Rheumatic Fever and Rheumatic Heart Disease

Gaining a solid understanding of the basic concepts of Rheumatic Fever and its causes, symptoms, and diagnosis is crucial to your NEET PG exam preparation. The topic has been frequently asked in the exam during previous years, which makes it a high-yielding one.
Familiarize yourself with rheumatic fever and rheumatic heart disease through this blog.

Rheumatic Heart Disease

• RHD is one of the most commonly acquired heart diseases in children in developing countries.
• Acute Rheumatic Fever /RHD is strongly associated with antecedent group A streptococcal pharyngitis (with strains M1,3,5,6,18,29)
• Pathogenesis: immune mediated

Modified Jones criteria (2015)

The Jones criteria is the primary guideline for diagnosing acute rheumatic fever (ARF). It was recently modified in 2015 by the American Heart Association. The modified Jones criteria entails the following:

Low risk	Moderate to high risk
Incidence = <2/lakh school going children	Incidence = > 2/lakh school going children
Rhd prevalence = <1/1000	Rhd prevalence = >1/1000

Major criteria

1. Carditis (clinical or subclinical): 50-60%
2. Arthritis (low risk population: polyarthritis, moderate to high risk population: polyarthritis, monoarthritis, polyarthralgia): 75%
3. Chorea (sydenham's chorea): 10-15%
4. Erythema marginatum: 1%
5. Subcutaneous nodules: <1%

Minor criteria 

1. Polyarthralgia (low risk population), monoarthralgia (moderate to high risk population)
2. Fever
3. Increased ESR/CRP
4. Prolonged PR interval 

Essential criteria: Evidence of antecedent group A streptococcal infection (increased or rising ASO titres)

Modified Jones criteria 

• Initial episode of RF = 2 major or 1 major + 2 minor criteria 
• Recurrence of RF = 2 major or 1 major + 2 minor or 3 minor 

Important Information
Mc manifestation of RF: arthritis f/b carditis is (mitral valve f/b aortic valve)

Treatment of ARF

Acute Rheumatic Fever treatment includes the following:

• A course of antibiotics: 10 days of oral amoxicillin or penicillin or single dose of IM benzathine penicillin (azithromycin in penicillin allergy)
• Aspirin: 50-70 mg/kg/day initially
• Corticosteroids: carditis +CCF/cardiomegaly 
• Best rest: carditis

Primary prophylaxis

• Any streptococcal pharyngitis: appropriate antibiotics should be started within 9 days of onset of illness to prevent RHD (poverty/overcrowding: risk factors for ARF/RHD)

Secondary prophylaxis

• Inj. Benzathine penicillin IM 6 lakh IU children </=27 kg
• Inj. Benzathine penicillin IM 1.2 million IU in 27 kg every 3-4 weeks
• Till when secondary prophylaxis
  • Without carditis: 5 yr or till 21 yr age, whichever is later
  • With carditis but without residual heart disease: next 10 yr or till 21 yr, whichever is later
  • With residual heart disease: next 10 yr or 40 of age, whichever is later 

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