Professional Documents
Culture Documents
FEVER
ETIOLOGY
1. Immunologic
Streptococcus Beta hemolytic group A
2. Predisposing factors
- Family history
- Socio economic status
- Age 5 -15 years ( peak 8 years)
PATHOLOGY
Inflammatory lesion : heart, brain, joints,
skin
CLINICAL MANIFESTATIONS
History
Streptococcal pharyngitis, 1-5 wks, (ave 3
wks) before onset; chorea 2-6 mos
Pallor, easy fatigability, epistaxis, abdo
minal pain
Positive family history
* Affects 70 % of cases
* Large joints : knee, ankle, elbow, wrist
* Often > 1 joints, simultaneously or
in succession, migratory
* Swelling, heat, redness, severe pain,
tenderness, motion <
* Dramatic response to salicylate
2. Carditis
50 % of cases, usu within first 3 wks
Diagnosis requires presence of 1 of 4:
- organic heart murmur
- pericarditis (friction rub, pericard effusion,
chest pain, ECG changes)
- cardiomegaly on chest X ray
- congestive heart failure
3. Erythema marginatum
- <10 % of cases
- Non pruritic erythematous rashes,
never
on face
- Most prominent on trunk and inner
proximal portions
- Disappear on exposure to cold,
seldom detected on AC hospitals
Erythema marginatum
4. Subcutaneous nodules
- 2-10 % of cases, esp in recurrences
- Hard, painless, non pruritic, freely
moveable, swelling 0.2-2 cm
- Usually symmetric on extensor surfaces
of joints, scalp, along spine, lasts for
weeks
Subcutaneous Nodule
5. Sydenhams chorea
- 15 % of patients, more often in prepubertal
girls.
- begin with emotional lability and personal
ity changes
- spontaneous, purposeless movement
followed by motor weakness, slurred speech
- Dysfunction of basal ganglia and cortical
neuronal components
Minor criteria
-
Arthralgia
Fever
Elevated acute phase reactants: CRP,
ESR
- ECG : PR interval > : not specific
Diagnosis of rheumatic
fever
Based on
2 major criteria
or
1 major + 2 minor
ASTO
Exeptions
Chorea may occur as the only
manifestations of RF
Indolent carditis may be the only
manifestation
Occasionally patients with RF
recurrences
may not fulfill the Jones criteria
Differential diagnosis of RF
Juvenile rheumatoid arthritis
Collagen vascular diseases
Virus associated acute arthritis
Note
* Rheumatic fever is a clinical syndrome for
which no specific diagnostic test exist !
* No symptom, sign or lab test result is
pathognomonic, although several
combinations of them are diagnostic
* Only carditis can cause permanent cardiac
damage. Signs of mild carditis disappear
rapidly in weeks but severe carditis may last
for 2-6 months. Chorea and arthritis usually
subside without permanent damage.
Management of RF
Benzathin penicillin G 0.6 1.2 M units IM
for eradication and prophylaxis
Bed rest
Acetosal for mild cases
Prednison for severe cases
Antiinflammatory agents not needed for
isolated chorea
Arthritis
Mild
Moderate
alone
carditis
carditis
__________________________________________________
Prednisone
0
0
0
Aspirin
1-2 wk
3-4 wk#
6-8 wk
___________________________________________________
Severe
carditis
2-6 wk*
2-4 mo
____________________________________
Arthritis
Mild
Moderate
Severe
Alone
Carditis
Carditis
Carditis
__________________________________________________________
Bed rest
1-2 wk
3-4 wk
4-6 wk as long as HF +
Indoor ambulation
1-2 wk
3-4 wk
4-6 wk
2-3 mo
_________________________________________________________
ESR: important for duration of restriction of activities.
Full activity : ESR normal, except significant cardiac involvement _
cardiomegaly
Moderate carditis : definite but mild
cardiomegaly
Severe carditis : marked
cardiomegaly or
HF (heart failure)
Prevention
- Ideally prophylaxis is indefinite
- Benzathin Penicillin (600,000-1,200,000
Mitral stenosis
Prevalence
Most common valvular involvement in
adult
Requires 5-10 years from the initial
attack
Pathology
Clinical manifestations
Mild MS : asymptomatic
More severe : dyspnea with/out
exertion :
orthopnea, nocturnal
dyspnea or palpitation
Physical Examinations
Increased RV impulse along the LSB
Weak peripheral pulse with narrow
pulse pressure
Pulmonary hypertension : loud S1 at
apex and narrow split S2, accentuated
P2
Mid diastolic/presystolic murmur
Treatment of MS
Prophylactic antibiotic
Restriction of activity depends on
severity
Symptomatic patients (dyspnea on
exertion, pulmonary edema,
paroxysmal dyspnea) : baloon or
surgery
MITRAL REGURGITATION
Most common in RHD
Pathology
Mitral valve leaflets are shortened
because of fibrosis.
When degree of MR increases,
dilatation of LA and LV results, mitral
ring becomes dilated
Echocardiography
Clinical manifestations
* Asymptomatic during childhood
* Rare : fatigue, palpitation
Physical examination
Heaving, hyperdynamic apical impulse
in severe MR
S1 normal or diminished. S2 may split
(shortening of LV ejection, early aortic
closure)
Pansystolic murmur at apex left
axilla
ECG
Normal in mild cases
LVH or LV dominance, with or without LAH
CXR
LA and LV enlarged
Pulmonary congestion pattern in CHF
Treatment
Prophylactic antibiotic
No restriction of activity in mild cases
Surgical : intractable CHF,
progressive
cardiomegaly, pulmonary
hypertension
AORTIC REGURGITATION
Less common than MR. Mostly
associated with mitral valve disease.
Pathology
* Semilunar cusps are deformed and
shortened.
* Valve ring is dilated
* Commisures usually are fused
Aortic Valvulitis
Clinical Manifestations
Physical Examination
Precordium may be hyperdynamic. Diastolic thrill
at 3 LICS
S1 decreased, S2 may be normal or single
High pitched diastolic cresendo murmur at
3 LICS or 4 LICS
Systolic murmur at 2 RICS due to relative AS
Severe AS : middiastolic murmur at apex
ECG
Normal in mild cases
Severe : LVH, LAH
CXR
Cardiomegaly (LVH)
Dilated ascending aorta
Treatment
Prophylactic antibiotics
Mild cases : no restriction in activity
Surgical : in anginal pain or dyspnea
on exertion, significant cardiomegaly
Thank
You
NO PAIN NO GAIN