Rheumatic fever, acute

I01.9

*Notifiable condition.

DESCRIPTION

Rheumatic fever is an inflammatory condition that may follow a throat infection with group A streptococci. It is an important cause of acquired heart disease with significant morbidity and mortality rates, both in the acute phase of the disease and as a result of chronic valvular sequelae.

DIAGNOSTIC CRITERIA

Revised Jones criteria:

  • Evidence of recent streptococcal infection:
    • Elevated ASO-titre or other streptococcal antibody titres.
    • Positive throat culture for group A beta haemolytic streptococcus.

PLUS

  • Two major manifestations, or one major and two minor manifestations, justifies the presumptive diagnosis of acute rheumatic fever.
Major manifestations Minor manifestations
- polyarthritis
- carditis
- erythema marginatum
- subcutaneous nodules
- Sydenham’s chorea 		- polyarthralgia
- fever
- acute phase reactants: increased
erythro­cyte sedimentation rate
(ESR) or C-reactive protein (CRP)
- ECG: prolonged PR-interval,
≥ 0.18 seconds in the absence of
carditis
  • Chorea for which other causes have been excluded, provides adequate evidence of rheumatic fever without the other criteria for diagnosis being required.
  • In children with rheumatic heart disease with fever, it is critical to differentiate recurrence of acute rheumatic fever from infective endocarditis.

For children with rheumatic heart disease, recurrence of some of the above criteria would suggest a recurrence of rheumatic fever but other causes such as IE should be excluded.

GENERAL AND SUPPORTIVE MEASURES

  • Hospitalise with bed rest until sleeping pulse is normal and signs of rheumatic activity have resolved.
  • Restrict physical activity for at least 2 weeks after acute phase reactants have normalised.
  • Keep a record of patients on rheumatic fever prophylaxis so that attendance can be monitored.

MEDICINE TREATMENT

Antibiotic therapy

To eradicate any streptococci:

  • Benzathine benzylpenicillin (depot formulation), IM, as a single dose.
    • If < 30 kg: 600 000 IU.
    • If ≥ 30 kg: 1.2 MU.

OR

  • Phenoxymethylpenicillin, oral, 250 (<30kg)–500 mg 12 hourly for 10 days.

LoEIII [8]

Anti-inflammatory therapy

Do not start until a definite diagnosis is made.
Severe arthritis:

  • Aspirin soluble, oral, 20 mg/kg/dose 6 hourly until the arthritis resolves.

OR

If aspirin cannot be tolerated:

  • Ibuprofen, oral, 5 mg/kg/dose, 6 hourly.

Cardiac failure: See Heart failure .

Chorea: See Sydenham’s Chorea .

Prevention of repeated attacks

Any patient with documented rheumatic fever must receive prophylaxis.
Intramuscular penicillin is superior to other forms of prophylaxis.

  • Benzathine benzylpenicillin (depot formulation), IM, every 3-4 weeks.
    • If < 30 kg: 600 000 IU.
    • If > 30 kg: 1.2 MU.

OR

  • Phenoxymethylpenicillin, oral, 250 mg 12 hourly.

Continue therapy until patients reach 21 years of age if no rheumatic valvular disease, and until 35 years of age in patients with rheumatic valvular disease.

LoE: III [8]

REFERRAL

Rheumatic fever:

  • with residual valvular damage electively for planning of care,
  • with symptomatic valvular damage,
  • unresponsive to treatment.