Acute rheumatic fever: Difference between revisions

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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]] 1.2 MU every 2 to 4 weeks (for adults and children ≥20 kg) or 600 KU (for children <20 kg)
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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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**Excellent resource with clear, evidence-based guidance.
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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]]

Latest revision as of 21:01, 21 August 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 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. 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
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