rheumatic heart disease

Question 1

Major manifestations of RHD

Answer 1

1. Joints- Polyarthritis
2. Carditis
3. Nodules (subcutaneous)
4. Erythema Marginatum
5. Sydenhams Chorea

Question 2

Minor

Answer 2

Clinical- Arthralgia and Fever

Laboratory- Elevated ESR/CRP and Prolonged PR

Question 3

Features of arthritis

Answer 3

1. Most common manifestation -70%
2. Large joints
3. More than one usually affected and migrates
4. Respond dramatically to salicylates (if present >48/24 question the diagnosis of ARF)
5. Subsides in days to weeks, doesn’t cause permanent damage

Question 4

Features of Carditis

Answer 4

1. Occurs in 50%
2. Tachycardia out of proportion of degree of fever
3. Heart murmur is always present
   - Echo may detect pericardial effusion, increased LV dimension, or impaired LV function
4. Pericarditis may be present (always occurs with MV involvement)
5. Cardiomegaly on CXR indicative of severity of disease
6. Signs of CHF indicate severe cardiac dysfunction
7. Can cause permanent damage

Question 5

Features of Erythema marginatum

Answer 5

1. Fewer than 10%
2. Non pruritic serpiginous or annular erythema
3. Mostly on trunk and inner proximal portions of limbs, never on face
4. Evanescent- appear when warm, disappear in cold

Question 6

Features of subcutaneous nodules

Answer 6

1. Found in 2-10% of patients and usually in recurrence
2. Hard, painless, non pruritic, mobile swellings 0.2-2cm
3. Symmetrical, single or clusters on extensor surfaces of small jnts, scalp and spine
4. Not transient, last for weeks
5. Not exclusive to ARF (10% with rheumatoid arthritis, and SLE)

Question 7

Features of Sydenham’s Chorea

Answer 7

1. 15% of patients
2. prepubertal girls >boys
3. Neuro- choreic movements and hypotonia
4. Psychiatric- Lability, hyperactivity, sep anxiety, Obs/compulsions
5. Elevated titres of antineuronal antibodies targeting basal ganglia found in 90%. Levels proportional to severity of chorea
6. Gradually subsides in 6-7 months
7. Usually doesn’t cause permanent neuro sequelae

Question 8

What is most reliable laboratory evidence of antecedent streptococcal infection?

Answer 8

Streptococcal antibodies.
Antistreptolysin O titres elevated in 80% of pts with ARF and 20% of normal. A single low ASOT doesn’t exclude ARF.
If 3 Antistrep Abs are obtained (ASOT, Antideoxyribonuclease B, antihyaluronidase) at least 1 is elevated in 95%

Question 9

How is ARF diagnosed?

Answer 9

Revised Jones criteria.
- Either 2 major, or
- one major and 2 minor + evidence of antecedant strep infection
Absence of evidence of recent strep infection make Dx unlikely
Stills murmur often mistaken for MR

Question 10

differentials for ARF

Answer 10

1. JRA (involvement of peripheral small joints, symmetrical involvement of large joints without migration, pallor, indolent course, no recent strep or response to salicylates)
2. Other collagen vascular disorders (SLE); infective and reactive arthritis including post strep arthritis; serum sickness
3. Virus associated acute arthritis (Rubella, parvo, Hep B, herpes, entero) more common in adults
4. Haematological disorders; sickleamia and leukaemia

Question 11

When suspecting ARF on history and exam, what investigations are warranted?

Answer 11

FBP, CRP, ESR, throat swab, ASOT (and a second Ab titre), CXR, ECG
Cardiology consult for ECHO and doppler

Question 12

How is ARF treated acutely?

Answer 12

1. Benzathine penicillin G (erythromycin in penicillin allergy)
2. Anti-inflammatory with salicylates or steroids must not be started until definitive diagnosis
3. Education and continued streptococcal prophylaxis
4. Bed rest until the ESR is normalized (unless CHF present)

Question 13

How is CHF treated in ARF?

Answer 13

1. Complete bed rest with orthopnoeic position and moist cool O2
2. Prednisone with severe carditis of recent onset
3. Digoxin with caution
4. Frusemide if indicated

Question 14

How is Sydenhams treated?

Answer 14

1. Reduce physical and emotional stress
2. Benzathine penicillin G (to prevent valvular disease in isolated SC)
3. Anti-inflammatory agents are NOT needed with isolated SC
4. In severe cases; Phenobarb, haloperidol, Valproate, Chlorpromazine, diazepam or steroids.
5. Plasma exchange and IVIg work better than steroids

Question 15

What determines prognosis in ARF

Answer 15

1. Cardiac status at start of Rx
2. Recurrence of RF. Severity of valvular disease increases each time
3. Regression of heart disease; in 10-25% of pts cardiac involvement disappears after 10 yrs from initial attack. PROPHYLAXIS

Question 16

Which valves most commonly affected?

Answer 16

mitral>aortic>tricuspid and pulmonary