Introduction
Rheumatic Fever is a result of abnormal reaction of antibodies developed against antigens of group A B-haemolytic streptococcus.
Infection is usually of the throat; occasionally the skin in a sensitized individual.
Antigen-Antibody complex damages the heart (endocardium, myocardium and pericardium).
The commonest streptococcal strains in Africa are C and G
Clinical features
Duckett-Jones’ diagnostic criteria
Major:
- Carditis.
- Sydenham’s chorea
- Erythema marginatum
- Subcuoeous nodules.
- Arthritis (migratory polyarthritis)
Minor:
- Fever
- Leucocytosis
- Arthralgia
- Raised ESR
- Raised ASO titre (>200 IU)
- Prolonged PR interval
- Supporting evidence of antecedent group A streptococcal infection:
- Positive throat culture or rapid streptococcal antigen
Diagnosis
2 major criteria
Or:
1 major plus 2 (or more) minor criteria
Differential diagnoses
- Malaria
- Viral infection
- Pyrexia of undetermined origin
- Connective tissue disease
Complications
- Rheumatic heart disease
- Arrhythmias
- Cardiac failure
Investigations
- ASO titre
- ESR
- Electrocardiograph
- Full Blood Count and differentials
- Throat swab for microscopy, culture and Echocardiography
- Chest radiograph sensitivity
Treatment objectives
- Relieve symptoms
- Treat the bacterial throat infection
- Reduce or abolish inflammatory process
- Treat cardiac failure if present
Non-drug treatment
- Bed rest
Drug treatment
1. Antibiotics
Penicillin V
- Adult: 500 mg orally every 6 hours, increased up to 1g6hourly in severe infections
- Child:
- 1 month – 1 year: 62.5 mg orally every 6 hours increased in severe infection to ensure at least 12.5mg/kg/dose
- 1-6 years: 125 mg every 6 hours increased in severe infection to ensure at least 12.5 mg/kg/dose
- 6-12 years: 250 mg every 6 hours, increased in severe infection to ensure at least 12.5 mg/kg/dose
- 12-18 years 500 mg every 6 hours, increased in severe infection up to 1 g/dose
Or
Erythromycin
- Adult and child over 8 years: 250-500 mg orally every 6 hours or 500 mg – 1 g every 12 hours; up to 4 g daily in severe infections
- Child: up to 2 years, 125 orally mg every 6 hours; 2-8 years 250 mg every 6 hours; doses
2. Salicylates
Aspirin (acetylsalicylic acid) doubled for severe infections
- Adult: 300 mg-1 g orally every 4 hours after food; maximum dose in acute conditions 8 g daily
- Child: not recommended for use
Steroids (if salicylates are ineffective)
3. Prednisolone
- Initially, up to 10-20 mg orally daily; up to 60 mg daily in severe disease
(preferably taken in the morning after breakfast); dose can often be reduced within a few days, but may need to be continued for several weeks or months - Maintenance 2.5-15 mg orally daily
Prophylaxis against rheumatic fever
Benzathine penicillin 720 mg (1.2 million
units) intramuscularly 3-4 weekly until the age of 25 years or for life
Notable adverse drug reactions
- Penicillin: anaphylactic reaction
- Salicylates; steroids: peptic ulceration, Cushingnoid effects are increasingly likely with doses of prednisolone above 7.5 mg
daily
Prevention
- Good sanitation
- School surveys – identify carriers of
streptococcus and treat - Secondary prevention and prophylaxis against endocarditis