Rheumatic Fever and Bacterial Endocarditis

Question 1

_____ is an inflammatory, immune process that develops as sequelae from untreated or inadequately treated streptococcal pharynx infection (i.e. strep throat)

Answer 1

Rheumatic fever

Question 2

What causes Rheumatic Fever?

Answer 2

Caused by Group A beta-hemolytic streptococcal infection (GAS)

Question 3

Rheumatic Fever Epidemiology

Answer 3

● Peak incidence is between ages 5-15 years
● More common in underdeveloped countries
● responsible for 275,000 deaths in young
people worldwide each year

Question 4

Pathophysiology of Rheumatic Fever

Answer 4

There is a latent period of 2-3 weeks between GAS infection and the start of rheumatic fever symptoms

Question 5

Rheumatic Fever Diagnosis - Jones Criteria

Answer 5

Diagnosis: 2 major criteria or 1 major + 2 minor criteria
MAJOR CRITERIA
1. Polyarthritis
2. Erythema Marginatum
3. Carditis
4. Subcutaneous Nodules
5. Sydenham Chorea

MINOR CRITERIA
1. Clinical findings
a. Fever
b. Polyarthralgias
2. Lab Findings:
a. ↑ ESR
b. ↑ CRP
c. Prolongation of the PR interval

Question 6

Usually the 1st symptom that develops for Rheumatic fever

Answer 6

Polyarthritis

Question 7

Polyarthritis

Answer 7

● Usually the 1st symptom
● More common and severe in teenagers and young adults
● Affects several joints in quick succession, seems to migrate
○ Knees, ankles, elbows, wrists
● Responds well to anti inflammatory medication
● No lasting damage or deformity

Question 8

T/F there is no lasting damage or deformity with polyarthritis

Answer 8

T

Question 9

Erythema marginatum

Answer 9

● Rapidly enlarging maculopapular lesions that assume the shape ofrings or crescents with CENTRAL CLEARING.
● Can be raised, confluent and either transient or persistent.
● Blanches w/ pressure, not itchy or painful

Part of the JONES criteria

Question 10

_____: Inflammation of the myocardium, pericardium, endocardium, and/or valves

Answer 10

Carditis
● Mitral or Aortic murmurs
● Pericarditis
● Cardiomegaly
● Heart failure

Part of the JONES criteria

Question 11

Subcutaneous Nodules are typically

Answer 11

Small (2 cm or less in diameter), firm,
and nontender
Attached to fascia or tendon sheaths
over bony prominences

Part of JONES criteria

Question 12

● Small (2 cm or less in diameter), firm,
and nontender.
● Attached to fascia or tendon sheaths
over bony prominences.
○ Elbow most common
● Persist for days or weeks, recurrent
● Smaller and shorter-lived than RA
nodules

Describes what

Answer 12

Subcutaneous Nodules

Question 13

LEAST COMMON but MOST diagnostic manifestation of acute rheumatic fever

Answer 13

Syndeham Chorea

Question 14

Describe Syndeham Chorea

Answer 14

Neurologic disorder consisting of
abrupt, nonrhythmic, involuntary
movements, muscular weakness, and
emotional disturbances.

LEAST COMMON finding (3% of cases)
● LONG latent period, 1-8 months after
GAS infection
● Sometimes the only symptom
● More common in girls

Question 15

_____ is the MAJOR complication of Rheumatic Fever

Answer 15

Rheumatic heart disease

Question 16

Complications of Rheumatic Fever

Answer 16

1. Rheumatic heart disease is the MAJOR complication
2. Arrhythmias
3. Pneumonitis
4. Pericarditis with pericardial effusion
5. Heart Failure (severe cases)

Question 17

Excess fluid between the heart and the pericardium, Can turn into Cardiac Tamponade is called what

Answer 17

Pericardial Effusion

Question 18

Pericardial Effusion is Excess fluid between the
heart and the _____

Answer 18

pericardium.

Question 19

Rheumatic Pneumonitis

Answer 19

A pneumonia occurring in severe acute rheumatic fever
● High Mortality Rate

Question 20

Most common cause of acquired heart valve
disease in the world

Answer 20

Rheumatic Heart Disease

Question 21

_____ results from single or repeated attacks
of rheumatic fever that produce valvular stenosis and/or regurgitation

Answer 21

Rheumatic heart disease

Question 22

_____ is attacked in 75-80% of cases of Rheumatic heart disease

Answer 22

Mitral valve

Question 23

Treatment goals of Rheumatic Fever

Answer 23

1. Eradication of group A beta-hemolytic Streptococcus (GAS)
2. Symptomatic relief of acute disease manifestations (eg, arthritis, fever)
3. Manage rheumatic heart disease (RHD; eg, carditis, heart failure) if present
4. Manage chorea if present
5. Prophylaxis against future GAS infection to prevent progression of cardiac
   disease
6. Provision of education for the patient and patient’s caregivers

Question 24

Infection management for Rheumatic Fever

Answer 24

● Intramuscular penicillin G benzathine
● Cefdinir or azithromycin are potential alternatives if allergic

Question 25

Arthritis management for Rheumatic Fever

Answer 25

● NSAIDs are 1st line ● Alternatives include aspirin and glucocorticoids ● Typically will add PPI to prevent gastritis

Question 26

Cardiac management of RF

Answer 26

● Monitor EKG, echocardiogram ● Heart failure management if needed

Question 27

Sydenham chorea management for RF

Answer 27

● Usually self-limited ● Chronic antibiotic therapy to prevent recurrence of ARF ● Anti inflammatory meds can be helpful ● Possible follow up w/ neurologist

Question 28

Improvement in socioeconomic conditions and public health is critical to reducing effects of ____

Answer 28

RF

Question 29

1st line treatment for prevention of Recurrent Rheumatic Fever

Answer 29

Benzathine penicillin G IM every 4 weeks. ■ Oral penicillin V (250 mg twice daily) = less reliable than IM ■ If PCN allergic = azithromycin or sulfadiazine dail

Question 30

Bacterial infection of the valvular or endocardial surface of the heart.

Answer 30

Bacterial Endocarditis

Question 31

Usually need 2 factors are required for Bacterial Endocarditis

Answer 31

○ Predisposing abnormality of endocardium ○ Bacteremia

Question 32

Risk factors for bacterial endocarditis

Answer 32

● Underlying valvular disease ● Recent dental, respiratory, urologic and GI diagnostic and surgical procedures ● IV drug users (mostly staph aureus) ● Patients with recent prosthetic valve replacement

Question 34

How can presentation depend on the infecting organism and the valve(s) that are involved for Bacterial Endocarditis?

Answer 34

● Highly virulent organisms (think staph aureus) tend to produce a rapidly progressive and destructive infection. ● Subacute bacterial endocarditis often caused by Strep Viridans, less aggressive presentation ● Left side most commonly involved (mitral and aortic valves) ● Only 10-20% of cases involve right side valves (think IV drug use)

Question 35

Presentation of Bacterial Endocarditis

Answer 35

● Fever, chills, anorexia, weight loss, malaise, night sweats, abdominal pain, dyspnea ● Characteristic peripheral lesions (mostly caused by septic emboli) ● Strokes and/or other major embolic events ● Hematuria and/or Proteinuria ● Changing regurgitant murmur

Question 36

Characteristic peripheral lesions of Bacterial Endocarditis

Answer 36

○ Petechiae: oropharynx, conjunctiva, or subungual “splinter” hemorrhages ○ Osler nodes: painful, raised (immunologic phenomena) ○ Janeway lesions: nonpainful, flat (vascular phenomena) ○ Roth spots: eye

Question 37

Osler Nodes

Answer 37

PAINFUL violaceous raised lesions of the fingers, hands, toes and/or feet

Question 38

Janeway Lesions

Answer 38

PAINLESS, flat, erythematous lesions of the palms or soles

Question 39

Imaging/Diagnostics for Bacterial Endocarditis

Answer 39

● Chest X-ray ● EKG ● Transthoracic Echocardiography ● Transesophageal echocardiography ● Blood cultures

Question 40

DUKE Criteria (Major and Minor)

Answer 40

2 major or 1major/3minor or 5 minor Major: 1. Positive blood cultures from two separate cultures(for bacteremia) 2. Evidence of endocardial involvement documented by echocardiography 3. Development of a new regurgitant murmur Minor: 1. Predisposition 2. Microbiologic Evidence (single positive blood culture) 3. Fever > 38 C 4. Vascular phenomena 5. Immunologic phenomena

Question 41

Complications of Bacterial Endocarditis

Answer 41

● Destruction of infected heart valves ● Infection can extend into the myocardium → abscesses → conduction problems/arrhythmias. ● Embolization ● Pulmonary emboli (PE)

Question 42

Empiric regimens for bacterial endocarditis while culture results are pending should include agents active against ______

Answer 42

staphylococci, streptococci, and enterococci. ○ Native valve: Vancomycin ○ Prosthetic valve: Vancomycin AND cefepime ● Once culture and sensitivity results are back, switch to targeted antibiotic therapy

Question 43

T/F you should consult cardiology on ALL cases of bacterial endocarditis

Answer 43

T