Rheumatic Fever, Acute

Description

Diagnostic criteria

General and supportive measures

Medicine treatment

Referral

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ICD-10 code: I01.9

* Notifiable condition.

DESCRIPTION

Rheumatic fever is an inflammatory condition that may follow a throat infection with group A streptococci. It is an important cause of acquired heart disease with significant morbidity and mortality rates, both in the acute phase of the disease and as a result of chronic valvular sequelae.

DIAGNOSTIC CRITERIA

Revised Jones criteria:

• Evidence of recent streptococcal infection:
  • Elevated ASO-titre or other streptococcal antibody titres.
  • Positive throat culture for group A beta haemolytic streptococcus.

PLUS

Two major manifestations, or one major and two minor manifestations, justifies the presumptive diagnosis of acute rheumatic fever (Jones Criteria 2015 – South African children are defined as members of a high risk population).

Major manifestations	Minor manifestations
- Mono or polyarthritis/polyarthralgia - Carditis - Erythema marginatum - Subcutaneous nodules - Sydenham’s chorea	- Monoarthralgia - Fever ≥ 38°C - Acute phase reactants: increased erythrocyte sedimentation rate (ESR) ≥ 30 mm/hr or C-reactive protein (CRP) ≥ 30 mg/l - ECG: prolonged PR-interval, ≥ 0.16 seconds in the absence of carditis

 

• Carditis is either defined clinically or after an echocardiographic study.
• Chorea, for which other causes have been excluded, provides adequate evidence of rheumatic fever without the other criteria for diagnosis being required.
• In children with rheumatic heart disease with fever, it is critical to differentiate recurrence of acute rheumatic fever from infective endocarditis.

For children with rheumatic heart disease, recurrence of some of the above criteria would suggest a recurrence of rheumatic fever but other causes such as IE should be excluded.

GENERAL AND SUPPORTIVE MEASURES

• Hospitalise with bed rest until sleeping pulse is normal and signs of rheumatic activity have resolved.
• Restrict physical activity for at least 2 weeks after acute phase reactants have normalised.
• Keep a record of patients on rheumatic fever prophylaxis so that attendance can be monitored.

MEDICINE TREATMENT

Antibiotic therapy

To eradicate any streptococci:

• Benzathine benzylpenicillin (depot formulation), IM, as a single dose.
  • If < 30 kg:    600 000 IU.
  • If ≥ 30 kg:    1.2 MU.

OR

• Phenoxymethylpenicillin, oral, 15 mg/kg (up to a maximum of 500 mg) 12 hourly for 10 days.

LoE III^10,11

Patients with penicillin allergy:

• Azithromycin, oral, 10 mg/kg/day for 5 days.
   

Anti-inflammatory therapy

Do not start until a definite diagnosis is made. Paracetamol can be administered for joint pain. Anti-inflammatory therapy is no longer recommended for carditis alone.

Severe arthritis:

• Ibuprofen, oral, 10 mg/kg/dose, 8 hourly, oral, (non-steroidal anti-inflammatory agents are preferred to aspirin as a result of the side effect profile) until the arthritis resolves.

OR

• If necessary, with specialist consultation, aspirin, soluble, oral, 20 mg/kg/dose 6 hourly.

Cardiac failure: See: Heart failure.

Chorea: See: Sydenham’s chorea.

Prevention of repeated attacks

Any patient with documented rheumatic fever must receive prophylaxis. Intramuscular penicillin is superior to other forms of prophylaxis.

• Benzathine benzylpenicillin (depot formulation), IM, every 3–4 weeks.
  • If < 30 kg: 600 000 IU.
  • If > 30 kg: 1.2 MU.

OR

• Phenoxymethylpenicillin, oral, 250 mg 12 hourly.

Patients with penicillin allergy:

• Evidence is not robust in this area, thus consultation with a specialist on a case-by-case basis will be required.

Continue therapy until patients reach 21 years of age if no rheumatic valvular disease and until 35 years of age in patients with rheumatic valvular disease.

LoE III⁸

REFERRAL

Rheumatic fever: all patients need to be referred for echocardiography and further evaluation.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 4: Cardiovascular System , 4.4 Rheumatic Fever, Acute