Rheumatic Fever: Clinical Features, Carditis Diagnosis, and Long-Term Prophylaxis

Rheumatic Fever: Clinical Features, Carditis Diagnosis, and Long-Term Prophylaxis

Question. Describe clinical features of rheumatic fever and the diagnosis of carditis with a strategy of prophylaxis.

Answer.

It is an acute inflmmatory disease which occurs due to infection by group A hemolytic streptococci, which involves the heart, joints, skin, and nervous system, and develops as an autoimmune reaction to the infecting organism.

Etiology

1. Predisposing causes:
   Age should be 5 to 15 years.
   Sex has an equal incidence
2. Genetic factors: Family incidence is known.
3. Social and economic factors: Dampness, overcrowding, and undernutrition increase incidence.
4. Idiosyncrasy is presumably a factor since 3% of people who are involved in streptococcal epidemics develop rheumatic fever.

Clinical Manifestations of Rheumatic Fever

1. Prodromal phase: Tonsillitis or sore throat 1 to 4 weeks before the onset of acute rheumatic fever. Besides this, anorexia, pallor, fatigability, and nervous irritability are present.
2. Latent phase: When antibodies to the preceding streptococcal infection are produced.
3. Phase of onset of rheumatic fever/mode of onset.
   Arthritis and fever 2–3 weeks after infection.
4. Cardiac symptoms 3–6 weeks after infection is first to draw attention.
5. Abdominal symptoms: Abdominal pain and tenderness, nausea, vomiting, feve,r and leukocytosis.
6. Pyrexia of unknown origin
7. Typhoid or influenza-like mode of onset with fever
8. Nodules of skin lesion.

Treatment of Acute Rheumatic Fever

1. Bed rest is important to reduce joint pain and cardiac workload.
   Duration of bed rest is guided by markers of inflammation like temperature, WBC count and ESR.
2. Benzathine penicillin 1.2 mu IM 4 hourly.
   If patient is allergic to penicillin, erythromycin 40–50 mg / kg for ten days is given.
3. Aspirin usually relieves symptom of arthritis rapidly.
   A starting dose of 60 mg / kg body weight per day is given divided into 6 doses.
   The dose may be increased to 120 mg / kg body weight.
   This dose may produce severe symptoms like vomiting, tachypnea and acidosis is given till ESR comes to normal.
4. Corticosteroids like prednisolone produces rapid symptomatic relief than aspirin and is indicated in cases with severe arthritis or carditis.
   Prednisolone is given in doses of 1.2 mg / kg body weight till ESR comes to normal.

The term acute pulmonary edema refers to collection of flid into alveoli its wall and alveolar sac due to an acute increase in left atrial pressure.

Causes rheumatic fever

1. Cardiogenic:

1. Left ventricular failure
2. Myocardial infarction
3. Mitral stenosis
4. Pulmonary infarction
5. Cardiac arrhythmia.

2. Non-cardiogenic:

1. Fluid overload
2. Shock
3. Inhalation of gastric acid (Mendelson’s syndrome)
4. High altitude pulmonary edema.

Clinical Features rheumatic fever

1. Feeling of *oppression in chest
2. Acute and distressing dyspnea
3. Short cough and pink frothy sputum, sometimes blood tinged flid from mouth and nose.
4. Sweat and feeble pulse.
5. Fall of temperature.

Management rheumatic fever

1. Bed rest is provided as the sittng position tends to reduce
   venous return.
2. Oxygen is provided
3. Inj. Morphine 15 mg subcutaneously is given.
4. Inj. Furosemide 80 mg IV relieves pulmonary edema.
   If patient has not received digoxin during last fortnight
5. Inj. Digoxin (0.5. to 1 mg) is given.
6. Inj. Aminophylline 0.24 gm slow IV in 10 min is effctive.
7. Patients not responding above regimen IV nitroprusside 20–30 unit g per minute is given.

Management Acute Rheumatic Fever.

1. Treatment of acute attck: Rheumatic Fever

1. Bed rest is important to reduce joint pain and cardiac workload.
   Duration of bed rest is guided by markers of inflmmation like temperature,
   WBC count and ESR.
2. Benzathine penicillin 1.2 mu IM 4 hourly. If patient is allergic to penicillin, erythromycin 40–50 mg / kg for ten days is given.
3. Aspirin usually relieves symptom of arthritis rapidly.
   A starting dose of60 mg/kg body weight per day is given divided into 6 doses.
   The dose may be increased to 120 mg / kg body weight.
   This dose may produce severe symptoms like vomiting, tachypnea and acidosis. Aspirin is given till ESR comes to normal.
4. Corticosteroids like prednisolone produces rapid symptomatic relief than aspirin and is indicated in cases with severe arthritis or carditis.
   Prednisolone is given in doses of 1.2 mg / kg body weight till ESR comes to normal

2. Secondary prevention: Rheumatic Fever

To prevent further attck of rheumatic fever, long­term prophylaxis is needed.

1. Benzathine penicillin 1.2 mu IM is injected at the interval of 21 days.
   Further attck is unusual after the age of 21 years and treatment can be stopped.
2. To prevent chances of endocarditis prophylactic antibiotic therapy should be given