1. AM Report March 5, 2010 Amy Auerbach
Acute Rheumatic Fever
AM Report
March 5, 2010
Amy Auerbach

2. Predisposing Factors
Typically preceded by group A streptococcal tonsillopharyngitis (two to four weeks prior to ARF)
? Whether GAS skin infections could also predispose
Most frequent in children between 4 and 9 years of age

3. Clinical Manifestations
Migratory arthritis (involving large joints)
Carditis and valvulitis
Central nervous system involvement (Sydenham chorea)
Rash

5. Arthritis
Typically migratory arthritis- knees, ankles, elbows, wrists most commonly
Often earliest manifestation
May see monoarticular arthritis if patient has received salicylates or other NSAIDs
Joint analysis demonstrates steril inflammatory fluid
Minimal changes in serum levels of complement

6. Carditis
Pancarditis affecting the pericardium, epicardium, myocardium, and endocardium
Symptoms may be subtle or non-existent
May see mitral regurgitation early on
Mitral stenosis is manifestation of late scarring and calcification
Echocardiography always indicated to assess for valvular disease

7. Chorea
Sydenham chorea- abrupt, purposeless, nonrhythmic involuntary movements, muscular weakness, emotional disturbances
Commonly more marked on one side and cease during sleep
Emotional disturbances typically manifest as inappropriate behavior, crying, restlessness
Can see diffuse hypotonia
Often has longer latent period than other manifestations

8. Subcutaneous Nodules
Firm and painless, typically a few milliliters to one to two centimeters
Typically located over bony surface or near tendon
Present for 1-2 weeks but rarely more than a month
Least common manifestation (in the US)

10. Erythema marginatum Typically occurs early in the disease
May persist or recur even when all other manifestations have disappeared
Typically occurs only in patients with carditis

12. Jones Criteria
High probability of ARF if the following criteria are met:
Evidence of preceding group A streptococcal infection
Two major manifestations OR
One major and two minor manifestations

13. Major Manifestations Carditis Polyarthritis Chorea Erythema marginatum
Subcutaneous nodules

14. Minor Manifestations Arthralgia Fever Elevated ESR or CRP
Prolonged PR interval

15. Other Factors
Three settings in which diagnosis can be made without Jones Criteria
Chorea as only manifestation
Indolent carditis months after acute infection
Recurrent rheumatic fever in patients with history of rheumatic fever or rheumatic heart disease

16. Therapy Symptomatic relief Eradication of GAS
Prophylaxis against future GAS infection to prevent recurrent disease
Primary prevention most important: prompt diagnosis and treatment of group A streptococcal tonsillopharyngitis

18. Take Home Points
Polyarthritis is typically the first manifestation but may present weeks after GAS tonsillopharyngitis
Patients already treated with aspirin and NSAIDs may not meet criteria for ARF despite having the disorder
Carditis is most severe manifestation and can be prevented by prompt treatment of GAS