Presentation is loading. Please wait.

Presentation is loading. Please wait.

Diagnosis of ARF in children. Speakers November 2012 Alan Ruben FRACP, FAFPHM Paediatrician and Public Health Physician, Apunipima Cape York Health Council,

Similar presentations


Presentation on theme: "Diagnosis of ARF in children. Speakers November 2012 Alan Ruben FRACP, FAFPHM Paediatrician and Public Health Physician, Apunipima Cape York Health Council,"— Presentation transcript:

1 Diagnosis of ARF in children

2 Speakers November 2012 Alan Ruben FRACP, FAFPHM Paediatrician and Public Health Physician, Apunipima Cape York Health Council, Cairns and Hinterland Health Service District, Queensland Health. Alan is a paediatrician and public health physician who has worked in Aboriginal health for over 20 years. Ben Reeves MBBS, FRACP Paediatric cardiologist, Cairns and Hinterland Health Service District, Queensland Health. Ben is a paediatric cardiologist based in Cairns, providing outreach paediatric cardiology services to Cape York and the Torres Strait. 2

3 Learning objectives November 2012 Appreciate the pathway to ARF and then RHD Recognize who is at risk for ARF/RHD Understand the Jones criteria used for diagnosis Present the recommended investigations Outline current management guidelines 3

4 Take home messages November 2012 Incidence in Aboriginal Australians and Torres Strait Islander people amongst the highest in the world Predominantly affects children aged 5 to 15 Largely affects disadvantaged populations High index of suspicion in high risk populations Diagnosis needs clinical criteria and investigation results Diagnosis often requires hospital admission 4

5 Abbreviations November 2012 ARaortic regurgitation ARFacute rheumatic fever BPGbenzathine penicillin G CRPC-reactive protein ESRerythrocyte sedimentation rate GASgroup A beta-haemolytic streptococcus MRmitral regurgitation RHDrheumatic heart disease 5

6 November 2012 More information – Guidelines 6

7 More information – Quick reference November

8 More information – other modules November 20128

9 ARF: some basics 3-6% of any population susceptible Incidence and prevalence in females >males ARF/RHD can run in families Specific genetic markers have been identified There is no racial predisposition November

10 Amongst the highest rates in the world ARF commonest in remote and disadvantaged areas Some Australian medical staff unfamiliar with ARF Australian setting November

11 November 2012 Environment 11

12 Risk factors Established clear link with poverty  household overcrowding -poor sanitation -housing quality and appropriateness -educational disadvantage Limited access to health services -variability of health infrastructure and follow up Geographically remote November

13 GAS pharyngitis Arthritis Carditis Chorea Fever Exaggerated immune response Acute rheumatic fever – ARF November

14 ARF recurs - often many times Valve damage is cumulative and silent Rheumatic heart disease (RHD) Cardiac failure, early death * November 2012 ARF progression 14

15 Jones criteria November

16 Diagnosis and GAS Definite initial or recurrent ARF diagnosis requires: 2 major plus evidence GAS infection 1 major plus 2 minor plus evidence of GAS infection -Throat swab -ASOT -Anti DNAse B No other probable diagnosis November

17 Major manifestations November

18 Major manifestations High risk groups Polyarthritis or aseptic mono- arthritis or polyarthralgia Carditis (including subclinical evidence of rheumatic valvulitis on echocardiogram) Chorea Erythema marginatum Subcutaneous nodules Low Risk groups Polyarthritis Carditis Erythema marginatum Subcutaneous nodules Chorea November

19 Monoarthritis present in 17% of ARF presentations Migratory asymmetric polyarthritis Affects peripheral large joints Often intense pain – will not tolerate passive movement Limited duration: 2 days to 3 weeks Dramatic response to salicylates -rapid response assists diagnosis Arthritis November

20 Can a monarthritis be ARF? In high risk populations: -aseptic monoarthritis can be a major manifestation -monoarthritis often associated with carditis -if joint aspirate sterile, prior to treatment for septic arthritis, investigate for ARF November

21 Polyarthralgia A major criteria ONLY in high risk populations: -Multiple painful joints -Can be migratory -Unlike arthritis lacks: o Effusions o Heat o Morning stiffness November

22 Carditis Can involve all layers of the heart -Pericardium – can cause effusions -Myocardium – affects heart function and conduction -Endocardium – the classic valve lesions MR then AR most common lesions Right sided valves rarely involved Stenosis is a late finding November

23 Carditis: investigations Early echocardiography essential -repeated at 2 to 6 weeks Chest x-ray Electrocardiogram November

24 Carditis: treatment Often requires inpatient bed rest and care if : -moderate/severe carditis suspected by clinical findings Consider steroids for severe carditis If signs of heart failure or cardiomegaly -consider diuretics and ACE inhibitors November

25 Sydenham’s chorea Rapid, uncoordinated jerking movements Primarily the face, feet and hands Female to male ratio of 2:1 Occurs up to 6 months after acute infection Mostly children, 5 to 13 years “Milkmaids” sign Tongue fasciculations Emotional lability November

26 Erythema marginatum Rare finding -reported in less than 2% Australian Aboriginals -difficult to see on dark skin Presence of rash diagnostic of ARF Pale center and darker margins Blanch under pressure Circular snake like pattern Occurs on trunk and extremities Not itchy or painful November

27 Subcutaneous nodules Rare, only seen in 2% cases Highly specific of ARF Strongly associated with carditis Round firm and freely mobile 0.5 to 2.0 cm in diameter Appear 1 to 2 weeks after symptom onset Occur in crops of up to 12 -over elbows knees, wrists, ankles, achilles tendons, occiput, and posterior spinal processes November

28 Minor manifestations High risk groups Monoarthralgia Fever ESR ≥30 mm/h or CRP ≥30 mg/L ECG changes Low Risk groups Fever ESR ≥30 mm/h or CRP ≥30 mg/L ECG changes Polyarthralgia or aseptic monoarthritis November

29 Fever Temperature greater than 38  C In the absence of fever documentation -reliable history if anti-inflammatory therapy given already given November

30 ESR & CRP Repeat serology 10 to 14 days if not confirmatory To satisfy minor criteria: -serum CRP ≥30mg/L -ESR ≥30mm/hr Elevated WBC insensitive marker for ARF November

31 ECG If ARF suspected always ECG Check P-R interval Normal 0.16 sec if 3 to 12 years old If prolonged -repeat ECG in 1 to 2 months If P-R interval returns to normal: -ARF more likely November

32 Diagnosis: key investigations November

33 Differential diagnosis November

34 Diagnosis key points ARF remains a difficult diagnosis -requires recommended tests to be performed High index of suspicion for populations at greatest risk Cardiology opinion recommended for suspected ARF In high risk populations also consider ARF if: -child < 5 years of age presents with arthritis Monoarthritis is a common presentation Simple falls rarely cause joint effusions Hospital admission recommended for initial presentations November

35 Probable ARF November

36 ARF diagnosis and management First requires diagnosis then secondary prophylaxis Inpatient assessment recommended Specialist review for ongoing management Bed rest NSAIDs Initial then follow up echocardiography Chest x-ray If heart failure: ACE inhibitors, diuretics Consider steroids for carditis November

37 Principles of secondary prevention November 2012 Secondary prevention first requires the diagnosis of ARF/RHD Long term antimicrobial prophylaxis prevents recurrent ARF -but significant challenges in service delivery Success requires: -register-based program -effective recall system -functioning primary health care service 37

38 Take home messages Incidence in Aboriginal Australians and Torres Strait Islander people amongst the highest in the world Predominantly affects children aged 5 to 15 Largely affects disadvantaged populations High index of suspicion in high risk populations Diagnosis needs clinical criteria and investigation results Diagnosis often requires hospital admission November

39 More? November

40 November 2012 More? Register for… Downloadable PowerPoint presentations Additional resources Additional assessment items for training providers for notification about new modules and updates 40

41 November 2012 How’d you go? Test your knowledge with a brief self-assessment quiz 41

42 Diagnosis of ARF in children


Download ppt "Diagnosis of ARF in children. Speakers November 2012 Alan Ruben FRACP, FAFPHM Paediatrician and Public Health Physician, Apunipima Cape York Health Council,"

Similar presentations


Ads by Google