Acute Rheumatic Fever
- Is a systematic disease characterized by inflammatory lesions of connective tissue and endothelial tissue, primarily affecting the heart and joints.
- The pathogenesis is thought to be an autoimmune response to group A beta-hemolytic streptococcus.
- There is cross-reactivity between cardiac tissue antigens and streptococcal cell wall components.
- The unique pathologic lesions of rheumatic fever is the Aschoff body, a collection of reticuloendothelial cells surrounding a necrotic center on some structure of the heart.
- Acute Rheumatic Fever is commonly seen in children ages 5 to 15 but may occur in adults.
- There is a high recurrence rate, and 75% of those with ARF progresses to acute rheumatic heart disease in adulthood.
- Complications include significant heart failure, pericarditis, pericardial effusions, aortic or mitral valve insufficiency, and permanent cardiac damage.
- History of streptococcal pharyngitis or upper respiratory infection 2 to 6 weeks before onset of illness.
- Jones criteria, presence of two major manifestations, or one major and two minor manifestations, plus evidence of preceding streptococcal infection, are required to establish diagnosis.
- Major manifestations:
- Erythema marginatum
- Subcutaneous nodules
- Minor manifestations:
- History of previous rheumatic fever or evidence of pre-existing rheumatic disease.
- Arthralgia: pain in one or more joints without evidence of inflammation, tenderness to touch, or limitation of motion.
- Fever: temperature in excess of 100.4 degree Fahrenheit (38 degree Celsius).
- Erythrocyte sedimentation rate (ESR) – elevated.
- C – reactive protein – positive.
- Electrocardiogram (ECG) changes – mainly pulse rate interval prolongation.
- White blood cell count – elevated (leukocytosis).
- Throat culture for group A beta-hemolytic streptococci and blood sample for titter of streptococcal antibodies ( antistreptolysin O, or ASO titer) to support evidence of recent streptococcal infection.
- Complete blood count, ESR, and C-reactive protein for changes described above.
- Baseline ECG and echocardiogram may be done to evaluate valve function.
- Chest x-ray for cardiomegaly or heart failure.
- Antibiotics to treat streptococcal infection – generally I.M. penicillin or erythromycin in penicillin allergy.
- Corticosteroids for patients with carditis complicated by heart failure to prevent permanent cardiac damage.
- Salicylates or nonsteroidals for patients with arthritis (but not while on high-dose corticosteroids because of risk of GI bleeding) and antipyretics to control fever, after diagnosis has been established.
- Phenobarbital, diazepam if chorea is present.
- Prophylactic antibiotics for at least 5 years after ARF.
- Monitor temperature frequently, and patient’s response to antipyretics.
- Monitor the patient’s pulse frequently, especially after activity to determine degree of cardiac compensation.
- Auscultate the hear periodically for development of new heart murmur or pericardial or pleural friction rub.
- Observe for adverse effects of salicylate or nonsteroidal anti-inflammatory drug (NSAID) therapy, such as stomach upset, tinnitus, headache, GI bleeding, and altered mental status.
- Monitor the patient’s response to long-term activity restriction.
- Restrict sodium and fluids and obtain daily weights as indicated.
- Administer medications punctually and at regular intervals to achieve constant therapeutic blood levels.
- Explain the need to rest (usually prescribed for 4 to 12 weeks, depending on the severity of the disease and health care provider’s preference) and assure the patient that bed rest will be imposed no longer than necessary.
- Assist the patient to resume activity very gradually once asymptomatic at rest and indicators of acute inflammation have become normal.
- Provide comfort measures.
- Provide safe, supportive environment for the child with chorea.
- Observe for the disappearance or any major or minor manifestations of the disease and report signs of increased rheumatic activity as salicylates or steroids are being tampered.
- Encourage continuous prophylactic antimicrobial therapy to prevent recurrence.