By ULY CLINIC
Acute rheumatic fever
It is a non–suppurative sequela of a group A ß haemolytic streptococcal (GABHS) pharyngeal infection.
Sign and Symptoms
• Migratory polyarthritis
• Sydenham’s chorea
• Erythema Marginatum
• Elevated Acute Phase Reactants eg CRP
• Prolonged PR interval
Plus Supporting evidence of recent group A streptococcal infection e.g. positive throat culture or antigen detection and/or elevated streptococcal antibody tests* *Anti –Streptolysin O, Anti –Deoxyribonuclease B
• Two major criteria or
• One major criterion with two minor criteria, with evidence of antecedent streptococcal infection
- Treatment of acute attack for eradication of streptococci in throat: Regardless of the presence or absence of pharyngitis at the time of diagnosis.
• Benzathine Penicillin 1.2MU single dose IM. Paediatric> 5 years 0.3MU, 5–10 years 0.6 MU > 10 years 1.2.mu single dose IM.
• Penicillin V 500mg two to three times daily for 10 days orally. Children > 10years 500mg, 5–10 years 250mg, < 5years 125mg two to three times daily for 10 days orally
Patients allergic to penicillin
• Erythromycin 500mg or 40mg/kg 4 times per day for 10 days orally.
Treatment of Acute Arthritis and Carditis:
• Aspirin orally 25mg/kg, 4 times a day as required. Aspirin should be continued until fever, all signs of joint inflammation and the ESR have returned to normal and then tapered gradually over 2 weeks. If symptoms recur, full doses should be restarted. Dose should be reduced if tinnitus or other toxic symptoms develop
In severe carditis with development of increasing heart failure or failure of response to aspirin,
• Prednisolone 1–2mg/kg once a day for 3–4 weeks.
Then review and gradual reduction and discontinuation of prednisolone may be started after 3–4 weeks when there has been a substantial reduction in clinical disease.
Heart failure should be managed in the usual way (see Heart Failure Section 20.7).
Treatment of Sydenham’s Chorea:
• Haloperidol 1.5–3mg (O) 8hourly a day as required (Adult). Paediatrics 50µg/kg in 2 divided doses.
Referral: Ideally all patients should be referred to high level of care a specialized hospital care; where surgery is contemplated
Antibiotic prophylaxis after rheumatic fever:
Prophylaxis should be given to all patients with a history of acute rheumatic fever and to those with rheumatic heart valve lesions. The optimum duration of prophylaxis is controversial, but should be continued up to at least 21 years of age.
Note: Specific situations requiring prophylaxis for longer periods (up to 30 years as a guide):
• Definitive carditis in previous attacks
• high risk of exposure to streptococcal infection at home or work (crowded conditions, high exposure to children)
Medicine of choice
• Benzathine Penicillin IM Adult 2.4MU monthly or every three weeks. Paediatrics <12yrs 1.2MU every 4 weeks or 3 weeks for up to 21–30yrs
• Penicillin V (PO) 250mg 12 hourly Adult. Paediatric <12yr 125–250mg 12 hourly a day up to 21–30yrs
• Erythromycin 250mg 12hourly a day Adult. Paediatric <12yr 125–250mg 2 times a day up to 21–30yrs, Every 3week regimen is more effective
- Treatment Acute stage:
• Bed rest and supportive care until all evidence of active carditis has resolved
• Patient education.
• Intensive health education for prevention of sore throats
5 Novemba 2020 11:31:27