Professional Documents
Culture Documents
HEART DISEASE
Contributors
179
Check whether
Keep patient
under
observation for
2 weeks
10
Meets the
Jones'
Criteria?
the streptococcal
infection was
treated
Classify the
case
11
13
12
Carditis?
Discharge
14
180
Send patient
to
hospital
If there is no
hospital, treat with
inflammatory drugs.
Let patient rest and
begin secondary
prevention.
FIGURE 1
15
Meets the
Jones'
Criteria?
Medical
Examination
Patient
sees a physician
within 48
hours?
Send for
consultation
Send for
registry
3
by mouth for
10 days
Begin or
continue preventive
administration of
IM penicillin
every month
Continue preventive
regimen with a daily
dose erythromycin
250 mg twice daily
on evolution
11
10
Y Has reached
18 years
of age?
Keep an eye
Y Suspend the
prevention
treatment
13
Over 5 years
since acute
attack?
12
Maintain
preventive
regimen for
whole life
Keep an eye on
evolution
Continue preventive
regimen until 5
years have elapsed
14
15
Functionally
stable?
16
Has RHD?
erythromycin
Treatment with
Hypersensitive
to penicillin?
Continue
preventive
regimen
Send to
specialist for
evaluation
FIGURE 2
181
Child 5 to 15 years
of age with an acute
infection of the upper
respiratory tract
2
Consultation
3
Examination by
physician, nurse or
trained auxiliary
A single dose of
benzathine penicillin
or 10 days of oral
penicillin
Treatment
with
erythromycin
for 10 days
Allergic to
penicillin?
Health
education
10
Positive throat
culture
(Typical Strep
throat)
Discharge
FIGURE 3
182
Manual of Operation of the Primary and Secondary Prevention of Rheumatic Fever-Rheumatic Heart Disease
INTRODUCTION
The RF/RHD Registry is one major component of the Program
for the Prevention and Control of RF/RHD, being spearheaded
by the Philippine Foundation for the Prevention and Control
of RF/RHD in coordination with the Department of Health
and other professional organizations and societies, such as the
Philippine Heart Association, Philippine Society of Pediatric
Cardiology and the Philippine Pediatric Society.
The RF/RHD Registry will serve at least two purposes. Firstly,
it will verify referred cases of RF/RHD, which will eventually
permit a long-term follow-up study of verified cases of RF/
RHD. Secondly, it will act as means through which secondary
prophylaxis will be administered.
SCREENING AND MANAGEMENT OF CASES OF ACUTE
RF
If the patient is a child aged between 5 and 15 who is suffering
from joint pain and high temperature, he must be sent to a
physician as soon as possible. If no physician is available,
the patient is advised to rest and symptomatic treatment is
given.
The physician should examine the patient before 48 hours
have elapsed and check whether he presents the symptoms
mentioned in the Jones' Diagnostic Criteria (Tables 1-3 and
Figure 1). If he does not, he should be kept under observation
for two weeks and then discharged if the diagnosis cannot be
established within the period. If the Jones' criteria are fulfilled,
the physician will check whether the streptococcal infection
has been treated and will classify the case as to presence or
absence of carditis.
If the patient is not suffering from carditis, he can be treated
by a general practitioner but whenever possible, he should
be admitted to a hospital as an in-patient for confirmation
of the diagnosis and for treatment. A patient with carditis
must always be admitted to a hospital for treatment and after
hospital discharge, must be on home rest for at least six (6)
weeks (Algorithm Fig. 1). Patient is also sent to a registry for
secondary penicillin prophylaxis (Algorithm Fig. 2).
Table 1: Diagnostic Criteria
Modified Jones' Criteria for Diagnosis of Rheumatic Fever
A. Major Criteria
B. Minor Criteria
1. Arthritis 1.
2. Carditis 2.
Fever
Arthralgia (pain in
joints without objective
findings)
Minor
Carditis
Minor
Polyarthritis Clinical
Chorea Fever
Erythema marginatum Arthralgia
Subcutaneous Nodules Laboratory
Elevated ESR
Positive CRP
Prolonged P-R interval
184
Dosage of Prednisone:
Mild (without cardiomegaly) 40 mg/day
Moderate (with cardiomegaly) 60 mg/day
Severe (with cardiomegaly and hearth failure) 60
mg/day
95%
100
PERCENT OF PATIENTS
WITH TITER .200 u./cc.
*Carditis:
80
90%
78%
60
40
20
0
ASO
ASO
only
or AH
ASO = Antistreptolysin O
AH = Antihyaluronidase
ASK = Antistreptokinase
ASO
or AH
or ASK
Primary Prevention
Primary prevention is the treatment of upper respiratory
tract infection due to group A beta-hemolytic streptococci
to prevent an initial attack of acute rheumatic fever. Studies
have demonstrated that appropriate antibiotics, given early in
the course of streptococcal infection, essentially prevents the
development of rheumatic fever (Table 5).
Mode of
Antibiotics
Administration
Benzathine Intramuscular
Penicillin
injection)
Phenoxymethyl
Oral
Penicillin (V)
Dose
-1,200,000 units for
adults & children more
than 30 kg
600,000 units for
children weighing
less than 30 kg
(given as a single
-250 mg 3-4 times a
day for 10 days. Very
small children
weighing less than
20 kg may be given
125 mg 4 times a day.
185
186
2.6
Non-Strep
Symptoms
Pain on swallowing
Fever
Headache
Abdominal pain
Nausea and vomiting
Coryza
Hoarseness
Cough
Diarrhea
Signs
Tonsillopharyngeal erythema
Tonsillopharyngeal exudate
Soft palate petechiae
("doughnut" lesions)
Beefy red, swollen ovula
Anterior cervical adenitis
Scarlantiniform rash
Conjunctivitis
Anterior stomatitis
Discrete ulcerative lesions
Appendix 1
RF-RHD Registry Center
Code
Number Region
Center
00000
NCR
00101
Philippine Heart Center
00102
St. Luke's Medical Center
00103 UERMMC
00104
Phil. Children's Medical Center
00105
Quezon City General Hospital
00201 UP-PGH
00202 UST
00301
Makati Medical Center
00401
MCU
01000
Region I
San Fernando, La Union
02000
Region II Tuguegarao, Cagayan
03000
Region III San Fernando, Pampanga
04100
Region IV Lipa City
05100
Region V Naga
15200
Legaspi
05300
Sorsogon
06100
Region VI Iloilo
07100
Region VII Cebu
07200
Bohol
08000
Region VIII Tacloban, Leyte
09100
Region IX Zamboanga City
10100
Region X Cagayan de Oro City
11100
Region XI Davao City
12000
Region XII Cotabato City
References:
1. Rheumatic Fever. Markowitz and Gordis. W.B. Saunders,
Philadelphia, 1972
2. Rheumatic Fever and Streptococcal Infection. Gene H.
Stallerman. Grine and Stratton, New York, 1975
3. Rheumatic Fever. Angelo Toronta and Milton Markowitz.
MTP Press Limited, Boston, 1981
4. Prevention and Control of Rheumatic Fever in the
Community. Pan American Health Organization.
Washington, D.C., 1985
5. Rheumatic Fever and Rheumatic Heart Disease. B.L.
Agarwal. Arnold Publishers. Bombay, 1988
6. Streptococcal Sore Throat Rheumatic Fever/Rheumatic
Heart Disease. Achutti, Kaplan, Nordet and Vynckt.
UNESCO, WHO and ISFC. 1992
7. Treatment of Acute Strep Pharyngitis and Prevention of
RF: Statement for Health Professionals. Committee on
Rheumatic Fever, Endocarditis and Kawasaki Disease
of the Council on Cardiovascular Diseases in the Young,
American Heart Association Rajumi, et al. Pediatrics 95
(96) 4: 758-68
8. Guidelines of the Diagnosis of Rheumatic Fever.
Jones Criteria, 1992 update by Special Writing Group
of Committee on Rheumatic Fever. Endocarditis and
Kawasaki Disease of the Council on Cardiovascular
Diseases in the Young. American Heart Association, JAMA
92 October 21; (268) 15:2069-73
187
Name of Patient:
Address:
School:
Year of Birth: [ ] [ ] [ ]
day month year
Source of Notification to Registry: [ ]
1 - Hospital in-patient department
2 - Hospital out-patient clinic
3 - Private physician
4 - Laboratory
Active Rheumatic Fever:
[ ] Diagnosis
Registration No.:
Date of Registration: [
Hospital No.: [
Sex: [ ] 1-Male 2-Female
] [
day
] [ ]
month year
Major Manifestation:
Minor Manifestation:
Evidence of previous Group A
Clinical
Laboratory
Beta-hemolytic Strep infection:
[ ] Carditis
[ ] Fever
[ ] Elevated ESR
[ ] Positive Throat Culture
[ ] Polyarthritis
[ ] Arthralgia
[ ] Positive CRP
[ ] Positive Rapid Antigen
[ ] Chorea
[ ] Prolonged P-R Test
[ ] Erythema Marginatum Interval
[ ] ASO Titer Elevation
[ ] Subcutaneous Nodules
[ ] Initial attack (1 - yes; 2 - no; 3 - not known)
[ ] Severity of heart damange
(0 - None; 1 - Mild; 2 - Moderate; 3 - Severe; 4 - not determined)
[ ] ASO Titer (1 - <200 units; 2 - 400 units; 3 - >800 units; 4 - not determined)
Chronic Rheumatic Cardiopathy:
Diagnosis
[ ] Mitral Stenosis
[ ] Aortic Insufficiency
[ ] Mitral Insufficiency
[ ] Aortic Stenosis
[ ] Organic Lesion of the Tricuspid Valve
[ ] Heart Failure
Year of Initial Attack:
[ ]
[ ]
[ ]
Year of last Attack:
[ ]
[ ]
day month year
day month
[ ] Number of Recurrences
1 - One
2 - Two
3 - More
4 - Not known
5 - None
6 - Initial Attack
1 - Regular Intramuscular
2 - Irregular Intramuscular
3 - Occasional Intramuscular
4 - Oral
PENICILLIN
5 - Sulphonamides
6 - Erythromycin
7 - Any Combination
8 - Initial Attack
9 - None
Source of Information:
Address: Telephone No.:
[ ]
year
Erythromycin
Am-Erythromycin
42
Ditron
42
DLI-Erythromycin
43
Drugmakers
Erythromycin
43
Ery-Max
43
Erybron*
43
Erycin
43
Erythrocin/
Erythrocin DS
43
Erythrolan
NP9, 43
Ethiocin
43
Gentrocin
43
Ilosone
43
J. McKnoll Erythromycin
44
Macrocin
44
Pharex-Erythromycin
44
Sarazine
44
Sefavex
44
Servitrocin
45
UL Erythromycin
45
Pen G benzathine
Penadur 6-3-3/
Penadur L-A*
Phenoxymethylpenicillin
Centrapen
Cimpicillin
Megapen
Mipacin
Pentacillin
Sumapen
UL Phenoxymethyl
Penicillin K
52
48
48
51
52
53
54
55
189