ACUTE RHEUMATIC FEVER IN CHILDREN

Dr.S.SrinivasanProfessor of Paediatrics

MBBS – Medical Undergraduate Theory Lecture for 8th and 9th Semester Students

ARF -Dated: 11th February 2016

World Heart Federation

“ Rheumatic heart disease (RHD) is the most common acquired heart disease in children in many countries of the world, especially in developing countries. 

 The global burden of disease caused by rheumatic fever currently falls disproportionately on children living in the developing world, especially where poverty is widespread ” 

Immuno-pathogenesis of Acute Rheumatic Fever & RHD

• Group A Beta Hemolytic Streptococcal infection• Autoantibody response against the heart• (Anti-myosin antibodies)• Antibody deposition on heart valve endothelium and in the

myocardial vessels and tissues.• Infiltration of myocardium and valvular region with

macrophages and autoreactive T lymphocytes.• Destruction of myofibers• (Cardiomyocytes in myocardium)• Valvulitis, Scarring, collagen deposition• (Heart murmur)

ARF -Dated: 11th February 2016

ARF -Dated: 11th Feb 2016

Acute Rheumatic Fever

Arthritis Carditis ChoreaRheumatoid arthritisSystemic lupus erythematosis,Serum sicknessSickle cell diseasePost infective reactive arthritis(Shigella, Salmonella, Yersinia)Leukemia

Kawasaki diseaseViral

myocarditis,Viral

pericarditisCongenital

heart diseaseInnocent murmur

TICS,Hyperactvity

Huntington choreaWilson disease

SLE

ARF -Dated: 11th February 2016

Revised Jones criteria of 1992 (WHO adoption of 2004)

Clinical and Laboratory

criteria

Major PolyarthritisCarditisChoreaSubcutaneous nodulesErythema marginatum

Minor FeverPolyarthralgia ESR, CRP. leukocytosisECG: Prolonged PR interval

Supportive evidence of preceding

streptococcal infection

Anti streptolysin O, Anti-deoxyribonuclease H/ of (within previous 45 days) streptococcal sore throat Scarlet feverPositive throat culturePositive rapid streptococcal antigen detection test

ARF -Dated: 11th February 2016

Management of Children with Acute Rheumatic Fever ANTIBIOTIC THERAPYA single deep IM injection: Benzathine Penicillin regardless of the throat culture results to eradicate GABS from the upper respiratory tract. or 10 days of orally administered Penicillin or Erythromycin

Anti-inflammatory TherapyAspirin (Arthritis) & Prednisolone + Aspirin (Carditis)

General Measures - Rest and ambulationAmbulate as soon as the signs of acute inflammation have subsided with longer periods of bed rest for carditis children

ARF -Dated: 11th February 2016

Treatment of Acute Rheumatic FeverClinical condition Anti-inflammatory DrugArthralgia Any analgesic can be usedArthritis Aspirin 100mg/kg/day in divided doses for two

weeks followed by 75mg/kg/day in divided doses for 4-6 weeks.

Carditis with cardiomegaly or CHF

Prednisolone 2mg/kg/day in divided doses x 2 weeks Tapering dose to be stopped in another two weeks. While tapering Steroids, Start Aspirin 75mg/kg/day in divided doses for 4-6 weeks to prevent re-bound phenomena.

CHF Antifailure measures – Bed Rest , Diuretics, Digoxin, Salt Restricted Diet.

Chorea Sodium valproate, Haloperidol

Duration of Acute Rheumatic Fever

• Average : About 12 weeks

• Rarely prolonged even up to 6 months especially with carditis or chorea

• “ Chronic Rheumatic Fever ”: Rare (active for more than six months )

COURSE AND PROGNOSIS of ARF “Rheumatic Fever licks the joints and bites the heart” (1884,

Lasegue)PROGNOSIS

Arthritis Good prognosisChoreaCarditis 25% ( 1in 4 ) of RF patients : Residual heart disease

( MR,MS,AR,AS ) If carditis is limited to systolic murmurARF with congestive cardiac failure develops chronic valvular heart disease over a period of 5-10 years

Death during acute ARF

Rare in the past 30 years ( better awareness and early Health seeking behaviour and treatment facilities )

Primary Prophylaxis for Rheumatic Fever Treatment of streptococcal tonsillo pharyngitis

(Adopted from WHO Technical Report Series 2004 )

Antibiotic Mode Dose DurationBenzathine Penicillin

Intramuscular <27 kg: 6 lac units>27 kg: 12 lac units

Single dose.

Phenoxymethyl penicillin (penicillin-V)

Orally 2-4 times/day Children:250-500 mg Adults:250 mg or 500mg

10 days.

Amoxicillin Orally 2-3 times/day 25-50 mg/kg/day Adult dose: 750-1,500 mg/day.

10 days

First generation Cephalosporin

Orally 2-3 times/day Varies with agent 10 days

Erythromycin ethyl succinate

Orally 4 times/day 40 mg/kg/day 10 days

Secondary Penicillin Prophylaxis

CONDITION DURATION OF PENICILLIN PROPHYLAXIS

No carditis 5 years or until 21 years old

Carditis without residual cardiac defect-

10 years or until 21 years old

Cardiac defect until 40 years old or later

Drugs for Secondary Rheumatic Prophylaxis Drugs Dose Route Frequency

Benzathine penicillin (benzathine penicillin G)

600,000 units for patients <27kg (60 lb)

im 3 to 4 weeks

1,200,000 units for patients ≥27kg (60 lb)

ORPhenoxymethyl penicillin

(penicillin V)250 mg Oral bd

Patients allergic to penicillin:Sulfadiazine 0.5g for patients <27kg

(60 lb)Oral od

1.0g for patients ≥27kg (60 lb)

Patients allergic to penicillin and Sulfadiazine:Erythromycin 250 mg Oral bd