Rheumatic Fever Vs. (?) Post Strep Reactive Arthritis Fever vs PSRA.pdfPost-streptococcal reactive...
Transcript of Rheumatic Fever Vs. (?) Post Strep Reactive Arthritis Fever vs PSRA.pdfPost-streptococcal reactive...
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2009ינואר
Rheumatic FeverVs. (?)Post Strep Reactive Arthritis
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Agenda
IntroductionArticles
Poststreptococcal reactive arthritis in children: is it really a different entity from rheumatic fever?Poststreptococcal reactive arthritis: what is it and how do we know? Differentation of Post-Streptococcal Reactive Arthritis from Acute Rheumatic Fever
Guidelines
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Post-streptococcal reactive arthritis (PSRA)
Definition:Arthritis of ≥1 jointsRecent group A streptococcal infection Does not fulfill the Jones criteria for the diagnosis of Acute Rheumatic Fever (ARF)
In 1982 - Goldsmith and Long –poststreptococcal syndrome in childrensymmetrical arthritis followed by intense arthralgiapoorly responsive to aspirin therapy
Some authors consider PSRA to be part of the spectrum of ARFOther authors consider it to be a different entity
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In 1993 Deighton:
Slow and partial
Prolonged/Recurrent
10 days
PSRA
Usually dramatic
Response to Aspirin
Few days - 3 weeks
Duration
2-3 weeksOnset after GAS
ARF
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In 1997 Ayoub and Ahmed:
PSRA:Arthritis of acute onset, symmetric or asymmetric, usually non-migratory, can affect any joint, persistent or recurrent Poorly responsive to salicylates/NSAIDsAntecedent GAS infectionFailure to fulfill the modified Jones criteria for the diagnosis of ARF
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Jones Criteria - ARF
Chorea
Prolonged PR interval Subcutaneous nodules
Elevated acute phase reactants
Erythema marginatum
Elevated or increasing streptococcal antibody
titer
FeverPolyarthritis
Positive throat culture or rapid streptococcal
antigen test
ArthralgiaCarditis
Supporting evidence of
antecedent GAS
Minor manifestations
Major manifestations
• 2 major
• 1 major + 2 minor
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2002 Jun;22(2):80-3
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Results
PSRA - 24 patients ARF - 20 patients Latency period from upper respiratory tract infection - shorter in patients with PSRA (P<0.01)However, 25% of the patients with ARF had also short (<10 days) latency periods
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ResultsNo significant difference for the distribution of mono-, oligo-, and polyarticular disease between PSRA and ARF patients
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Results
Unresponsiveness of articular symptoms to salicylate therapy within 72 h was more frequent in patients with PSRA (P<0.001)However, in a substantial part of the patients with ARF (nine patients, 45%), joint symptoms also had no response during the first 72 h
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Conclusion
Considerable overlap of symptoms, signs, and laboratory features of PSRA and ARF
The authors conclude that these two conditions are actually different presentations of the same disease
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Systematic Review
2004 Aug;43(8):949-54
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Main key points188 cases - 1982 - 2002 47% childrenThe clinical presentation – heterogeneousDifferent both from that of acute rheumatic fever (ARF) and from that of HLA B27-associated reactive arthritis. Carditis - rare
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`
Nov 2008 ;153(5):696-9
T, TauberL, HarelY, BerkunP, Elkan-NavonE, MashiachJ, BarashY; Pediatric Rheumatology study group of UzielPJ, HashkesS, Padeh
Israel .
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Study objectives
Search for differences in these 2 entities Well-defined, large cohort Discern whether these are 2 separate entities or varying clinical manifestations of the same disease Offer a simple clinical tool to differentiate between them
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Methods
<16 years old7 centers in IsraelIsraeli internet-based pediatric rheumatology registry1996 - 2005 (most after 2001)ARF with joint involvement - 68 patients PSRA - 159 patients
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Methods – cont.
ARF - diagnosed according to the revised Jones criteriaPSRA - diagnosed in cases of arthritis involving ≥1 joints associated with proven group A streptococcal infection in a patient not fulfilling the Jones criteria
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Results – Demographic Data
7.2%
5.9 ± 1.5
63%
10.2 ± 3.0 years
ARF
7.5%
6.5 ± 2.1
54%
9.3 ± 3.6 years
PSRA
Family history of ARF
Number of persons in the household
% Male
Age of onset
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The distribution in percent with active joints in patients with ARF and PSRA
Large LE, Large joint lower extremity; small LE, small joint lower extremity; large UE, large joint upper extremity; small UE, small joint upper extremity. *P = .0002.
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Results - Carditis
PRSA• 2 patients - prolonged P-R intervals • 3 patients - trace of mitral regurgitation (was not considered pathologic)
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Results – Treatment & Prophylaxis
22%1.4%Not treated with NSAIDS
8%12%Recurrence
50%87%Long-term prophylactic antibiotic treatment
PSRAARF
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Results – Prediction Equation
If the value was >0 ARFIf the value was <0 PSRA79% sensitivity rate (correct classification as ARF) 87.5% specificity rate (correct classification as PSRA)
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In contrary to other studies:
No axial involvementMore patients with symmetrical arthritis in the ARF groupLatency period between development of pharyngitis and joint symptoms did not differ between ARF and PSRA in this population
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Discussion
Several studies addressing the association of ARF and PSRA with class II HLA-DR antigens This association may suggest that the pathogenesis of PSRA, like that of ARF, may be related to the inheritance of certain class II HLA alleles
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Discussion
The authors were able to differentiate between ARF and PSRA in >80% of the cases on the basis of 4 criteria:
1. ESR at onset2. CRP at onset3. Number of days before resolution of joint
symptoms after starting anti-inflammatory therapy
4. Presence or absence of a recurrence of arthritis after discontinuation of anti-inflammatory therapy
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ConclusionsARF and PSRA appear to be 2 distinct entitiesARF –More acute presentation
FeverAcute phase responseGreater number of jointsCardiac involvement
Response to treatment - much quicker Course of arthritis - shorter than in PSRAIf PSRA was a milder form of the spectrum of ARF, we would not expect a slower response to treatment or a longer course of the arthritis
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Conclusion
The authors suggest usage of the equation When there is doubt about the diagnosis, the authors suggest to favor the diagnosis of ARF and administer the usual antibiotic prophylactic treatmentAmerican Heart Association + the Red Book - antibiotic prophylaxis for 1 year, and if no carditis is observed, then prophylaxis should be discontinued
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Study Problems
Retrospective studyRelatively small scale (n=227)Parental recall Physician diagnostic biases
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The Future
Large-scale prospective trialsAcute treatment Penicillin prophylaxis
Guidelines
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! תו דה רבה