Acute rheumatic fever: Difference between revisions
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**Still need to exclude other possibilities |
**Still need to exclude other possibilities |
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− | == |
+ | ==Differential Diagnosis== |
− | === |
+ | ===Arthritis=== |
− | * |
+ | *[[Septic arthritis]] including [[gonococcal arthritis]] |
− | * |
+ | *Connective tissue disease or other autoimmune diseases include [[juvenile idiopathic arthritis]] |
− | * |
+ | *Viral arthropathy |
− | * |
+ | *Reactive arthropathy |
− | * |
+ | *[[Lyme disease]] |
− | * |
+ | *[[Sickle cell anemia]] |
− | * |
+ | *[[Infective endocarditis]] |
− | * |
+ | *[[Leukemia]] or [[lymphoma]] |
− | * |
+ | *[[Gout]] or [[pseudogout]] |
− | * |
+ | *Post-streptococcal [[reactive arthritis]] |
− | * |
+ | *[[Henoch-Schonlein purpura]] |
− | === |
+ | ===Carditis=== |
− | * |
+ | *Physiological [[mitral valve regurgitation]] |
− | * |
+ | *[[Mitral valve prolapse]] |
− | * |
+ | *Myxomatous mitral valve |
− | * |
+ | *[[Fibroelastoma]] |
− | * |
+ | *Congenital mitral valve disease |
− | * |
+ | *Congenital aortic valve disease |
− | * |
+ | *[[Infective endocarditis]] |
− | * |
+ | *[[Cardiomyopathy]] |
− | * |
+ | *[[Myocarditis]] (including viral and idiopathic) |
− | * |
+ | *[[Kawasaki disease]] |
− | === |
+ | ===Chorea=== |
− | * |
+ | *Drug intoxication |
− | * |
+ | *[[Wilson disease]] |
− | * |
+ | *[[Tic disorder]] |
− | * |
+ | *Choreoathetoid [[cerebral palsy]] |
− | * |
+ | *[[Encephalitis]] |
− | * |
+ | *Familial chorea, including [[Huntington disease]] |
− | * |
+ | *Intracranial tumour |
− | * |
+ | *[[Lyme disease]] |
− | * |
+ | *Hormonal |
− | * |
+ | *Metabolic, including Lesch-Nyhan, hyperalaninemia, ataxia-telangiectasia |
− | * |
+ | *[[Antiphospholipid antibody syndrome]] |
− | * |
+ | *[[Systemic lupus erythematosus]] |
− | * |
+ | *[[Vasculitis]] |
− | * |
+ | *[[Sarcoidosis]] |
− | * |
+ | *[[Hyperthyroidism]] |
− | == |
+ | ==Diagnosis== |
− | * |
+ | *Acute rheumatic fever is diagnosed using the [[modified Jones criteria]] |
− | == |
+ | ==Management== |
− | === |
+ | ===Acute management=== |
− | * |
+ | *Supportive care |
− | ** |
+ | **Arthritis: NSAID, such as [[aspirin]], [[ibuprofen]], or [[naproxen]], until all joint symptoms are resolved |
− | ** |
+ | **Fever: [[acetaminophen]], if desired |
− | ** |
+ | **Heart failure: diuretics if mild or moderate; add [[ACE inhibitor]] if severe |
− | ** |
+ | **Atrial fibrillation: [[digoxin]] |
− | ** |
+ | **Chorea: if moderate, can use [[carbamazepine]] or [[valproate]]; if severe, can add [[risperidone]], [[haloperidol]], or [[diazepam]]; and if persistent or very severe, can add [[prednisone]] or [[methylprednisolone]] |
− | * |
+ | *Decolonization, achieved by treating as streptococcal pharyngitis with either benzathine [[penicillin]] G 1.2 MU IM once or [[amoxicillin]] 500 mg PO bid for 10 days |
− | === |
+ | ===Secondary prevention=== |
− | * |
+ | *Needed to prevent further infections with [[Streptococcus pyogenes]], which most commonly manifests as [[pharyngitis]] or [[pyoderma]] |
− | * |
+ | *Choice of antibiotic: |
− | ** |
+ | **The best evidence is [[benzathine penicillin G]] 1.2 MU every 2 to 4 weeks (for adults and children ≥20 kg) or 600 KU (for children <20 kg) |
− | *** |
+ | ***Although every 2 weeks provides the best protection, every 3 to 4 weeks is still good (and more common, since it is more acceptable to patients) |
− | *** |
+ | ***Can, for example, suggest patients get their injection every full moon |
− | ** |
+ | **Alternatively, can use oral [[penicillin V]] 250 mg PO bid |
− | ** |
+ | **If allergy, can use any alternative antibiotic, though they are inferior to [[penicillin]] |
− | * |
+ | *Duration, per Australian guidelines: |
− | ** |
+ | **Possible: 12 months, then reassess |
− | ** |
+ | **Probable: for at least 5 years and until at least 21 years of age |
− | ** |
+ | **Definite, without carditis: for at least 5 years and until at least 21 years of age |
− | ** |
+ | **Definite, with carditis: |
− | *** |
+ | ***Mild RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 21 years of age |
− | *** |
+ | ***Moderate RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 35 years of age |
− | *** |
+ | ***Severe RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 40 years of age |
− | == |
+ | ==Further Reading== |
− | * |
+ | *The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). 2020. [https://www.rhdaustralia.org.au/arf-rhd-guideline Available online]. |
+ | **Excellent resource with clear, evidence-based guidance. |
||
− | * |
+ | *Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography. ''Circulation''. 2015;131:1806-1818. doi: [https://doi.org/10.1161/CIR.0000000000000205 10.1161/CIR.0000000000000205] |
[[Category:Infectious diseases]] |
[[Category:Infectious diseases]] |
Revision as of 14:29, 14 August 2020
Background
- Post-infectious complication of Streptococcus pyogenes infection
- Caused by certain serotypes of M protein
Clinical Manifestation
- Presents 1 to 5 weeks following a streptococcal infection
- Clinical syndrome characterized by fever, carditis, polyarticular arthritis, subcutaneous nodules, Sydenham chorea, and erythema marginatum
- Diagnosed using the Modified Jones criteria
- Patients with a history of acute rheumatic fever or rheumatic heart disease may have recurrences with subsequent reinfection with Streptococcus pyogenes
- Recurrences do not require as many criteria to diagnose
- Still need to exclude other possibilities
Differential Diagnosis
Arthritis
- Septic arthritis including gonococcal arthritis
- Connective tissue disease or other autoimmune diseases include juvenile idiopathic arthritis
- Viral arthropathy
- Reactive arthropathy
- Lyme disease
- Sickle cell anemia
- Infective endocarditis
- Leukemia or lymphoma
- Gout or pseudogout
- Post-streptococcal reactive arthritis
- Henoch-Schonlein purpura
Carditis
- Physiological mitral valve regurgitation
- Mitral valve prolapse
- Myxomatous mitral valve
- Fibroelastoma
- Congenital mitral valve disease
- Congenital aortic valve disease
- Infective endocarditis
- Cardiomyopathy
- Myocarditis (including viral and idiopathic)
- Kawasaki disease
Chorea
- Drug intoxication
- Wilson disease
- Tic disorder
- Choreoathetoid cerebral palsy
- Encephalitis
- Familial chorea, including Huntington disease
- Intracranial tumour
- Lyme disease
- Hormonal
- Metabolic, including Lesch-Nyhan, hyperalaninemia, ataxia-telangiectasia
- Antiphospholipid antibody syndrome
- Systemic lupus erythematosus
- Vasculitis
- Sarcoidosis
- Hyperthyroidism
Diagnosis
- Acute rheumatic fever is diagnosed using the modified Jones criteria
Management
Acute management
- Supportive care
- Arthritis: NSAID, such as aspirin, ibuprofen, or naproxen, until all joint symptoms are resolved
- Fever: acetaminophen, if desired
- Heart failure: diuretics if mild or moderate; add ACE inhibitor if severe
- Atrial fibrillation: digoxin
- Chorea: if moderate, can use carbamazepine or valproate; if severe, can add risperidone, haloperidol, or diazepam; and if persistent or very severe, can add prednisone or methylprednisolone
- Decolonization, achieved by treating as streptococcal pharyngitis with either benzathine penicillin G 1.2 MU IM once or amoxicillin 500 mg PO bid for 10 days
Secondary prevention
- Needed to prevent further infections with Streptococcus pyogenes, which most commonly manifests as pharyngitis or pyoderma
- Choice of antibiotic:
- The best evidence is benzathine penicillin G 1.2 MU every 2 to 4 weeks (for adults and children ≥20 kg) or 600 KU (for children <20 kg)
- Although every 2 weeks provides the best protection, every 3 to 4 weeks is still good (and more common, since it is more acceptable to patients)
- Can, for example, suggest patients get their injection every full moon
- Alternatively, can use oral penicillin V 250 mg PO bid
- If allergy, can use any alternative antibiotic, though they are inferior to penicillin
- The best evidence is benzathine penicillin G 1.2 MU every 2 to 4 weeks (for adults and children ≥20 kg) or 600 KU (for children <20 kg)
- Duration, per Australian guidelines:
- Possible: 12 months, then reassess
- Probable: for at least 5 years and until at least 21 years of age
- Definite, without carditis: for at least 5 years and until at least 21 years of age
- Definite, with carditis:
- Mild RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 21 years of age
- Moderate RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 35 years of age
- Severe RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 40 years of age
Further Reading
- The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). 2020. Available online.
- Excellent resource with clear, evidence-based guidance.
- Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography. Circulation. 2015;131:1806-1818. doi: 10.1161/CIR.0000000000000205