CATUTD

  • Acute rheumatic fever occurs 2 to 4 weeks after pharyngitis.
  • Arthritis is more common and more severe in teenagers and young adults than in children.
  • The earliest manifestation is usually arthritis.
  • Arthritis in each joint lasts for less than one week.
  • The synovial fluid is sterile and inflammatory.
  • In ARF complement level is normal while in post streptococcal glomerulonephritis, hypocomplementemia occurs.
  • ARF can produce pure myocarditis.
  • Complete heart block can occur.
  • Almost all patients have carditis by echo.
  • Antimyosin scintigraphy has 80% sensitivity for rheumatic cardits, but it is not specific.
  • Sydenham chorea is also called chorea minor or “St. Vitus dance”.
  • Latent period of chorea may be upto 8 months.
  • Chorea is usually more prominent on one side.
  • Nodules last for 1 week to 1 month.
  • Nodules are smaller than rheumatoid nodules.
  • Nodules are shorter lasting compared to rheumatoid nodules.
  • Rheumatic nodules occur over the olecranon while rheumatoid nodules occur 3 to 4 cm distal to the olecranon.
  • Least common manifestation is nodules (< 5%).
  • Erythema marginatum is also called erythema annulare.
  • Erythema marginatum and nodules occur only in patients with carditis.
  • Erythema marginatum occurs early and persists when all other manifestations have disappeared.
  • Nodules appear only after the first week.
  • Jones criteria were made in 1944 and were revised in 1965, 1992 and 2002.
  • Echo evidence of MR or AR without auscultatory evidence will not qualify for carditis.
  • With known rheumatic heart disease, only one major or two minor criteria is enough to diagnose rheumatic fever.
  • In 2002 there was an update, not revision.
  • Throat culture is negative in 75% cases at the time of ARF.
  • Antibodies peak at 4 to 5 weeks after onset of pharyngitis, that is, at 2 to 3 weeks into ARF.
  • Take an antibody titer and repeat after 2 weeks.
  • In chronic throat Strep carriers, antibody will be low.
  • ASO is positive in only 80%.
  • Other antibodies measured are anti-DNAse B, streptokinase, and antihyaluronidase.
  • CRP is more useful to measure inflammatory response to treatment as it normalizes in days while ESR remains elevated for 2 months.
  • Latent period of post streptococcal rheumatic arthritis (PSRA) is 1 to 2 weeks while that of ARF is 2 to 3 weeks.
  • In PSRA, tenosynovitis and renal failure are more common.
  • PSRA responds less well to NSAIDs.
  • Carditis is usually not seen in PSRA.
  • PSRA fulfilling Jones criteria should be considered like ARF.
  • In ARF, no therapy can slow the progression of valve damage.
  • Therapeutic serum range of aspirin is 20 to 30 mg/dL.
  • Anti-inflammatory therapy should be given till all symptoms are gone and ESR and CRP have returned to normal.
  • When steroids are tapered, aspirin is started in the full dose.
  • Severe carditis is characterized by significant cardiomegaly, heart failure or third degree heart block.
  • Dose of prednisolone is 2 mg/kg/day.
  • Throat culture should be done for all family members.
  • 250 mg of penicillin V potassium contains 0.4 million units.
  • First choice for secondary prophylaxis is penicillin. Second choice is sulfadiazine. Third choice is erythromycin. Dose of sulfadiazine is 500 mg and 1 gm daily respectively for children and adults. Dose of erythromycin is 250 mg bid.
  • Recurrence of rheumatic fever can occur even in the sixth decade of life.
  • WHO guidelines for secondary prophylaxis-
    • No carditis- 5 yrs/ 18 age
    • Mild MR- 10 yrs/ 25 age
    • Severe valve disease/ valve surgery- life long.
  • Nephritogenic strains of Strep are well documented; but rheumatogenic strains are not.
  • If any strain of Strep can cause pharyngitis, it can cause ARF also.
  • Treatment of Strep pharyngitis reduces the incidence of ARF.
  • ARF can occur after scarlet fever with pharyngitis.