucocytosisThroat swabASOTCXR, ECGEchocardiogram
  31. 31. How to make the diagnosis Initial episode of ARF 2 MAJOR CRITERIA OR1 MAJOR CRITERIA +2 MINOR CRITERIA+ evidence of a preceding group A streptococcal infection
  32. 32. How to make the diagnosis Recurrent attack of ARF 2 MAJOR CRITERIA OR1 MAJOR CRITERIA +2 MINOR CRITERIA OR 3 of a preceding group A MINOR CRITERIA + evidence streptococcal infection
  33. 33. Evidence of a preceding group A streptococcal infectionIncreased antistreptolysin O titre (ASOT)Positive throat culture for GABHSPositive rapid antigen detection test
  34. 34. J oints - artritis O bvious - cardiac N odules - rheumatic AJ ORM E rythema marginatum S ydenham chorea I nflammatory cells (leukocytosis) T emperature R E SR/CRP elevatedMINO R aised PR interval I tself (Previous Hx of Rheumatic fever) A thralgia
  35. 35. TREATMENT Bedrest
  36. 36. TREATMENT Anti-Streptococcal Therapy IV C. Penicillin 50 000U/kg/dose 6H or Oral Penicillin V 250 mg 6H (<30kg), 500 mg 6H (>30kg) for 10 daysOral Erythromycin for 10 days if allergic to penicillin.
  37. 37. TREATMENTAnti-Inflammatory Therapy mild / no carditis:Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over 4 weeks.
  38. 38. TREATMENTAnti-Inflammatory TherapyPericarditis, or moderate to severe carditis:Oral Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks, taper with addition of aspirin as above.
  39. 39. TREATMENTAnti-Inflammatory Therapy Monitor Aspirin level and LFT
  40. 40. Watch out forREYESSYNDROMEEncephalopathyFatty liver degenerationTransaminase elevation.
  41. 41. TREATMENT Anti-failure medicationDiuretics, ACE inhibitors, digoxin (to be used with caution).
  42. 42. TREATMENT Secondary prophylaxis• IM Benzathine Penicillin 0.6 mega units (<30 kg) or 1.2 mega units (>30 kg) every 3 to 4 weeks. • Oral Penicillin V 250 mg twice daily.• Oral Erythromycin 250 mg twice daily if allergic to Penicillin.
  43. 43. TREATMENT Secondary prophylaxis Duration of prophylaxis• Until age 21 years or 5 years after last attack of ARF whichever was longer• Lifelong for patients with carditis and valvular involvement.
  44. 44. Summary Accurate diagnosis is important. Jones Criteria is a good guidelineManagement include post-strep therapy, anti-inflammatory therapy, anti-failure therapy and secondary prophylaxisARF is a large physical, emotional and financial burden.
  45. 45. In a case of knee swelling..Don’t forget your stethoscope!
  46. 46. References 1.  Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N (2007), Robbins Basic Pathology (8th ed.), Saunders Elsevier, pp. 403–6, ISBN 978-1-4160-2973-1. 2. "rheumatic fever" at Dorlands Medical Dictionary 3. Jones, T Duckett (1944). "The diagnosis of rheumatic fever". JAMA 126(8):481. doi:10.1001/jama.1944.02850430015005. 4. Ferrieri, P (2002). "Proceedings of the Jones Criteria workshop".Circulation (Jones Criteria Working Group) 106 (19): 2521–3.doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554. 5. Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP, FACEP. Retrieved 2007-07-14. 6. Malaysian Paediatric Protocol, 3rd Edition

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