Acute rheumatic fever: Difference between revisions
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(major changes to management, added further reading, and added DDx and Dx) |
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− | == |
+ | ==Background== |
− | * Post-infectious complication of [[Streptococcus pyogenes]] infection |
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− | * Caused by certain serotypes of M protein |
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+ | *Post-infectious complication of [[Streptococcus pyogenes]] infection |
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− | == Clinical Manifestation == |
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+ | *Caused by certain serotypes of M protein |
||
− | * Presents 1 to 5 weeks following a streptococcal infection |
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+ | |||
− | * Diagnosed using the [[Modified Jones criteria]] |
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+ | ==Clinical Manifestation== |
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+ | |||
+ | *Presents 1 to 5 weeks following a streptococcal infection |
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+ | *Clinical syndrome characterized by fever, carditis, polyarticular arthritis, subcutaneous nodules, Sydenham chorea, and erythema marginatum |
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+ | **Diagnosed using the [[Modified Jones criteria]] |
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+ | *Patients with a history of acute rheumatic fever or rheumatic heart disease may have recurrences with subsequent reinfection with [[Streptococcus pyogenes]] |
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+ | **Recurrences do not require as many criteria to diagnose |
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+ | **Still need to exclude other possibilities |
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+ | |||
+ | == Differential Diagnosis == |
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+ | |||
+ | === Arthritis === |
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+ | |||
+ | * [[Septic arthritis]] including [[gonococcal arthritis]] |
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+ | * Connective tissue disease or other autoimmune diseases include [[juvenile idiopathic arthritis]] |
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+ | * Viral arthropathy |
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+ | * Reactive arthropathy |
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+ | * [[Lyme disease]] |
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+ | * [[Sickle cell anemia]] |
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+ | * [[Infective endocarditis]] |
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+ | * [[Leukemia]] or [[lymphoma]] |
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+ | * [[Gout]] or [[pseudogout]] |
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+ | * Post-streptococcal [[reactive arthritis]] |
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+ | * [[Henoch-Schonlein purpura]] |
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+ | |||
+ | === Carditis === |
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+ | |||
+ | * Physiological [[mitral valve regurgitation]] |
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+ | * [[Mitral valve prolapse]] |
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+ | * Myxomatous mitral valve |
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+ | * [[Fibroelastoma]] |
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+ | * Congenital mitral valve disease |
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+ | * Congenital aortic valve disease |
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+ | * [[Infective endocarditis]] |
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+ | * [[Cardiomyopathy]] |
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+ | * [[Myocarditis]] (including viral and idiopathic) |
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+ | * [[Kawasaki disease]] |
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+ | |||
+ | === Chorea === |
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+ | |||
+ | * Drug intoxication |
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+ | * [[Wilson disease]] |
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+ | * [[Tic disorder]] |
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+ | * Choreoathetoid [[cerebral palsy]] |
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+ | * [[Encephalitis]] |
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+ | * Familial chorea, including [[Huntington disease]] |
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+ | * Intracranial tumour |
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+ | * [[Lyme disease]] |
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+ | * Hormonal |
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+ | * Metabolic, including Lesch-Nyhan, hyperalaninemia, ataxia-telangiectasia |
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+ | * [[Antiphospholipid antibody syndrome]] |
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+ | * [[Systemic lupus erythematosus]] |
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+ | * [[Vasculitis]] |
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+ | * [[Sarcoidosis]] |
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+ | * [[Hyperthyroidism]] |
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+ | |||
+ | == Diagnosis == |
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+ | |||
+ | * Acute rheumatic fever is diagnosed using the [[modified Jones criteria]] |
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+ | |||
+ | == Management == |
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+ | |||
+ | === Acute management === |
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+ | |||
+ | * Supportive care |
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+ | ** Arthritis: NSAID, such as [[aspirin]], [[ibuprofen]], or [[naproxen]], until all joint symptoms are resolved |
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+ | ** Fever: [[acetaminophen]], if desired |
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+ | ** Heart failure: diuretics if mild or moderate; add [[ACE inhibitor]] if severe |
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+ | ** Atrial fibrillation: [[digoxin]] |
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+ | ** 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]] |
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+ | * 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 |
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+ | |||
+ | === Secondary prevention === |
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+ | |||
+ | * Needed to prevent further infections with [[Streptococcus pyogenes]], which most commonly manifests as [[pharyngitis]] or [[pyoderma]] |
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+ | * Choice of antibiotic: |
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+ | ** The best evidence is [[benzathine penicillin G]] 900 mg (1.2 IU) every 2 to 4 weeks (for adults) |
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+ | *** 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) |
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+ | *** Can, for example, suggest patients get their injection every full moon |
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+ | ** Alternatively, can use oral [[penicillin V]] 250 mg PO bid |
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+ | ** If allergy, can use any alternative antibiotic, though they are inferior to [[penicillin]] |
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+ | * Duration, per Australian guidelines: |
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+ | ** Possible: 12 months, then reassess |
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+ | ** Probable: for at least 5 years and until at least 21 years of age |
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+ | ** Definite, without carditis: for at least 5 years and until at least 21 years of age |
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+ | ** Definite, with carditis: |
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+ | *** Mild RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 21 years of age |
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+ | *** Moderate RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 35 years of age |
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+ | *** Severe RHD: for at least 10 years (or 5 years if no preceding ARF) and until at least 40 years of age |
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+ | |||
+ | == Further Reading == |
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+ | |||
+ | * 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]. |
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+ | * 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] |
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[[Category:Infectious diseases]] |
[[Category:Infectious diseases]] |
Revision as of 09:31, 19 July 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 900 mg (1.2 IU) every 2 to 4 weeks (for adults)
- 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 900 mg (1.2 IU) every 2 to 4 weeks (for adults)
- 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.
- 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