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 ==
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==Background==
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* 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
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* 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]
   
 
[[Category:Infectious diseases]]
  
[[Category:Infectious diseases]]

Revision as of 09:31, 19 July 2020

Background

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
  • 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

Carditis

Chorea

Diagnosis

Management

Acute management

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
  • 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
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