Chapter 27-16: Rheumatic Fever

TEXTBOOK PRESENTATION

Rheumatic fever classically presents in a child in the weeks following streptococcal pharyngitis. The 5 cardinal manifestations are arthritis, carditis, rash, subcutaneous nodules, and chorea. The arthritis is typically migratory, involving the knees, ankles, and hands.

DISEASE HIGHLIGHTS

1. Rheumatic fever is an inflammatory disease that follows streptococcal pharyngitis by 2–4 weeks.

2. Unlike in children, clinical documentation of a previous streptococcal infection is rare in adults and the most pronounced symptoms are joint pain and stiffness.

3. The arthritis is classically a migratory polyarthritis.

   1. Individual joints are usually affected for less than a week.

   2. The joints in the legs are usually affected first.

   3. Subjective complaints are often more prominent than objective findings.

4. Carditis

   1. May involve any, or all, parts of the heart—pericarditis, myocarditis, endocarditis, or pancarditis.

   2. Endocarditis commonly causes valvular lesions that may progress over years to symptomatic valve disease, especially mitral stenosis.

EVIDENCE-BASED DIAGNOSIS

1. The diagnosis of rheumatic fever is based on the Jones Criteria.

2. The criteria require evidence of an antecedent group A streptococcal infection (culture, antibody titer) with either 2 major criteria or 1 major and 2 minor criteria (Table 27-13).

TREATMENT

1. Anti-inflammatories

   1. Aspirin is the mainstay of therapy.

   2. Corticosteroids are given to patients with severe carditis.

2. Antibiotics

   1. Penicillin for eradication of streptococcal infection.

   2. Lifelong prophylactic therapy with penicillin is usually recommended after the initial therapy.