Dr.Rajkumar Patil

Asstt. Prof., Community Medicine

AVMCH, Pondicherry

RF is the most common cause of

heart disease in 5-30 yr age group

RHD in IndiaRHD in India

Prevalence: 5/1000 population of 5-15 age group

1 million RHD cases in India

Hospital admissions due to RHD is 20-30% of CVD

Acute rheumatic fever (ARF) is a systemic disease of childhood

It is a delayed non-suppurative sequelae to URTI with GABH streptococci

It is a diffuse inflammatory disease of connective tissue,primarily involving heart,blood vessels,joints, subcut.tissue and CNS

Epidemiological Factors

Agent

Age: 5-15 yrs(most susceptible)

Sex: both

Environmental factors over crowding, poor sanitation,

poverty

Incidence more during winter & early spring

Host Factors

Flitting & fleeting migratory polyarthritis, involving major joints

Commonly involved joints-knee,ankle,elbow & wrist

Occur in 80%,involved joints are exquisitely tender

In children below 5 yrs:It is mild but carditis is more prominent

Arthritis do not progress to chronic disease

1.Arthritis

Manifest as pancarditis(endocarditis, myocarditis and pericarditis),occur in 50% of cases

Carditis is the only manifestation of rheumatic fever that leaves a sequelae & permanent damage to the organ

Valvulitis occur in acute phase

Chronic phase- fibrosis,calcification & stenosis of heart valves(fishmouth valves)

2.Carditis

Rheumatic heart disease. Abnormal mitral valve. Thick, fused chordae

Occur in 5-10% of cases

Mainly in girls of 1-15 yrs age

Clinically manifest as-clumsiness, deterioration of handwriting, emotional lability or grimacing of face

Clinical signs- pronator sign, jack in the box

sign , milking sign of hands

3.Sydenham Chorea

Occur in <5%.

Unique,transient,serpiginous lesions of 1-2 inches in size

Pale center with red irregular margin

More on trunks & limbs & non-itchy

Worsens with application of heat

Often associated with chronic carditis

4.Erythema Marginatum

Occur in 10%

Painless,pea-sized,palpable nodules

Mainly over extensor surfaces of joints,spine,scapulae & scalp

Associated with strong seropositivity

Always associated with severe carditis

5.Subcutaneous nodules

Other features (Minor features)

Fever(mild)

Polyarthralgia

Pallor

Anorexia

Loss of weight

Chorea alone, if other causes have been excluded

Insidious or late-onset carditis with no other explanation

Juvenile rheumatiod arthritis

Septic arthritis

Sickle-cell arthropathy

Kawasaki disease

Myocarditis

Scarlet fever

Leukemia

Prevention and control

• To prevent the first attack of RF,by detection and treatment of streptococcal throat inf.

• Many inf are inapparent or undiagnosed

• High risk approach: Surveillance for streptococcal pharyngitis among school children

Primary prevention

Sore throat should be swabbed and cultured

If strepto.— Give Penicillin(If culture is not possible a sore throat can be treated with Benzathine Benzyl Penicillin)

Dose: One IM inj.,1.2 miilion units(adults),0.6 million units(children)

Or Oral Penicillin G/Penicillin V for 10 days

Erythromycin (In case of allergy to Penicillin)

Primary prevention contd…

Secondary Prevention

Other measures in Secondary Prevention

Surveys to know the prevalence of RHD among school children

Every 5 years in 6-14 years age group

Rheumatic fever can recur whenever the individual experience new GABH streptococcal infection,if not on prophylactic medicines

Good prognosis for older age group & if no carditis during the initial attack

Bad prognosis for younger children & those with carditis with valvar lesions