Rheumatic Fever

Question 1

A 10-year-old Samoan girl presents with a 2-day history of fever and sore joints. Further questioning reveals that she had a sore throat 3 weeks ago but did not seek medical help at this time. Her current illness began with fever and a sore and swollen right knee that was very painful. The following day her knee improved but her left elbow became sore and swollen. While in the waiting room her left knee is now also becoming sore and swollen.

Answer 1

Impression
Given temporal relationship of symptoms to recent sore throat and constellation of am provisionally concerned about rheumatic fever, also given in a risk group.

Other clinical manifestations
- Sydenhams Chorea

Rheumatic fever
Is a type 2 hypersensitivity reaction/autoimmune reaction secondary to GAS infection. Get a directed immune response to synovium, cardiac, subcutaneous, neuronal, and epidermal tissue. Causes systemic symptoms including;
- Rheumatic heart disease: targets cardiac valves most commonly, get formation of Aschoff bodies - disrupt electrical conduction and get PR prolongation, arrhythmias
- Joint pain, swelling
- Erythema marginatum

Question 2

Jones Criteria

Answer 2

Is the diagnostic criteria for rheumatic heart disease;
MAJOR
J - Joints
♥️ - ‘O’ looks like a heart = myocarditis
N - Nodules (subcutaneous)
E - Erythema Marginatum
S - Sydenham Chorea

MINOR
C - CRP elevated
A - Arthralgia
F - Fever
E - ESR elevated

P - PR prolongation
A - anamnesis of rheumatism (past history of rheumatism)
L - Leukocytosis

Question 3

History (anamnesis)

Answer 3

History

• PC: fevers, joint pain, palpitations, jerky uncontrolled movements,
• REDS: tachy, dizzy, LOC, chest pain, SOB, signs of heart failure
• HPI: sore throat, skin lesions,
• Fam history
• social: crowded living quarters, poverty, indigenous population

Question 4

Exam

Answer 4

Exam

• general appearance + vitals
• Cardiovascualr: murmer, pericardial rub, raised JVP, tachycardia
• Resp: pulmonary oedeam, peripheral oedema
• derm: erythema marginatum, subcut nodules
• MSK: joint pain

Question 5

Investigations

Answer 5

Investigations
Key/diagnostic
- Echo - valvular lesions, regurg
- ECG -  PR prolongation, heart block, arrhythmia
- Blood cultures for GAS

• Bloods: CRP, ESR, FBC, others as necessary
• Imaging: CXR (signs of heart failure)

Question 6

Management

Answer 6

Management
Aims
- confirm diagnosis
- symptomatic management (no definitive treatment) to shorten acute phase

definitive
- antibiotics therapy (either prophylaxis or in confirmed rheumatic fever)
o ben pen

Symptomatic

• analgesia: paracetamol, ibuprofen
• ACEi and Diuretics for carditis
• corticosteroids for severe carditis +/- heart failure, consider concurrent PPI’s