RISK FACTORS : LOWER STANDARDS OF LIVING, OVERCROWDING. INCIDENCE OF RF AFTER STREPTOCOCCAL PHARYNGITIS IN PTS. WHO HAVE SUFFERED PREVIOUS ATTACKS OF RF IS NEARLY 50% IN COMARISION TO 3% IN NORMAL VIRGIN POPULATION
Medical Care: Treatment strategies can be divided into management of an ARF attack, management of the current infection, and prevention of further infection and attacks.
" The primary goal of treating the ARF attack is to eradicate streptococcal organisms and bacterial antigens from the pharyngeal region.
o Penicillin is the drug of choice in persons who are not at risk of allergic reaction.
o A single parenteral injection of benzathine benzylpenicillin can ensure compliance.
o Oral cephalosporins, rather than erythromycin, are recommended as an alternative in patients who are allergic to penicillin. However, be cautious of the 20% cross-reactivity of the cephalosporins with penicillin.
" By promptly treating streptococcal pharyngitis in susceptible hosts, repetitive exposure to pathologically reactive antigens can be avoided. However, management of the current infection probably will not affect the course of the current attack.
" Antimicrobial therapy does not alter the course, frequency, or severity of cardiac involvement.
" Analgesia is optimally achieved with high doses of salicylates, often inducing dramatic clinical improvement.
o A lower dose may be required to avert symptoms of nausea and vomiting.
o When salicylates are used as therapy, the dosage should be increased until the drug produces either a clinical effect or systemic toxicity characterized by tinnitus, headache, or hyperpnea.
" Corticosteroids should be reserved for the treatment of severe carditis.
o After 2-3 weeks, the dosage may be tapered, reduced by 25% each week.
o Overlap with high-dose salicylate therapy is recommended as the dosage of the prednisone is tapered over a 2-week period to avoid poststeroid rebound. In extreme cases, intravenous methylprednisolone may be used.
" Mild heart failure usually responds to rest and corticosteroid therapy.
" Digoxin can be useful in patients with severe carditis, but its use should be monitored closely because of the possibility of heart block.
" Nocturnal tachycardia may be a sign of cardiac involvement that may be responsive to digoxin. Vasodilators and diuretics also may be used.
" Protracted Sydenham chorea has responded to haloperidol.
o Chorea requires long-term antimicrobial prophylaxis, even if no other manifestations of rheumatic fever evolve.
o The signs and symptoms of chorea usually do not respond well to treatment with antirheumatic agents.
o Complete physical and mental rest is essential because the manifestations of chorea may be exaggerated by emotional trauma.
o Glucocorticoids or salicylates have little or no effect on chorea.
o Because chorea disappears with sleep, adequate sedation should be provided.
" Prevention has been successful in developed societies. The recommended approach can be divided into primary and secondary prevention.
o Primary prevention: Eradicate Streptococcus from the pharynx, which generally entails administering a single intramuscular injection of benzathine benzylpenicillin.
o Secondary prevention: The AHA Committee on Acute Rheumatic Fever recommends a regimen consisting of benzathine benzylpenicillin at 1.2 million units intramuscularly every 4 weeks. However, in high-risk situations, administration every 3 weeks is justified and advised. High-risk situations include patients with heart disease who are at risk of repetitive exposure.
o Oral prophylaxis, which is less reliable, consists of phenoxymethylpenicillin (penicillin V) or sulfadiazine. These can be used in compliant patients.
o If penicillin allergy is suspected, oral cephalosporins should be used.
o Although no consensus on the required duration of antibacterial prophylaxis has been reached, the AHA recommends prophylaxis be continued for at least 10 years after the last episode of rheumatic fever or until patients are well into adulthood. For those with heart disease who are at risk of repetitive exposures, prophylaxis should be continued for a longer duration, probably indefinitely. However, for those who have reached their early 20s, in whom more than 5 years have passed since their last attack, and who are free from rheumatic heart disease, discontinuing prophylaxis may be reasonable. The principles of treatment include the following:
" The risk of rheumatic fever recurrence is greatest during the first 3-5 years following the attack.
" Prophylaxis must continue indefinitely for those with established heart disease or for those frequently exposed to streptococci.
" Treatment for an indefinite period is required for those with frequent exposure to streptococci or for those who are difficult to monitor.
" In underdeveloped countries, prophylaxis should be continued as follows:
o Continue for 5 years after the first attack.
o Continue indefinitely for patients with established heart disease.
o Continue indefinitely for those who are frequently exposed to streptococci, are less than optimal, and are difficult to monitor.
" The decision to withdraw the antibacterial drugs should be individualized after carefully assessing the risk of repetitive exposures.
ALTERNATIVE DRUGS :
β’ Sulfadiazine may be used for prophylaxis in penicillin allergic patients. Patients who take sulfadiazine should
take at least 2 liters of fluid daily to guard against sulfadiazine crystalluria.
β’ Naproxen at a dose of 15-20 mg/kg/day, divided twice daily, for children, has been found to be safe and effective in rheumatic fever and has less adverse reactions than aspirin
Surgical Care:
" Valve replacement should be considered in patients with active carditis, especially if patients are refractory to medical care or require high doses of vasodilators and diuretics.
" Regurgitant lesions respond to valve replacement, while pure stenotic lesions may benefit from more conservative balloon mitral commissurotomy.
Diet:
" No dietary factors are known.
Activity:
" All patients should be restricted to bed rest and monitored closely for carditis.
" Aggressive use of acutely inflamed joints or other exercise has the potential to cause permanent joint injury to acutely inflamed joints.
" When carditis has been documented, a 4-week period of bed rest is recommended. As soon as the signs of acute inflammation subside, patients should resume active ambulation as tolerated.
" Most patients can be treated safely in an outpatient setting.
PATIENT MONITORING Each week initially, then every 6 months
PREVENTION/AVOIDANCE :
β’ Patients will need to be on prophylactic penicillin throughout childhood and possibly indefi nitely during
adulthood. Monthly injections of 1.2 million units of benzathine penicillin intramuscularly is the preferred
treatment.
β’ Adults should be treated for a minimum of five years after an attack. Some treat adults indefi nitely if there
has been valvular disease. Oral penicillin V-K, 125 mg twice daily is an alternative to monthly injections. In the
event of penicillin allergy, sulfadiazine, 500 mg daily for children weighing less than 30 kg or 1 gm daily for all
others may be used.
β’ If patients have valvular damage from acute rheumatic fever, they will require bacterial endocarditis prophylaxis for dental and other high risk procedures
POSSIBLE COMPLICATIONS:
β’ Subsequent attacks of acute rheumatic fever secondary to streptococcal reinfection
β’ Carditis
β’ Mitral stenosis
β’ Congestive heart failure
EXPECTED COURSE/PROGNOSIS :
Sequelae limited to the heart and dependent of severity of carditis during an acute attack