Acute rheumatic fever
I. Diagnosis
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
- Polyarthritis
- Chorea
- Subcutaneous nodules
- Erythema marginatum
- Minor diagnostic criteria
- Fever
- Arthralgia
- Prolonged PR interval on ECG
- Elevated acute-phase reactants (APRs), i.e ESR and CRP
- Evidence of previous GAS pharyngitis:
- Positive throat Cx or rapid strep test or Elevated or rising streptococcal antibody titer
II. Symptoms
- Polyarthritis: most common symptom and often earliest (70-75%). Begins in knees and ankles, migrates to other large joints. Responds to aspirin
- Carditis: Most serious complication and the second most common (50%). The murmurs of acute RF are from valve regurgitation, and the murmurs of chronic RF are from valve stenosis
- Sydenham Chorea: 10-30%. P/W difficulty writing, involuntary grimacing, purposeless movements of the arms and legs, speech impairment, generalized weakness, and emotional lability
- Erythema marginatum: aka erythema annulare, occurs in 5-13%. Erythema marginatum begins as 1- to 3-cm diameter, pink-to-red nonpruritic macules or papules located on the trunk and proximal limbs but never on the face. Spreads outward to form a serpiginous ring with central clearing. Can be accentuated by warm towels/hot bath. Occurs early, remains past the resolution of other sx
- DDx includes sepsis, drug reactions, and glomerulonephritis.
Subcutaneous nodules: Frequency has declined to 0-8%. Extensor surfaces. Firm, nontender, mobile, seveal millimeters to 1-2 cm.
- Histo: Like Aschoff bodies observed in the heart. Subcutaneous nodules generallyoccur several weeks into the disease and resolve within a month
III. Treatment
A. Eradicate GAS infection
1. PCN 0.6 to 1.3 million Units IM x 1 or
2. Oral PCN for 10 days or
3. Erythromycin if PCN-allergic
B. Future prophylaxis
C. Treatment of symptoms, e.g. arthritis
Source
7/2/09 PANI
3/10 Rosen