Rheumatic fever

Rheumatic fever - Acute
Rahul Soman, M. Pharm

 

Definition  

An inflammatory disease that stems from an autoimmune response to a group A streptococcal infection

 

Medical History  

* Past medical history of Streptococcal group A infection

 

Findings  

* Inflamed joint

* Heart murmur

* Limitation of joint movement

* Fever

* Heart failure

* Pleuritic pain

* Pericardial friction rub

* Heart sounds diminished

* Macular eruption

* Subcutaneous nodule

* Chorea

* Muscle weakness

* Altered behavior

 

Tests  

 

Suspected group A beta-hemolytic streptococcal throat infection  

* Microbial identification kit, rapid strep method: In the presence of concordant signs and symptoms, a positive rapid antigen detection test (RADT) is diagnostic for group A beta-hemolytic streptococcus infection in adults and children .

 

Confirmation of suspected streptococcal pharyngitis in children and adolescents with a negative antigen-detection (rapid strep) test  

* Throat culture: Throat culture is the gold standard for the diagnosis of group A beta-hemolytic streptococcus pharyngitis .

 

Suspected streptococcal pharyngitis in adults  

* Throat culture: Throat cultures are not recommended for the routine, primary evaluation of adults with suspected streptococcal pharyngitis .

 

Suspected recent streptococcal infection  

* Antistreptolysin O titer

 

Suspected group A beta-hemolytic streptococcal infection or post-streptococcal sequelae (rheumatic fever and acute glomerulonephritis)  

* Anti DNase B test: Elevated ADNase B titers, associated with certain clinical signs and symptoms, suggests past or current group A beta-hemolytic streptococcal infection .

 

Suspected and known rheumatic fever  

* Echocardiography: Echocardiography is used to evaluate cardiac function, but it is not recommended in patients who lack clinical findings .

 

Differential Diagnosis  

* Septic arthritis - Acute

* Rheumatoid arthritis - Chronic

* Juvenile rheumatoid arthritis

* Post-streptococcal reactive arthritis

* Post-infective arthritis

* Lyme disease

* Sickle cell anemia - Chronic

* Gout - Chronic

* Mitral valve prolapse - Chronic

* Congenital heart disease - Chronic

* Infective endocarditis - Acute

* Hypertrophic cardiomyopathy

* Systemic lupus erythematosus - Chronic

* Huntington's disease - Chronic

* Encephalitis

* Leukemia

* Malignant lymphoma

 

Treatment  

 

Drug Therapy  

 

 

Primary prevention of rheumatic fever  

 

PENICILLIN G BENZATHINE  

Adults (>27 kg): 1.2 million units IM single dose

Pediatrics (?27 kg): 600,000 units IM single dose ; observe children for 30 minutes after injection

 

PENICILLIN V POTASSIUM  

Adults: 500 orally two or three times daily for 10 days

Adolescents: 500 orally two or three times daily for 10 days

Pediatrics: 250 mg orally two or three times daily for 10 days

 

AMOXICILLIN  

Adults: 25 to 50 mg/kg/day orally in 3 doses for a total dose of 750 to 1500 mg/day for 10 days

Pediatrics: 25 to 50 mg/kg/day orally in 3 divided doses for 10 days

 

 

Symptomatic relief in rheumatic fever  

 

IBUPROFEN (Related toxicological information in IBUPROFEN)  

Adults: 200 to 800 mg orally every 6 to 8 hours as needed (maximum 3.2 g/day)

Pediatrics: 5 to 10 mg/kg orally every 6 to 8 hours as needed (maximum, lesser of 40 mg/kg/day or 2.4 g/day)

 

 

Primary prevention of rheumatic fever and treatment of group A streptococcal throat infection in patients allergic to penicillin  

 

ERYTHROMYCIN ESTOLATE  

Adults: 20 to 40 mg/kg/day orally divided two to four times daily (maximum 1 g/day) for 10 days

 

ERYTHROMYCIN ETHYLSUCCINATE  

Adults: 40 mg/kg/day orally divided two to four times daily (maximum 1g/day) for 10 days

 

AZITHROMYCIN  

Adults: 500 mg orally on the first day followed by 250 mg/day for the next 4 days

 

 

Secondary prevention of rheumatic fever  

 

PENICILLIN G BENZATHINE  

Adults (?30 kg): 1.2 million units IM every 3 to 4 weeks

Pediatrics (<30 kg): 600,000 units IM every 3 to 4 weeks

 

PENICILLIN V POTASSIUM  

Adults: 250 mg orally twice daily

Pediatrics: 250 mg orally twice daily

 

 

Secondary prevention of rheumatic fever in patients allergic to penicillin  

 

ERYTHROMYCIN  

Adults: 250 mg orally twice daily

Pediatrics: 250 mg orally twice daily

 

Procedural Therapy  

 

Rheumatic heart disease  

* Open heart surgery: In patients with acute carditis and heart failure, surgical treatment of severe valve lesions may be necessary for survival .

 

Non-Procedural Therapy  

 

Rheumatic fever  

* Bed Rest