Acute rheumatic fever: Difference between revisions
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{{Pediatric hip DDX}} | {{Pediatric hip DDX}} | ||
{{Differential Diagnosis Polyarthritis}} | |||
==Diagnosis== | ==Diagnosis== | ||
Revision as of 06:18, 30 July 2015
Background
- Primarily affects school age children 2-6wk after strep pharyngitis
- Connective tissue of heart, joints, CNS, subq tissues are targeted by immune reaction
Clinical Features
- Polyarthritis
- Most common symptom (75%)
- Migratory, fleeting polyarticular arthritis primarily affecting large joints
- Carditis (33%)
- Most serious complication and second most common
- New murmur, pericardial rub, CHF
- Most serious complication and second most common
- Chorea (10%)
- May appear months following strep infection, may be sole manifestation of RF
- Erythema marginatum
- Persists only for several days
- Usually coexists with presence of carditis in some form
- Nonpruritic, located on trunk and proximal limbs, never on face
- Nodules
- Located on extensor surfaces of wrists, elbows, knees
Differential Diagnosis
- Kawasaki Disease
- Viral or other forms of cardiomyopathy
- Leukemia
- Vasculitis (HSP, drug reaction)
Pediatric limp
Hip Related
- Acute rheumatic fever
- Developmental dysplasia of hip
- Femur fracture
- Juvenile idiopathic arthritis
- Legg-Calve-Perthes disease
- Septic arthritis of the hip (peds)
- Lyme disease arthritis
- Slipped capital femoral epiphysis
- Transient (toxic) synovitis
- Osteosarcoma
Other Causes of Limping
- Developmental dysplasia
- Fracture
- Toddler's fracture
- Tillaux fracture, adolescent
- Neoplasm:
- Leukemia
- Ewings
- Osteogenic sarcoma
- Metastatic neuroblastoma
- Osteomyelitis
- Myositis
- Other:
Polyarthritis
- Fibromyalgia
- Juvenile idiopathic arthritis
- Lyme disease
- Osteoarthritis
- Psoriatic arthritis
- Reactive poststreptococcal arthritis
- Rheumatoid arthritis
- Rheumatic fever
- Serum sickness
- Systemic lupus erythematosus
- Serum sickness–like reactions
- Viral arthritis
Diagnosis
Work-Up
- CBC
- ECG
- CXR
- ESR, CRP
Modified Jones Criteria (1992) for Acute Rheumatic Fever
REQUIRE: 2 major or 1 major and 2 minor criteria and evidence of previous GAS pharyngitis
- Major diagnostic criteria
- Carditis
- New or changing murmur, cardiomegaly, CHF, pericarditis
- Migratory polyarthritis
- Chorea
- Subcutaneous nodules
- Erythema marginatum
- Carditis
- Minor diagnostic criteria
- Fever
- Arthralgia
- History of previous attack of rheumatic fever
- Prolonged PR interval
- Elevated ESR, CRP
- Evidence of preceding streptococcal infection
- Increased ASO or other strep ab
- Positive throat culture for Group A strep
- Positive rapid GAS
- Recent scarlet fever
Treatment
- Penicillin
- Indicated for all with rheumatic fever even if culture for strep is negative
- 600K units IM if <27 kg
- 1.2 million units IM if >27 kg
- Penicillin V PO x10d
- Prophylaxis
- 5yr if no cardiac involvement, lifetime if cardiac involvement
- Pen G IM q month or oral penicillin daily
- Erythromycin x10d if pen allergic
- Arthritis
- High-dose aspirin therapy (75-100 mg/kg/d)
- Carditis
- Prednisone 1-2mg/kg/d
- Chorea
- Haloperidol 0.01-0.03 mg/kg/d in four divided doses
Disposition
- Admit for confirmation of diagnosis