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Rheumatic fever Flashcards

(86 cards)

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1
Q

What is rheumatic fever?

A

Autoimmune inflammatory process

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2
Q

What is the primary cause of rheumatic fever?

A

Sequelae of streptococcal infection

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3
Q

What group of streptococcus can cause rheumatic fever?

A

Group A

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4
Q

What is the primary strep species in group A strep?

A

Streptococcal pyogenes

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5
Q

What other conditions can Strep pyogenes (group A strep) cause?

A

Strep pharyngitis (strep throat)

Cellulitis

Scarlet fever

Post-streptococcal glomerulonephritis

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6
Q

What presentation of group A strep infection does acute rheumatic fever most commonly follow?

A

Strep pharyngitis (strep throat)

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7
Q

What is the risk of developing rheumatic fever after an episode of strep pharyngitis?

A

0.3-3%

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8
Q

Where, in australia, is rheumatic fever still a large concern?

A

Central aboriginal populations

500 per 100,000 children, 50x higher than non-indigenous

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9
Q

What is the pathophysiological cause of the development of acute rheumatic fever following group A strep infection?

A

Molecular mimicry with the M protein of the bacterial cell wall

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10
Q

Where is the largest global burden of acute rheumatic fever? How many cases are there, and how many new cases per year?

A

Developing countries

15.6 million people with it and 470,000 new cases per year

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11
Q

What percentage of people with acute rheumatic fever will likely, without intervention, go on to develop rheumatic heart disease?

A

60%

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12
Q

Does acute rheumatic fever show any gender bias?

A

No

Though mitral stenosis and Sydenham chorea are more common in post-puberty females

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13
Q

Which age group has a higher incidence of acute rheumatic fever?

A

Those aged 5-15 years. Pretty rare in adults past 35 years

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14
Q

What are the 5 main presentations of acute rheumatic fever?

A

Polyarthritis

Carditis

Erythema Marginatum

Sydenham chorea

Subcutaneous nodules

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15
Q

Of the 5 main presentations of acute rheumatic fever, what are the three that present the earliest? (around 1 month)

A

Polyarthritis

Carditis

Erythema marginatum

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16
Q

How long is it before Sydenham chorea and subcutaneous nodules typically present in acute rheumatic fever?

A

2.5 months

A great deal of variability though, particularly with the chorea. Might not appear, might appear very early, etc

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17
Q

What is the normal length of a bout of acute rheumatic fever?

A

3 months, if left untreated

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18
Q

Are the small joints of the fingers typically involved in the polyarthritis picture of acute rheumatic fever?

A

No

Only happens in post-streptococcal arthritis, a controversial related syndrome that doesn’t carry a risk of carditis

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19
Q

How does the polyarthritis of acute rheumatic fever typically present?

A

Ranges from arthralgia to frank polyarthritis

Swelling, redness, warmth and joint tenderness

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20
Q

What joints are typically involved in the polyarthritis of acute rheumatic fever?

A

Knees

Ankles

Elbows

Wrists

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21
Q

How long does it take for the polyarthritis of acute rheumatic fever to subside?

A

Typically within a few days up to a week

Fully disappears within 2-4 weeks

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22
Q

Does the polyarthritis of acute rheumatic fever ever move to new joints?

A

Yes

Typically described as migratory, though new joints are affected before the previously involved joints improve

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23
Q

Does the polyarthritis of acute rheumatic fever ever leave lasting damage?

A

Not normally

Can very rarely leave a Joccoud joint, where there is periarticular fibrosis

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24
Q

Does imaging of the joints in the polyarthritis of acute rheumatic fever typically show many gross changes?

A

No, aside from a slight effusion there are usually no changes

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25
If a patient with migratory polyarthritis suspected to be secondary to acute rheumatic fever is started on NSAIDs, how does that change the progression of the polyarthritis?
Usually prevents it from migrating further, and reduces the severity and clinical timeframe
26
In the carditis of acute rheumatic fever, is the inflammation normally a pericarditis?
No Usually it is a pancarditis, involving the pericardium, epicardium, myocardium and the endocardium
27
What are some of the signs that indicate a patient with acute rheumatic fever could have a pancarditis?
New murmurs, cardiac enlargement, pericardial rub and/or effusion S3
28
What two murmurs are most common in the pancarditis of acute rheumatic fever?
MR AR Carey-Coombs flow murmur
29
What are the features of MR?
High pitched Pan-systolic Apical Radiating into the axilla
30
What are the features of aortic regurgitation?
High pitched Decrescendo Diastolic
31
How often do patients with the pancarditis of acute rheumatic fever present with solitary aortic murmurs?
Very unusually
32
How can you make the diagnosis of acute rheumatic fever?
Two major JONES criteria (Joint arthritis, pancarditis, Nodules, Erythema marginatum, Sydenham chorea) Or, one major JONES criteria and two minor
33
What are the minor JONES criteria?
Fever Raised ESR or CRP Leukocytosis ^ PR interval (can't be included if pancarditis is used as major criteria) Arthralgia (can't be used if migratory arthritis used as major criteria) Previous episode of rheumatic fever
34
How would you describe erythema marginatum?
Evanescent, pink or faintly red, non-pruritic Central clearing Erythematous Can come and go very quickly
35
Where are the lesions of erythema marginatum of acute rheumatic fever found?
On the trunk and proximal aspects of the extremities
36
What is an interesting thing about erythema marginatum?
Aside from coming and going within minutes to hours, they may become more evident after a hot bath or shower
37
How are the nodules of acute rheumatic fever normally described?
Firm, painless lesions Normally a few mm's up to 2cm
38
How do the nodules of acute rheumatic fever compare with the nodules of rheumatoid arthritis?
Smaller and more short-lived Both conditions feature nodules on the elbow, but the nodules of acute rheumatic fever will be more over the olecranon whereas the nodules of rheumatoid arthritis will be 3-4cm distally Overlying skin shows no signs of inflammation
39
T/F the nodules of acute rheumatic fever are one of the more common features of acute rheumatic fever
False They are the least occurring of the JONES major criteria
40
When do the nodules of acute rheumatic fever typically present?
In the first week of the illness
41
What can be said about a rheumatic fever patient if they develop subcutaneous nodules?
The development of the nodules of acute rheumatic fever is usually associated with a worse pancarditis
42
Where are the nodules of acute rheumatic fever most commonly found?
Over bony surfaces (eg olecranon) and tendon sheaths Elbow, knee, wrists, ankles, calcaneal tendon, spinous processes of vertebrae
43
If you are assessing a patient for a pancarditis of acute rheumatic fever, what would you look for on examination?
A friction rub New AR, MR, Carey-Coombs flow murmur They will say the pain gets better when they lean forwards
44
How would you describe the Sydenham chorea as part of acute rheumatic fever?
Uncoordinated, involuntary, purposeless movements
45
Is Sydenham chorea as part of acute rheumatic fever associated with muscular weakness?
Yes
46
What is a classical thing that happens to the patients grip strength when they have Sydenham chorea?
Will increase and decrease sporadically Known as a relapsing grip, or milk maids sign
47
Other than muscular weakness, what is the other major part of Sydenham chorea?
Emotional disturbance, with often abrupt changes in disposition (crying, restlessness etc) Can have irritability, OCD symptoms, up to a transient psychosis
48
Can Sydenham chorea be reduced with sedation?
Yes Including sleep
49
Is Sydenham chorea unilateral or bilateral?
Normally worse on one side
50
What is the normal time of onset of Sydenham chorea after the initial presentation of acute rheumatic fever?
1-8 months
51
What are some DDx's of acute rheumatic fever?
Gonococcal arthritis SLE Juvenile rheumatoid arthritis Lyme disease Post-streptococcal reactive arthritis
52
What are three good ways to diagnose acute rheumatic fever?
+ve throat culture for group A strep +ve rapid strep antigen test Elevated or rising antistreptolysin O antibody titer
53
How useful are throat cultures in the diagnosis of acute rheumatic fever?
They are positive about 75% of the time by the time manifestations of ARF are present
54
What is the unit of ASO titers?
Todd units per mL
55
When do ASO titers peak in acute rheumatic fever?
Around 4-5 weeks post strep pharyngitis
56
What week after the presentation of symptoms of acute rheumatic fever does the peak of ASO titer correspond to?
Week 2-3
57
If a patient with suspected acute rheumatic fever is -ve for ASO (anti-streptolysin O), what do you do next?
Test for other strep antibodies
58
What are some other strep antibodies that you can test for?
anti-DNAse B Streptokinase Antihyaluronidase
59
What percentage of patients with acutee rheumatic fever have positive antibody tests if all 4 strep antibodies are tested for?
95%
60
When does testing for acute phase things (ESR, CRP) become not useful?
When you have started antirheumatic drugs
61
Is testing for acute phase reactants ever useful after starting on anti-rheumatic drugs?
Yes Useful when you are tapering treatment down, because you can look for acute rebound of inflammation
62
Is ESR or CRP more useful in acute rheumatic fever?
CRP Because it normalises faster
63
What kind of anaemia can chronic inflammation lead to?
Normocytic normochromic
64
What is an investigation that you could order that could separate acute rheumatic fever from post-streptococcal glomerulonephritis?
Complement levels Usually normal in ARF, but hypocomplementaemia is common in poststreptococcal glomerulonephritis
65
What are 5 points of difference that mark acute rheumatic fever from post-streptococcal reactive arthritis?
Latent period between strep infection and the migratory arthritis is 1-2/52 with PSRA, cf 2-3/52 with ARF PSRA has worse response to aspirin and NSAIDs cf ARF No pancarditis in PSRA, and arthritis is much worse Extra-articular manifestations such as tenosynovitis and renal abnormalities are often seen in PSRA ESR and CRP tend to be lower in PSRA
66
Does post-streptococcal reactive arthritis and acute rheumatic fever typically start around the same time?
No Acute rheumatic fever will start about a week later than post-streptococcal reactive arthritis
67
Is it thought that NSAIDs are very useful in post-streptococcal reactive arthritis?
Not as much as they are helpful in acute rheumatic fever
68
T/F there is pancarditis in post-streptococcal reactive arthritis
F
69
How important is it, to differentiate between post-streptococcal reactive arthritis, and acute rheumatic fever?
Not important because there is evidence that lots of people with post-streptococcal reactive arthritis can still go on to develop valvular damage
70
What is the relationship between post-streptococcal reactive arthritis patients and the Jones criteria?
They usually fulfill the Jones criteria (one major, two minor)
71
If a patient with post-streptococcal reactive arthritis is found to be Jones criteria positive, what should be done for treatment?
They should be treated as though they have acute rheumatic fever with antibiotics, NSAIDs
72
What are the three cornerstones of management of acute rheumatic fever?
Antibiotic therapy Heart failure management Anti-inflammatory therapy
73
Why are rheumatic fever patients put on antibiotics?
To reduce the carriage of group A streptococcal (GAS)
74
Should household contacts be tested for GAS if the patient is infected?
Yes And they should also be started on antibiotics even if they have no symptoms
75
How should the heart failure of acute rheumatic fever be managed?
With standard heart failure drugs Valve repair/replacement when the HF is due to regurgitant lesions
76
Is valve replacement or repair generally preferred?
Repair Avoids the long-term need for anticoagulation
77
What is the anti-inflammatory of choice in acute rheumatic fever?
Asprin, 4-8g/day in adults, 80-100mg/kg/day in children
78
When should you stop administering anti-inflammatories in acute rheumatic fever?
When there are no more symptoms Or, when acute phase reactants are normal, but this should mainly be CRP not ESR which can be +ve for much longer
79
What are some options for oral prophylactic antibiotics for acute rheumatic fever?
Penicillin V Sulfadiazine Macrolides
80
Despite there being oral antibiotics available for acute rheumatic fever prophylaxis, what is the preferred antibiotic?
Benzathine penicillin G Because it is given IM every four weeks, which prevents issues with compliance
81
How should we change the administration of prophylactic antibiotics in high incidence rheumatic fever populations?
Increase the frequency of administration of benzathine penicillin G to every 2-3 weeks
82
What are some side effects to benzathine penicillin G?
Life threatening allergic reaction Pain at site of injection
83
For the oral antibiotics used in preventing rheumatic fever, how do you decide which to administer?
Penicillin V is the preferred agent Sulfadiazine if allergic to penicillin V Macrolide (azithromycin) if allergic to penicillin and sulfadiazine
84
What is the big factor that prolongs the time required for prophylactic antibiotics in the setting of acute rheumatic fever?
The presence or absence of pancarditis
85
If a rheumatic fever patient has pancarditis and residual heart disease, how long should they take antibiotics?
10 years or until 40 years of age, whichever is longer Sometimes lifelong prophylaxis
86
If a rheumatic fever patient has pancarditis but no residual heart disease, how long should they take antibiotics?
10 years or until 21 years of age, whichever is longer

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