acute rhematic fever.ppt

8/20/2019 acute rhematic fever.ppt

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Acute Rheumatic Fever

And

Rheumatic heart disease

Agus Priyatno by


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Etiologi :

1. Immunologic Streptococcus beta hemolytic group A

2. Predispositing Factor: - Family history - Socio-economic status - Age 5 – 15 years pea! " years#


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Pathology

• Inflamatory lesion; heart,brain,joint,skin

• Ashoff bodies ( in atrial myocardium):

characteristic !entral necrosis surrounded by lym"hocytes, "lasma cell, and large mononuclear and giant multinucleate cell


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!linical manifestations

#istory$tre"tococcal "haryngitis, % & ' eeks (ae *) beforeonset+

!horea & - mos+Pallor, easy fatigability, e"ista.is, abdominal "ainPositie family history+

Strep throat

$heumatic %e&er

Acute glomerulonephritis

Strep s!in


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Histologic section of typical RF


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/ones criteria ( u"date %00)

o 1ajor criteria :

2 arthritis 2 carditis 2 erythema marginatum 2 subcutaneous nodules 2 $ydenham3s chorea+

o 1inor criteria :

2 arthalgia 2 feer

2 eleated acute "hasereactan ( !4P, E$4)

2 E!5 : P4 interal 6 : not s"ecific

"lus $u""orting eident of antecedent $tre" 7 grou" A infec+ 2 culture (8) or ra"id stre"t antigent test 2 eleated or rising A$9


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%+ Arthritis

Affects of cases

?arge joints : knee, ankle, elbo, rist ften 6 % joints, simultaneously or

in succession, migratory+ $elling, heat, redness, seere "aint, tenderness, motion @ ramatic res"onse to salicylate


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Migratory arthritis


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+ !arditis

2 '= > of cases

2 iagnosis reBuires "resence of :

%+ 9achycardia + #eart murmur of alulitis ( 14 and A4 ) *+ Pericarditis( friction rub, "ericard

effusion,chest "ain, E!5 changes) C+ !ardiomegaly on chest D ray

'+ !ongestif heart failure ( seere carditis)


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Involve of the heart; pericarditis


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Involve of the heart;myocardium andendocardium


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*+ Erythema marginatum

2 @ %= > of cases2 on "ruritic erythematous rashes,

neer on faces2 1ost "rominent on trunk and inner "ro.imal "ortion2 isa""ear on e."osure to cold, seldom detected on A! hos"ital


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Erythemamarginatum


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C. $ubcutaneous nodules

2 & %=> of cases, es" in recurrences2 #ard, "ainless, non "ruritic,freely moeable, selling =, & cm2 Fssually symmetric on e.tensor surfaces of joint, scal", along s"ine, last for eeks


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Subcutaneousnodules


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'+ $ydenham3s chorea+

2 %'> of cases, more often in "re"ubertal girl2 Gegin ith emotional lability and "ersonality

changes+2 $"ontaneous, "ur"oseless moement folloed by motor eakness, slurred s"eech2 ysfunction of basal ganglia and cortical neural com"onents


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Involuntary grimaces


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iagnosis of rheumatic feer

Gased on

major criteria or % minor criteria

8 A$9


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E.ce"tion to the /ones criteria

%+ !horea may occur as the only manifestation of 4H+ Indolent carditis may be the only manifestation

*+ ccasionally "atients ith 4H recurrences maynot fulfill the /ones criteria


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ifferential diagnosis of 4H

• /uenile rheumatoid arthritis• !ollagen ascilar disease• irus associated acute arthritis• #ematologic disorder: sicklemia and leukemia


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ote

• 4H is a clinical syndrom for hich no s"esific diagnostic test e.ist• o sym"tom, sign or lab test result is "athogno monic, although seeral combinations of them are diagnostic• nly carditis can cause "ermanent cardiac damage+

$ign of mild carditis disa""ear ra"idly in eeks but seere carditis may last for & - month+

!horea and arthritis usually subside ithout"ermanent damage


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1anagement of 4H

• GenJathin "enicillin 5 =,- & %, 1 units i+m for eradication and "ro"hyla.is+ Allergic to "enicillin : erythromisin C= mgKkgKday in to to four doses for %= days+• Ged rest• Acetosal for mild cases• Prednison for seere cases• Anti inflammatory agents not needed for isolated

chorea• 9reatment of congestie heart failure


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4ecommended anti2inflammatory agents

Arthritis alone

'ildcarditis

'oderate carditis

Se&ere carditis

Prednison ( ( ( 2-) *!+

Aspirin 1-2 *! ,- *! )-" *! 2-mo

•Prednison should be tapered and aspirin started during the the %inal *ee!.

Aspirin may be reduced to )( mg/!g/day

0osages: Prednison: 2 mg/!g/day in di&ided doses Aspirin : 1(( mg/!g/day in -) di&ided doses


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Ged rest and indoor ambulation

Arthritis 'ild 'oderate se&ere alone carditis carditis carditis

ed rest 1-2 *! ,- *! -) *! as longas 34F

Indoor amb 1-2 *! ,- *! -) *! 2-, mo

utdoor acti& 2 *! 2- *! 1-, mo 2-, mo school#Full acti&ity 6-) *! 6)-1( *! 6,-) mo &ariable

E$4: im"ortant for duration of restriction of actiitiesHull actiity: E$4 normal, e.ce" significant cardiac inolement

1ild card: Luestionable cardiomegaly, moderate: definite but mild,$eere: marked cardiomegaly or !#H


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Preention

• Ideally "ro"hyla.is is indefinite• GenJathin "enicillin eery M days, min till age % & ' ys

• $ulfadiaJine =,' g %. daily ( b @ < kg) % g %. daily (b 6 < kg)• Peniccilin . '= mgKday• Erythromycin . '= mgKday


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4#EF1A9I! #EA49 I$EA$E

Affecs; 2 1itral ale 2 9ricus"id ale rare

2 Pulmonary ale neer

$tenosis and regurgitation usually occurtogether+


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1I94A? $9E$I$

• "realent• most common alular inolement in adult

• reBuires ' & %= ys from the initial attack• if 4H is "realent, 1$ occurs under age %' ys


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Pathology

• 9hickening of the leaflets and fusion of thecommisure

• !alsification result oertime

• ?A and right2sides heart chambers become dilated and hi"ertro"hied• Pulmonary enous hy"ertension, "ulmonary congestion and edema and fibrosis of the aleolar alls, hy"ertro"hy of the "ulmonary aleolar, loss of lung com"liance


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Aortic and mitral valve


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!linical manifestations

• 1ild 1$ : asym"tomatic• 1ore seere: dys"nea ithKout e.ertion, ortho"neu, nocturnal dys"nea and "al"itation+

Physical E.aminations:

• Increased 4 im"ulse along ?$G

• Neak "eri"heral "ulse ith narro "ulse "ressure• Pulmonary hy"ertension: loud $% at a"e. and narro s"lit $, accentuated P• 1ild diatolicK"resystolic murmur


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Cardiac nding of MS


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E!5 :2 4A, ?A#, 4# ( due to P# )

2 atrial fibrilation is rare in children!D4 : 2 enlarge ?A and 4,2 1PA segment "rominent2 "ulmonary enous congestion

Echocardiogra"hy :

• accurate noninasie tool to detection of 1$• 12mode; diminished E to H slo"e, thickened mitral leaflets, large ?A dimention

• 9o : doming of thick mitral, a small mitral orifice, dilated ?A, 1PA, 4 and 4A• o""ler: estimate of "ressure gradient;1itral ale and "ulmonary ale+


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9reatment of 1$• "ro"hylactic antibiotic• restriction of actiity de"ends on seerity• sym"tomatic "atient ( dys"nea on e.ertion,

"ulmonary edema, "aro.ysmal dys"nea): balloon or surgery


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7ypical appearances o% ad&anced 'S on mediastinal

organ and lung


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1I94A? 4E5F45I9A9I1ost common in 4#

Pathology:

2 mitral ale leaflets are shortened because of fibrosis+2 hen degree of 14 increases, dilatation of ?A and ? result, mitral ring becomes dilated+


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!linical manifestation:• asym"tomatic during chilhood• rare; fatigue, "al"itation

Physical e.amination

• heaing, hy"erdinamic a"ical im"uls in seere 14• $% normal or diminished+• $ may s"lit ( shortening of ? ejection, early

aortic closure )

• $* commonly is "resent and loud• Pansystolic murmur at the a"e., ith transmision to the left a.illa


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Cardiac nding of MR


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E!5:2 normal in mild cases

2?# or ? dominance, ith or ithout ?A#2Atrial fibrilation is rare in children

!D4:

2?A and ? enlarged2Pulmonary congestion "attern in !#H

Echocardiogra"hy:

2to : dilated ?A and ?2color2flo ma""ing; regurgitant jet into the ?A2do""ler: asses the seerity of the regurgitation


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9reatment:

• Pro"hylactic antibiotic• o restriction of actiity in mild cases• $urgical: intractable !#H,

"rogressie cardiomegaly,"ulmonary hy"ertension• If atrial fibrilation; digo.in• Afterload2reducing agent; maintaining the forard stroke olume+


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A49I! 4E5F45I9A9I

?ess common than 14+ 1ostly associated ithmitral ale disease+

Pathology• semilunar cus"s are deformed and shortened• ale ring is dilated• commisures usually are fused


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!linical manifestation

• mild regurgitation: asym"tomatic• more seere; reduce e.ercise tolerance test

Physical e.amination

• "recordium may be hy"erdinamic, distolic thrill at * ?I!$• $% decreased, $ may be normal or single• high "itched diastolic cresendo murmur at * ?I!$ or C ?I!$• systolic murmur at 4I!$ due to relatie A$• seere A$ : middiastolic murmur at a"e.


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Cardiac nding of AR


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E!5 : 2 normal in mild cases 2 seere ; ?#, ?A#

!D4 : 2 cardiomegaly (?#) 2 dilated ascending aorta

Echocardiogra"hy :

• the ? dimension is increased• color2flo and do""ler to estimate the seere of the regurgitation+


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9reatment:

• "ro"hylactic antibiotics• mild case : no restriction in actiity• surgical : in anginal "ain or dys"nea on e.ertion, significant cardiomegaly


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Streptococcal infectionAnd reccurentFor three prophylactic!"# Sulphadia$in%# &enicillin'# (en$atin penicillin


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)ecline in ne* cases of RF admitted to hospital


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9hank Oou

acute rhematic fever.ppt

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