Professional Documents
Culture Documents
Hamzeh Al-Rashdan
Abdullah Al-Shorman
Thursday 29/11/2012
Today lecture about acute Rheumatic Fever ,its very easy lecture and won't take
more than 30 min.
The doctor was reading from the slides. Good luck.
Common streptococci:
The most common Streptococcus species isolated from humans are as follows
1) Streptococcus Pyogenes
2) Streptococcus Agalactiae
3) Streptococcus bovis
4) Streptococcus pneumoniae
5) and the Streptococcus Viridans group.
Streptococcus Pyogenes is a beta hemolytic streptococci and cause bacterial
phyrangitis.
It also causes Scarlet fever due to the erythrogenic toxin . They are also
known as "flesh eating" bacteria and can cause life-threatening disease,
necrotising facitis.it also causes Skin infections and Streptococcal toxic shock
syndrome.
This is pus formation from the tonsils ,most likely caused by Streptococcus Pyogenes
Epidemiology :
Pathogenesis :
The pathogenesis of acute Rh.fever is Delayed immune response to group.A beta
hemolytic streptococci. After a latent period of 1-3 weeks, and there is antibody
induced immunological damage occur to heart valves, joints, subcutaneous tissue
& basal ganglia of brain.
GABHS strains that cause ARF are: M types l, 3, 5, 6,18 & 24
Pharyngitis- produced by GABHS can lead to:
Post sterp.coccal glomerulo niphritis
Acute Rh.fever
Rheumatic heart disease
Skin infection- produced by GABHS leads to :
It will not result in Rh.Fever or carditis because skin lipid cholesterol will
inhibit antigenicity.
Pancaritis
Artharits
Ashcoff nodules in the subcutaneous tissue
Basal ganglia lesions resulting in chora
Migratory:in first 24hr afeecting the knee,then the other knee then elbow
and its not chronic
This is the abnormal movment in Sydenham Chorea we can see while the patient
is writing or walking or putting his button on.
4) Erythema Marginatum :
o Occur in less than 5%.
Unique,transient,serpiginous-looking lesions of 1-2 inches in size
Pale center with red irregular margin
More on trunks & limbs & non-itchy
Worsens with application of heat
Often associated with chronic carditis
05/05/1999
24
5)Subcutaneous nodules :
Occur in 10%
Painless,pea-sized,palpable nodules
Mainly over extensor surfaces of joints,spine,scapulae & scalp
Associated with strong seropositivity
Always associated with severe carditis.
Fever-(up to 38-39 )
Arthralgia
Pallor
Anorexia
Loss of weight
Laboratory finding :
High ESR
Anemia, leucocytosis
Elevated C-reactive protien
ASO titre >200 Todd units.
Anti-DNAse B test (+)
Throat culture-GABHstreptococci (+)because this is delayed inflammatory
reaction after 1-3 weeks.
ECG- prolonged PR interval, 2nd or 3rd degree blocks,ST depression,T
inversion
2-dimention Echo cardiography- valve edema,mitral regurgitation, LA & LV
dilatation,pericardial effusion,decreased contractility.
Minor
Manifestations
Clinical
Previous
rheumatic
fever or
rheumatic
heart disease
Arthralgia
Fever
Laboratory
Acute phase
reactants:
Erythrocyte
sedimentation
rate,
C-reactive
protein,
leukocytosis
Prolonged PR interval
Supporting Evidence
of Streptococal Infection
Increased Titer of AntiStreptococcal Antibodies ASO
(anti-streptolysin O),
others
Positive Throat Culture
for Group A Streptococcus
Recent Scarlet Fever
*The presence of two major criteria, or of one major and two minor
criteria, indicates a high probability of acute rheumatic fever, if
supported by evidence of Group A streptococcal nfection.
Differential Diagnosis :
6. Scarlet fever
7. Leukemia
Treatment:
we have 4 steps :
Penicillin V,
(phenoxymethyl penicillin)
For individuals
allergic to penicillin
Erythromycin:estolate
Dose
600 000 U
for patients 27 kg
(60 lb)
mode
IM
1 200 000 U
for patients >27 kg
Children:
oral
250 mg 2-3 times
daily
Adolescents
duration
once
10 d
20-40
oral
mg/kg/d
2-4 times
daily (maximum 1
g/d)
Ethylsuccinate
40 mg/kg/d
oral
10 d
10 d
For carditis
Aspirin:75-100mg/kg/day
Gives as 4 divided doses for 6 week
Attain blood level 20-30kg/dl
Predinsolone : 2-2.5mg/kg/day give as
two divided dose for 2 weeks
Taper for 2 week &while tapering add
aspirin 75mg/kg/day for two weeks,
continue aspirin alone 100mg/kg/day for
4 weeks
Bed rest : if there is carditis with congestive heart failure we must put the
patient in bed rest
If there with congestive heart failure beside giving pre we must treat
symptom of congestive heart failure by digitalis, diuretics and bed rest .
For chorea we 3 drugs used now : diazepam, haloperidol and valproic acid
We use one of them.
Also Rest to joints & supportive splinting is important.
STEP IV : Secondary Prevention of Rheumatic Fever (Prevention of Recurrent
Attacks)
agent
Benzathine penicillin G
Penicillin V
Sulfadiazine
dose
1 200 000 U every 4
weeks*
250 mg twice daily
0.5 g once daily for
patients 27 kg (60 lb)
1.0 g once daily for
patients >27 kg (60 lb)
mode
IM
oral
Oral
oral
duration
At least 10 y since last episode and at
least until age 40 y, sometimes lifelong
prophylaxis
10 y or well into adulthood, whichever
is longer
5 y or until age 21 y ,whichever is
longer
Prognosis :
Rheumatic fever can recur whenever the individual experience new GABH
streptococcal infection, if not on prophylactic medicines
Good prognosis for older age group & if no carditis during the initial
attack
Bad prognosis for younger children & those with carditis with valvar
lesions
Finally a Student ask if the patient didn't take long acting penicillin for one or two
months, would he develop symptom?
Dr : no he won't develop symptom unless he have another attack of
streptococcus infection this will result in recurrent acute Rh.fever.
THE END