Rheumatic Fever Ок

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Rheumatic

fever


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Rheumatic feveris acute systemic disease of

the connective tissue immune

inflammatory genesis,characterised mainly by

arthritis, carditis, chorea,

subcutaneous nodules and

erythema marginatum.


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Rheumatic fever(RF)

is common world-wide and is

responsible for many causesof damage heart valves.


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Etiology:

Group A, hemolytic streptococcus(strains 3,5,18,24,28,49 ) is the maine

etiologycal factor. RF occurs about 2weeks after exudative tonsi l i tis

(quinsy,soa throat), scar let

fever,streptodermia or otherstreptococcus infections, if it goes

without treatment.


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Person who has high hyperensitivi ty toimmune system on streptococcus

suffered more frequently. This

hypersensibil i ty of immune systemgenotype determinate with HLA system

antigen A11, B

27, B

35, CW

2, CW

5, DR

5,

DR7.


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Pathogenesis:

On the basis of pathogenesis RF is

immunoinflamatory reaction

(reaction antigen-antibody) with

edema,

hyperemia,


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lymphocyte infiltration of

connective tissue heart (valvule,endocardium, myocardium,

pericardium), brain, vessels,

synovial membrane of joints,skin,

other organ and formatione

rheumatic granuloma (Aschoffsnodule) in connective tissue.


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Immunoinflamatory reaction (react ion

ant igen-ant ibody) is always

accompanied by elimination ofinflammatory mediators: histamine,

bradikinin, prostaglandin E2 and

other.Histamin is dilated capillares andbring on oedema, hyperemia,

infiltratione connective tissue with

cells of immune response

(lymphocytes, plasmatic cells, mast

cells, eosinophils, basophils).


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Prostaglandin E2 - causeincrease to C.

Cluster circulate immune

complex in connective tissue

is cause formation ofpointing necroses in

particular area.


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during immunoinflamatory

reaction morphologically we are

different 4 stages:

mucoid swelling;fibrinoid swelling;

granulomatosis;sclerosis and hyalinosis.


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Outcome of the

immunoinflammatory reaction

are sclerosis,hialinosis,deformation,calcification

valvulas and formatione

anatomical defects (valvula

heart d isease) .


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Sclerosis of myocardium -

myocard iosc leros is(cardiacinsufficiencyheart failure,

arrhythmias, blockades).


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Clinical PICTURE

symptoms and signs ar ise 2 weeks

after pharyngitis or tonsi l l i tis (soa

throat) or scarlet fever.


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major cr i ter ia (manifestation)of RF are:

1.Migratory polyarthritis

2.Carditis

3.Chorea

4.Subcutaneous nodules

5.Erythema marginatum


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m ino r cr i ter ia o f RF are:

high toC;abdominal pain, anorexia;

heart failure;

epistaxis;

pneumonia;

asthenia;malaise;

fatigue.


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Migratory polyarthritis is the most

common clinical manifestation,monoarthritis can also occur. Joints

become painful and tender ,red, hot,

swollen, sometimes with effusion.

Knees, elbows or wrists are most

commonly involved. It leaves nopermanent joint deformility.


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Cardit is

(involves 2 or 3 wall of heart)endocarditis+myocarditis=

rheumocard i t is :


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Rheumatic myocarditis, mature Aschoff nodule


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CLINICAL SIGNS OF CARDITIS:

Cardiac failureChanges heart sounds

Cardiac enlargement

Murmurs;

1. systolic myocardial murmur;

2. murmurs of VS, MI, AS, AI.

pericardial rub.


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ChoreaSydenhamS chorea

emotional instability,muscular weakness and

rapid, uncoordinated jerky

movements affecting

primarily the face, foot and

hands.


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Subcu taneus nodu les

These are firm,

colorless, painlessnodules 1-2 cm in size,

near the tendens orbony prominences of

joints, especially elbow.


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Subcutaneous nodules (rheumatic fever

nodules/Aschoff nodules)


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Erythema marg inatum

This is a nonpruritic, flat,

circular or serpigious rash

on thoraxic trunk and near

joints.


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DIAGTOSTICS

For diagnostic we use:

* major and minor rheumatic criterias* rheumatic anamnesis

* markers of streptococcus infection

* laboratory findings* ECG

* Doppler USG of heart.


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2 major criteria or one major criteria

and 2 minor criteria with markers of

streptococcus infection are basement

for support the diagnosis of RF.

NB!


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LABORATORY FINDINGS:

General blood analysis (blood test)anemia, leycocytosis, shift in leycocyt formulaleft, accelerated erythrocyte sedimentation rate(ESR);

biochemical blood analysis:

reumoprobs:

Level of C-reactive protein;

Level of Seromucoids

Level of Glycoproteins


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positive throat culture;

elevated level of antistreptolisin O,

antistreptokinaze or other streptococcalantibody.


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ECG findings:

PQ prolongation more than 0,18-0,20 sec;

Signs of enlargement of atria or

ventricules;

Signs of pericarditis.


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Doppler USG heart:

Thickening of walls

Patological blood flows

(regurgitatione)

Enlargement atrium or ventricles;

Signs of effusion in pericardium.


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Treatment regimenthe patient must take rest

before normalizaton of his temperature ;

Diet N10;

Ethyologycal treatment: :- ant istreptoc cocal ant ib iot ics

- Benzilpenicillini-natrii 1,21,5 million U

per day,

- Benzathine penicillini G 1,2 million U perday


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Or Amoxicillin 0,5 - 4 times per day;

Ampicillin 0,5 - 4 times per day

If the patient have allergic to penicillinwe use:

Erytromicinum Cephalexin 50mg/kg

Cephadroxil 50mg/kg

2 times per day

Azithromycin 15mg/kg

Clarithromicin 15mg/kg


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One of this ant ib iot ics adm inister

du r ing 10 day, than we change

ant ib io t ic and prescr ibe pro longate

ant ib iot ics:

Bicillinum-3 (1,5 million U forone injection weeks;

Or Bicillinum-5 (1,5 milliom U

one jnjectione for 3 weeks

during the year)


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4. Anti-inflammatory drugs:(NONSTEROID ANTI INFLAMMATORY

DRUGS)NSAID This drugs

blocked Pr a2.NONSELECTIVE:

1) Sal icy l ic Ac id:Acetylsalicylic acid;Sodium salicylate;Mg salicylate.

2) A t l i id


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2) An tray l ic ac id-Mefenamic acid 0,250,5;

- Flufenamic acid;

- Meclofenamic acid.

3) A ry lbenzene ac ids-Diclofenac Sodium ( Voltaren,

ortofen ) - tablets 0,0250,05;

-ampules 0,075; suppository 0,05;

gel 1 %;-Alclofenac;

-Fenclofenac;

- Fentiazak.


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4) Prop ion ic acids :

Ibuprofen ( brufen )Dragee 0,2;

FlorbiprofenDragee 0,05;

Ketoprofen;

Naproxen;

Fenoprofen;

Fenbufen;

Piridofen.


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INDOL DERIVATIVES :

Indomethacin ( Metindol, Indosid )Dragee 0,025 Suppository 0,05;

SulindacTablets 0,2.

PYRAZOLE DERIVATI VES :

Butadion ( Phenylbutazone );

Analgin;

Amidopirin.


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SELECTIVE COX2

BLOKERS:OXICAMSPiroxicam ( Felden ) Tablets 0,01

Izoxicam

Sudoxicam

Meloxicam ( Movalis )

COXI BS :Celecoxib ( Celebrex, Rancelex

Rofecoxib ( Rofica )


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5. Cort icos teroid therapy :

Prednizoloni 0,5-1 mg/kg orally 3times daily(during 3-5 week) with

decrease dose step by step on

regime 5 mg for weeks.


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6.Symptomatical therapy:

If the patient have signs of carditis and

heart failure we administrate:

diuretic drugs:

furosemid 20-40 mg orally daily in the

morning before meal;

Hypothyazidi 50-100 orally daily.


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- Cardiotonic drugs such as

Digoxin 0,0001 1-2 times orally

daily.

If the patient has arrhythmiasahtiarrhythmic drugs.

If the patient has signs vasculitis we

are administed ac. Ascorbinici 0,53times orally daily.


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Prognos is :

In case of initial RF with advantage arthritisand initial carditis prognosis will be favourable

if the patient receive adequate therapy.

In cases severe RF with arthritis, severe

carditis, chronic rheumatic disease, heartvalvule diseases are observed.

If RF is not treated, chronic rheumatic disease

and heart valvule diseases are always occur. Arthritis, chorea, subcutaneous nodulus

erythema marginatum have favorable outcome.


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Prophylaxis (prevention):

Primary prevention:is prevention from

streptococcal infection (tonsilitis,

pharingitis, scarlet fever).

Secondary prevention:

---Antistreptococcal prophylaxis should

be conducted after attack of acute RF in

order to prevent recurrence.


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---Bicillini-5 1,5milliom U (or Benzilinepenicillin 6 1,2 million) one injection for

month due to 3 month

---Aspirini 0,54 times daily

orally during 3 weeks or other

NSAID.


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