REMATIC FEVER (RF)

Definition :
Collagen disease
Occur following group A beta hemolytic streptococcal
(ABHS) pharyngitis
Carditis irreversible
Frequency : depends on the nutrition & environmental
status : 3 30 cases/10.000 population
7 14 years

1
Pathogenesis:
RF ABHS epidemiologic evidence
- throat culture ABHS
- R/ antibiotic against ABHS RF
Hypothesis :
Autoimmune response / antigenic similarity
Similarity of human tissues and somatic antigens
(ABHS)
ABHS infection (M protein) anti M antibodies cross-
react with components of heart tissue (sarcolemmal

membranes, valve glycoproteins)

ABHS elaborate streptolysins O (STO) marker of
ABHS
2
 Predisposition :
- RF history in the family
- age 5 15 yrs ( 8 yrs)
- sosec, winter season
PA : joints, heart Aschoff bodies
Clin.Manifestations :
Std. I : throat infection 2-4 days. RF 0.3-3%
II : latent phase 1 3 weeks

3
III : acute phase:
Arthritis : large joints, migratory, > 1 joint,
signs of infection, sterile joint fluid
persists for 2-4 days (rarely 4 weeks)
Carditis : endo-myo-peri (Pancarditis)
new/changing mmr, cardiomegaly, CHF
ECG : prolong PR interval
Chorea (Syndenham) :
F, 8 12 yrs, difficulty in writing, involuntary
grimacing
emotional lability, purposeless movement of arm/leg.

4
 Erythema marginatum : 1-3 cm diameter, pink to red
macula/papula, form serpiginous ring, raised margin,
central clearing, fade/reappear within hours
Location :Trunk, proximal limbs, never on the face
Subcutaneous nodules, firm, nontender, free from
attachment to the skin, diameter 1-2 cm.
Location : extensor of elbows, knees, ankles, scalp,
spinosuss processus lumbar/thoracic vertebrae
Epistaxis, abdominal pain, pneumonia
IV. Inactive phase : acute exacerbation
5
Laboratory studies:

SDR, leucocytosis, Hb , plasma cell

Throat culture : ABHS

ASTO progressive , C-reactive protein (+)

6
 Diagnosis (revised Jones criteria, 1992)

I
MAJOR MINOR
-Carditis - Fever
-Arthritis - Arthralgia
- Chorea - ECG : Prolonged P-R interval
- Erythema marginatum - Elevated acute phase reactans:
- Subcutaneous nodules ESR >>, C-reactive protein (+)

Diagnosis : 2 major or 1 major + 2 minor & evidence of

previous ABHS pharyngitis (culture , ASTO)

7
II. Three notable exceptions :
A. Chorea (without any cause of the brain)
D/ without evidence of ABHS infection
B. Late onset carditis:
R F ??
CHF, valve involvement
Signs of acute infections (leucocytosis, ESR)
ECHO : no other cause of carditis could be proved,
valve involvement
D/ without evidence of ABHS infection

8
C. Recurrent (RF) carditis
- History of RF / RHD
- Recent ABHS infection
- 1 major or several minor criteria
III. Evidence of previous ABHS infection
pharyngitis (1 must be present) :
- positive throat culture or rapid
streptococcal antigen test
- elevated or rising streptococcal antibody
titer

9
X-ray : enlargement of left atrial appendage
Treatment :
1. Eradication of ABHS : Penicillin, erythromycin
2. Antirheumatic drugs: salicylates and steroids
Mild RF (arthritis): salicylates (aspirin): 6-8 wks
90-120 mg/kgBW/hr 4-6x/d, tapering off.
Moderate-severe carditis (cardiomegaly, CHF, AV block 3:
salicyaltes + steroids (prednison)
prednison 2,5 mg/kgBW/d 2-6 wks, tapering off

10
3. Diet

4. Bed rest : - mild RF: 3 wks

- severe RF : 3 mts

5. Others :

- Chorea : phenobarbital, diazepam

CHF : anticongestive drugs

- Surgery

11
 Prognosis : mild - severe

Inactive : SDR / leucocyt (6-10 weeks)

Residive : clin.manifestation as a new case
- mostly in the first year after first attack
- carditis
Prognosis : poor : cardiomegaly, CHF,
chorea

12
Prevention :

1. Primary prophylaxis : eradication of ABHS

2. Secundary prophylaxis : prevention of RF/RHD

Penicillin : Penadur (long acting) 1x/3 wks

Sulfa, erythromycin

Indefinitely for patients at high risk for ABHS

AHA: 5 yrs / aged 21 (RF minus carditis)

10 yrs / aged 40 (RF with carditis / valve)

Before surgical/dental procedure Antibiotic

13
 MIOCARDITIS DIFTERI

Etiology : Corynnebacterium diphtheriae

Cardiovascular involvement :

early peripheral collapse (wk I)

late myocardial injury (Myocarditis) wk 2-3

thromboemboly

Prevalence : 10 - 20% of D cases

14
Pathophysiology :
port dentre (tonsil, pharynx, larynx, mucocutaneous
exotoxin heart, ren, neuron
protein syntesis disturbances in the cardiac tissues
long chain fatty acid defect
PA : cardiomegaly, pale and soft
Predisposition:
Bacteriae virulence
Location
Immunization of DPT
Treatment (ADS, corticosteroid)
Bullneck

15
Clinical manifestation :

Pheripheral collapse : shock, ECG : N

Myocarditis : - reconvalescence state

- tachycardy / bradycardy

- CHF

- soft/muffled S, gallop rhythm

ECG : abnormal and block of rhythm

16
X-ray: normal or enlargement of heart

Lab. : tissues damaged cardiac enzym

(SGPT, SGOT, LDH, CPK)

Therapy: - bedrest, AB, ADS, corticosteroid

- CHF and arrhythmia

Prognosis : moratality rate 20-70 %

17
 VIRAL MIOCARDITIS

Etiology: Coxsackie B type 1-5 virus

Prevalence : neonatus < 2 wks
Clin.picture :
Antepartum maternal history : URTI
Fever, feeding difficulties, irritable, cyanosis,
convulsion), shock, CHF)
X-ray : cardiomegaly
Prognosis : died in the first week of life
18
 ANEMIC HEART DISEASE

Definition : due to anemia, 1-2%

Etiology : all kind of anemia
Pathogenesis : hyperkinetic circulatory state
adequate O2
tachycardia, increased Venous pressure
CO anoxia of cardiac muscles
dilatation and hyperthrophy
PA : cardiomegaly and increased weight

19
Clin.manifestation :

Signs of anemia, palpitation, fatique, anorexia, dizziness

Pulse pressure , neck veins pressure

Loud S2, hemic murmur, blood circulation increased &

blood viscosity decreased

Signs CHF

20
X - ray :

Cardiomegaly

Aorta & PA : prominent

Therapy :

PRC transfusion 10 ml/kgBB

Treat the underlying causes

Prognosis : good if anemia disappear

21
 CONGESTIVE HEART FAILURE (CHF)

Definition : - inadequate O2 supply to the whole body

- normal venous return (CO )
Prevalence : CHD 90% age < 1 yr, AHD age > 5 yrs
P overload (Syst/Pulm hypertension, obstruction)
V overload (L-R shunt, reflux, water retention)
Hyperkinetic ( increased vol/mnt) : anemia
Arrhythmia (brady / tachyarhythmia)
Myocarditis
Postoperative
Combined
22
Pathophysiology:
Normal heart accommodate the body requirement
6-10 x resting state
cardiac reserve
STARLING law the more stretch the muscles the more
strong the contraction
Heart failure the heart failts to accommodate the
excessive overload
4 factors : 1. Preload 3. Myocard contraction
2. Afterload 4. Heart rate

23
PRELOAD (myocardial end diastolic fiber length) :

Related to filling of ventricles ( pulm & syst. venous return)

Venous return increased stretching of myofilaments at

end diastolic Preload contraction CO

In CHF venous return stretching of myofilament cannot

meet the increased preload CO

R/ diuretic & venodilator preload CO

24
AFTER LOAD : (impedance/outflow resistance)
Related to systolic function
Stretching of myofilament ventricular wall
thickness
Overload of cardiac muscles in systolic phase
Afterload :
Increased peripheral vascular resistance
Myocard contraction (myocarditis)
Valve anomalies

25
 - R/ vasodilator & diuretic afterload

CO

MYOCARD CONTRACTION :

Myocard disturbances cardiac contraction

R/ symphatomimetic and digitalis

HEART RATE:

tachycardia shortage of diastolic phase, stroke

volume CO

26
Factors involve in CHF :
Nervous system and hormon
CHF sympathetic n.s cathecholamine :
- receptor : contraction / increased heart rate
- receptor : decreased peripheral blood circulation
(vasoconstriction)
Renal, water and electrolytes :
CO , RBF & GFR renin aldosteron (adrenal)
reabsorption of Na (tubulus) Na retension ADH
secretion water retention

27
 RBC : dissosiation of O2 HB (anemia & hipoxia)
Clinical manifestation :
Mostly CHF R + L, rarely L
CHF R : obstruction of systemic circulation
CHF L : obstruction of pulmonary circulation
Trias biventricular failure (R + L)
o Tachycardia (R + L)

o Tachypnea (L)

o Hepatomegaly (R)

28
Lab.: Hb , lecocytosis, glukose

Radiology : cardiomegaly

DD : CHD R L

Prognosis : age, R/

Therapy : (cause & CHF)

Bedrest

29
 Digitalis :
contraction , heart rate CO
diuresis preload (digoxin)

Intoxication : no drugs, KCl

Diuretic : - water retention and Na

- inadequate effect of digitalis

- water electrolytes imbalance

Supportive : O2, sedative

sleep position 200 300,

electrolyte, low salt intake

30
 PERICARDITIS

Mild severe (tamponade)

Infection of pericardial visceralis and parietalis
Etiology : mostly RF
Pathophysiology :
N : 10 15 ml fluid
Underlying myocard
Infection : increased amount of fluid compression of
the heart increased pressure in RA, LA, syst/pulm.
veins stroke volume CO

31
 Compensatory mechanism :
tachycardia, vasoconstriction peripheral blood vessels
Syst P increased Diast P decreased narrow pulse
pressure
pericardiocentesis
digitalis contraindication
Clinical picture :
Sharp, stabbing pain referred left chest, shoulder,
neck and scapula exaggerated by lying down and
relieved by sitting up
The result of diaphragm and pleura involvement

32
Physical exam depends on the quantity of fluid
1. Dry fibrinous P : friction rub
pulse, JVP, S & cardiac size N
2. Effusion : cardiomegaly, soft/muffled S
3. Tamponade :
Severely ill, cyanosis, dyspnea
JVP , pulse pressure , tachycardia,
Syst P , hepatomegaly, peripheral edema,
pulsus paradoxus (Syst pressure during
inspiration > 20 mmHg)
33
Radiology : - No effusion Normal heart
- Tamponade a water bottle
ECG : low voltage, abnormal T & ST wave
Echo : progress and amount of fluid
Therapy : - underlying disease (RF)
- thoracocentesis
Prognosis : - depends on the etiology

34