Rheumatic Fever

Epidemiology

  • Peak Age: 6-15 y/o
  • Sex-Predominance: only 20% of first time attacks occur in males

Etiology

  • Streptococcus Pyogenes (Group A Strep) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])
    • Site of Instigating Streptococcus Pyogenes Infection
    • Latency After Streptococcus Pyogenes Infection: usually 2-3 weeks

Physiology

  • Antibody Cross-Reactivity Against Antigens Present in Heart, Joints, Skin, and Brain: xxx

Diagnosis

  • Antistreptolysin O (ASO): xxx
  • Streptococcal Antibody Titer: xxx
  • Throat Culture: xxx

Clinical-Jones Diagnostic Criteria

General Comments

  • Required for Diagnosis
    • Presence of 2 Major Criteria
    • Presence of 1 Major Criterion + 2 Minor Criteria
  • Potential Pitfalls with Strict Adherence to Jones Criteria: in areas of high rheumatic fever prevalence (for example, in Australian aboriginals), these criteria may result in underdiagnosis of rheumatic fever cases (where monoarthritis and low-grade fever were noted to be important clinical manifestations)
  • Alternative Clinical Scenarios Where Diagnosis Can Be Made Without Strict Adherence to Jones Criteria
    • Chorea as the Only Manifestation
    • Indolent Carditis as the Only Manifestation in Patient Evaluated Months After Streptococcus Pyogenes Infection
    • Recurrent Rheumatic Fever in Patient with a History of Prior Rheumatic Fever or Rheumatic Heart Disease: in these cases, caution should be exercised in diagnosing recurrent rheumatic fever in the presence of a single criterion (such as monoarthritis, fever, arthralgias, etc)

Major Criteria

  • Migratory Arthritis (see Arthritis, [[Arthritis]]): predominantly involving the large joints (typically starting in lower extremities and migrating upward)
    • Treatment with non-steroidal anti-inflammatory drugs (NSAID’s) may instead result in monoarthritis, rather than polyarthritis
    • Treatment with NSAID’s or corticosteroids before the presentation of rheumatic fever becomes recognizable may mask the clinical diagnosis: additionally, there is no evidence that withholding such treatment has any adverse impact on disease outcome
      • For these reasons, NSAID’s or corticosteroids should be used cautiously if rheumatic fever is suspected
  • Pancarditis
  • Central Nervous System Involvement
    • Sydenham Chorea (“St. Vitus’ Dance”): rapid movements of face and arms
      • May occur late in the course, months after the initial infection
  • Erythema Marginatum: long-lasting rash that begins as macules on trunk/arms -> clear in the middle to form rings -> coalesce into snake-like appearance
    • Typically spares the face
    • Typically exacerbated by heat
  • Subcutaneous Nodules (see Papular-Nodular Skin Lesions, [[Papular-Nodular Skin Lesions]]): painless, firm, and typically located over bones or tendons (back of wrist, elbows, knees)

Minor Criteria

  • Arthralgia (see Arthralgias, [[Arthralgias]])
  • Fever (see Fever, [[Fever]])
  • Elevated Acute Phase Reactants
    • Elevated Erythrocyte Sedimentation Rate [ESR)
    • Elevated C-Reactive Protein (CRP)
  • First Degree Heart Block (see First Degree Heart Block, [[First Degree Heart Block]])
    • Excluded if pancarditis is a major criterion
  • Leukocytosis (see Leukocytosis, [[Leukocytosis]])

Clinical-Other Manifestations


Treatment


References

  • xxx