1. EPIDEMIOLOGY OF REUMATIC FEVER
Dr Faris Al Lami

2. Definition
A non supportive complication of Group A , B Hemolytic Streptococcal (GABHS) Upper Respiratory Tract Infection (URTI).
A systemic disease, more frequently involving :
joints and the heart
less frequently Involving:
CNS, skin and subcutaneous tissue.

3. Risk factors :
1.Over weight 2.Low socioeconomic status 3.High latitude 4.Positive family history 5.Age 5-15 years

4. Clinical Manifestations
Major criteria
1.Polyarithritis
It occurred in 75% of cases
migratory in nature
affecting two and more joints
lasts 3-4 weeks

5. Carditis Occurs in 40-50% of cases Most serious
Occur within 1-2 weeks of onset
Lasts for 6 weeks- 6 months
Presented with
significant murmer
pericardits
CHF
Sometimes silent

6. Subcutaneous nodules Occurs in 1% of cases
Presented with rounded, mobile, non –tender, over the joints, scalp, vertebra column
Seen in severe cases only

7. Erythema marginatum:
Seen in 5% of cases

8. Sydenham Chorea:
Seen in 10-15% of cases

9. Minor criteria Clinical: Polyarithralgia
Fever
Polyarithralgia
Past history of Acute Rheumatic Fever (ARF) or Chronic Rheumatic Cardiopathy (CRC)

10. Minor criteria Laboratory: Prolonged PR interval on ECG
Acute Phase Reaction ( high ESR, high CRP, high WBC)

11. PLUS
Evidence of preceding streptococcal URTI (positive culture, high ASOT, Scarlet fever)

12. Other manifestations:
Erythema multiforme
Abdominal pain
Backache
Precordial pain
Epistaxis
Vomiting
Malaise
Weight loss
Anemia

13. Diagnosis:
Two major or one major and two minor plus evidence of recent streptococcal infection

14. Epidemiological characteristics
About 20% of URTI ( especially sore throat) that occurred in school age children are caused by GABHS
Only 20% of streptococcal URTI produce symptoms ( for every symptomatic streptococcal URTI there are four asymptomatic cases )
3. The attack rate of ARF varies from 0.3% ( under endemic condition) to 3% ( during epidemics of untreated severe exudative pharyngitis)

15. 4.Positive association between severity of pharyngitis and risk of ARF 5.For every two cases of ARF with history of streptococcal URTI , there is one case without such history 6.For every three cases of ARF , one will develop CRC

16. 7.For every case of CRC with history of ARF , there is another case of CRC without such history 8.Symptomatic streptococcal pharyngitis can infect 8-50% of household contacts 9.Healthy carriers form 20-50% of school children , but they are not important source of infection or of cases of ARF

17. PRIMARY PREVENTION
Aim: Definite diagnosis and eradication of streptococcal URTI

18. Definite diagnosis of Streptococcal URTI:
Scarlet fever
Positive culture
Increasing ASOT

19. Characteristic Symptoms of streptococcal URTI:
Exudates on throat
Temperature of > 38 C
Enlarged tender anterior cervical lymph nodes
Erosion of the edges of the nostril with scabbing

20. Non characteristic symptoms:
Cold
Cough
Trachitis
Conjunctivitis

21. Eradication of streptococcal URTI achieved by:
Achieving bactericidal level of antibiotic within 9 days of onset of symptoms for 10 days
Benzathin Penicillin 600,000 (< 6 years)
1,200,000 (> 6 years)
If sensitive:
Erythromycin 20 mg / kg / day (< 12 years in four divided doses
250 mg x 4 (12 years and over)
Treatment should continue for 10 days

22. SECONDARY PREVENTION
Indicated for patients with CRC, and ARF Aim: to interrupt reinfection – recurrence cycle

23. A bacteriostatic level of antibiotic against GABHS for 5 consecutive years or till age of 16 years
Benzathin Penicillin 600, 000 (< 6 years)
1,200,000(6+ years) every month
If sensitive:
Sulfadiazine 0.5 gm/ day (< 6 years)
1 gm/day (6+ years)

24. Patients with CRC and those with CV surgery should be kept on this regimen for life
The risk of recurrence of ARF following subsequent GABHS infection is 50% for the next 5 years
A child with ARF has 150 times risk for further attacks as a child without such history