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IM IMMUNO/RHEUMA > ARF > Flashcards

ARF Flashcards

1
Q
  • multisystem disease resulting from an autoimmune reaction to infection with GAS
  • cardiac valvular damage (rheumatic heart disease [RHD]), which may persist after the other features have disappeared
A

ARF

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2
Q

GLOBAL CONSIDERATIONS

A
  • ARF and RHD are diseases of poverty
  • RHD is the most common cause of heart disease in children in developing countries
  • major cause of mortality and morbidity in adults
  • 95% of ARF cases and RHD deaths now occur in developing countries
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3
Q
  • ARF is mainly a disease of children age
  • peaks between
A
  • 5-14 years
  • 25 and 40 years
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4
Q

ARF is exclusively caused by infection of the upper respiratory tract
with

A

GAS

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5
Q

appear to be associated with susceptibility

A

HLA-DR7 and HLA-DR4

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6
Q

class I] alleles have been associated with protection

A
  • HLA-DRS,
  • HLA-DR6,
  • HLA-DR51,
  • HLA-DR5S2,
  • HLA-DQ
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7
Q

Associations have also been described with polymorphisms at the ___, high levels of circulating mannose-binding lectin, and Toll-like receptors

A

tumor necrosis factor a locus (TNF a-308 and TNF-a-238)

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8
Q

latent period of ARF

A

3 week (1-5 weeks)

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9
Q

Clinical Features of ARF

A
  • Polyarthritis (60-75%)
  • carditis (50-60%)
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10
Q

Erythema marginatum and subcutaneous nodules are now rare, being found in

A

<5% of cases

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11
Q

Up to 75% of patients with ARF progress to

A

RHD

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12
Q

hallmark of rheumatic carditis

A

Valvular damage

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13
Q

is almost always affected

A

mitral valve

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14
Q

characteristic manifestation of carditis in previously
unaffected individuals is ____, sometimes
accompanied by ____

A
  • mitral regurgitation
  • aortic regurgitation
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15
Q

WHF Criteria for Echocardiographic Dx of RHD in Individuals <20 y.o

DEFINITE RHD

A
  • Pathologic MR and at least two morphologic features of RHD of the mitral valve
  • MS mean gradient 4 mmHg (note: congenital MV anomalies must be
    excluced)
  • Pathologic AR and at least two morphologic features of RHD of the AV note: bicuspid AV and dilated aortic root must be excluded
  • Borderline disease of both the MV and AV
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16
Q

WHF Criteria for Echocardiographic Dx of RHD in Individuals <20 y.o

BORDERLINE RHD

A
  • At least two morphologic features Of RHD of the MV without pathologic MR or MS
  • Pathologic MR
  • Patholorgic AR
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17
Q

WHF Criteria for Echocardiographic Dx of RHD in Individuals <20 y.o

NORMAL ECHOCARDIOGRAPHIC FINDINGS

A

ALL 4

  • MR that does not meet all 4 Doppler criteria (physiologic MR)
  • AR that does not meet all 4 Doppler criteria (physiologic AR)
  • An isolated morphologic feature of RHD of the MV (e.g valvular thickening without any associated pathologic stenosis or regurgitation
  • Morphologic feature of RMD of the AV (e.g valvular thickening) w/o any associated Pathologic Stenosis or regurgitation
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18
Q

most common form of joint involvement in ARF

A

Arthritis

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19
Q
  • migratory, moving from one joint to another over a period of hours
  • ARF almost always affects the large joints
  • most commonly the knees, ankles, hips, and elbows—and is
    asymmetric
A

Polyarthritis

20
Q

commonly occurs in the absence of other manifestations

A

Sydenham’s chorea

21
Q
  • follows a prolonged latent period after group A streptococcal infection
  • found mainly in females
  • The choreiform movements affect particularly the head (causing characteristic darting movements of the tongue) and the upper limbs
  • More than 50% of patients presenting with chorea will have carditis, for which reason echocardiography should be part of the workup
A

CHOREA

22
Q

classic rash of ARF

A

erythema marginatum

23
Q

painless, small (0.5—2 cm), mobile lumps beneath the skin
overlying bony prominences

A

Subcutaneous nodules

24
Q

The most common serologic tests for Evidence of a preceding GAS infection

A
  • anti-streptolysin O (ASO)
  • anti-DNase B (ADB) titers
25
Q

Diagnosis: initial ARF

A

2 major manifestations or 1 major plus
2 minor manifestations

26
Q

Diagnosis: recurrent ARF

A

2 major or 1 major and 2 minor or
3 major

27
Q

Major Criteria

A
  • Low-risk populations
    + Carditis
  • Clinical and/or subclinical
    + Arthritis
  • Polyarthritis only
    + Chorea
    + Erythema marginatum
    + SC nodules
28
Q

Minor Criteria

A
  • Low-risk populations
    + Polyarthralgia
    + Fever (238.5°C)
    + ESR =60 mm in the first hour and/or
    CRP 23.0 ma/dl
    + Prolonged PR interval, after
    accounting for age variability (unless
    carditis is a major criterion)
29
Q

Test to Always request :

A
  • Electrocardiogram (ECG)
  • Echocardiogram
  • Complete blood count (CBC)
  • C-reactive protein (CRP)
  • Streptococcal serology (antistreptolysin and anti-DNase B)
30
Q

Tests to exclude alternative diagnoses, depending on clinical presentation and locally endemic infections

for Neisseria gonorrhoeae

A

Urine molecular test

31
Q

Tests to exclude alternative diagnoses, depending on clinical presentation and locally endemic infections

Chlamydia trachomatis

A

Urine molecular test

32
Q

Tests to exclude alternative diagnoses, depending on clinical presentation and locally endemic infections

for viral hepatitis, Yersinia spp., cytomegalovirus
(CMV), parvovirus 819, respiratory viruses, Ross River virus, Barmah
Forest virus

A

Serologic or other testing

33
Q

is the drug of choice for ARF

A

Penicillin

34
Q
  • no proven value in the treatment of carditis or chorea
  • At higher doses, the patient should be monitored for symptoms such as nausea, vomiting, or tinnitus
A

SALICYLATES AND NSAIDs

35
Q

Drug of choice for Carditis or chorea

A

Aspirin

36
Q

Is a suitable alternative to aspirin and has the advantage of twice-daily dosing

A

Naproxen

37
Q

In patients with severe chorea, ___ is preferred to haloperidol.

A

carbamazepine or sodium valproate

38
Q

Are effective and lead to more rapid symptom reduction in
chorea. They should be considered in severe or refractory cases.

A

corticosteroids

39
Q

Untreated, ARF lasts on average

A

12 weeks

40
Q

With treatment, patients are usually discharged from hospital within

A

1-2 weeks

41
Q

inflammatory markers should be monitored every

A

1-2 weeks until
they have normalized (usually within 4-6 weeks)

42
Q

should be performed after 1 month to determine if
there has been progression of carditis.

A

echocardiogram

43
Q

if commenced within 9 days of sore throat onset, a course of ___ will prevent almost all cases of ARF that would otherwise have developed.

A

penicillin

44
Q

SECONDARY PREVENTION

  • best antibiotic for secondary prophylaxis
  • can be given every 3 weeks, or even every 2 weeks, to persons considered to be at particularly high risk
A

benzathine penicillin G

45
Q

AHA Recommendations for Duration of Secondary Prophylaxis

CATERGORY OF PX
- Rheumatic fever without carditis

A

For 5 years after the last attack or 21 years of age (whichever is longer)

46
Q

AHA Recommendations for Duration of Secondary Prophylaxis

CATERGORY OF PX
- Rheumatic fever with carditis but no residual valvular disease

A

For 10 years after the last attack, or 21 y.o (whichever is longer)

47
Q

AHA Recommendations for Duration of Secondary Prophylaxis

CATERGORY OF PX
- Rheumatic fever with persistent valvular disease, evident clinically or
On echocardiography

A

For 10 years after the last attack, or 40 years of age (whichever is longer);
Sometimes lifelong prophylaxis

IM IMMUNO/RHEUMA (9 decks)

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