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
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
Evidence of a preceding group A streptococcal infectionIncreased antistreptolysin O titre (ASOT)Positive throat culture for GABHSPositive rapid antigen detection test
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
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.
TREATMENTAnti-Inflammatory Therapy mild / no carditis:Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over 4 weeks.
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.
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 3 to 4 weeks. • Oral Penicillin V 250 mg twice daily.• Oral Erythromycin 250 mg twice daily if allergic to Penicillin.
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.
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.
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.), 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