ACUTE RHEUMATIC FEVER (ARF) &

RHEUMATIC HEART DISEASE (RHD)

SYARIF HIDAYAT
RSUD SERANG
INTRODUCTION, DEFINITION,
PATHOPHYSIOLOGY
Streptococcus
group A
haemolyticus
ARF RHD
An immune-mediated, multisystem inflammatory
disease that follows group a streptococcal
infection.
Characterized by tissue inflammation that gives
rise to typical clinical characteristics, including
carditis, valvulitis, arthritis, chorea, erythema
marginatum, and subcutaneous nodules.
Carditis occurs in 3080% of patients with ARF, and
at least 60% of untreated patients develop chronic
RHD.
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Inflammation leads to neo vascularization, which enables further
recruitment of t cells, leading to granulomatous inflammation
Molecular mimicry between group a streptococcal antigens and human host
tissue is thought to be the basis of this cross-reactivity.
Both cross-reactive anti-bodies and cross-reactive t cells are believed to have
a role in the disease.
Interaction between a group a streptococcal strain and a host seems to lead
to an abnormal immune response and the development of autoimmunity.
Predominantly affects the mitral valve and, less commonly, the aortic
valve.
Mitral insufficiency is the most common valvular lesion, particularly in
the early stages of the disease.
Mitral stenosis develops later as a result of persistent or recurrent
valvulitis, although rapid progression has been described in some
developing countries.
Patients with mitral insufficiency can remain relatively asymptomatic for
up to 10 years, as a result of compensatory left atrial and left ventricular
dilatation before the onset of left ventricular systolic dysfunction.
Tricuspid regurgitation can occur as a result of volume overload, usually
caused by mitral stenosis.
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DIAGNOSTIC CRITERIA & CATEGORY FOR
ARF & RHD
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1)
2 MAYOR/ 1 MAYOR + 2 MINOR
MANIFESTATIONS PLUS
2)
2 MINOR MANIFESTATIONS PLUS
PLUS EVIDENCE OF A PRECEDING GROUP
A STREPTOCOCCAL INFECTION
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CARDITIS
POLYARTHITIS
MIGRANS
CHOREA
ERYTHEMA
MARGINATUM
SUBCUTANEUS
NODUL
Commonly presents as a heart murmur; Chest pain and/or
difficulty breathing may be present in more severe cases
Pain and swelling in more than one large joint (ankles, knees,
wrists); Often the first complaint; Usually migratory finishes
in one joint, begins in another
Twitchy, jerking movements and muscle weakness (most obvious in the face,
hands and feet); May occur on both sides or only one side of body; More
common in teenagers and females (rare after age 20); May begin up to 3-6
months after the streptococcal throat infection, and often occurs without
other symptoms; Usually resolves within 6 weeks rarely (may last 6 months
or more)
Painless, flat pink patches on the skin that spread outward in a
circular pattern; Usually occurs early, may last months, rarely
lasts years; Usually on the back or front of body, almost never
on the face; Hard to see in dark-skinned people
Painless lumps on the outside surfaces of elbows, wrists, knees,
ankles in groups of 3-4 (up to 12) ; The skin is not red or
inflamed; Last 1-2 weeks (rarely more than 1 month); Nodules
are more common when Carditis is also present
MANAGEMENT &
PREVENTION OF ARF
& RHD
Secondary
Primary
Group A
Streptococcus
heamolyticus
infection
ACUTE RHEUMATIC
FEVER
PRIMARY
PREVENTION
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SORE THROAT
TREATMENT (Y)
VACCINE (N)
1)
Oral penicillin V 500mg 23 times per
day for 10 days [250mg for children], 50
mg/kg amoxicillin per day for 10 days, or
2)
A single 1,200,000u [600,000u for
children 27 kg] dose of intramuscular
benzathine penicillin G
CLINICAL GROUPS BED REST (WEEKS) MOBILIZATION (WEEKS)
CARDITIS (+),
ARTHRITIS (-)

2 2
CARDITIS (+),
CARDIOMEGALY (-)

4 4
CARDITIS (+),
CARDIOMEGALY (+)
6 6
CARDITIS (+), CHF (+)

> 6 > 12 Paracetamol; Salisilat : 100mg/kg in 4-5 dose (Max 6mg/d)
2weeks then 60-70mg/kg/d for 3-6weeks; Prednison :
2mg/kg/d (max 80mg/d) 2weeks tappering off 20-25% every
week; Carbamazepine, valproic acid, diazepam
FEVER,
ARTHRITIS,
CHOREA
Eradication; For 10days; QID ERYTHROMYCIN
Eradication; For 10days; 25-20mg/kg/d in 3
dose (max adults 50-1000mg/d)
AMOXCILLIN
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DIURETICS, ACE-I/ARB, DIGOXIN, BB, A-
THROMBOTIC
CARDITIS
(PERICARDITIS,
MYOCARDITIS,
ENDOCARDITIS)
ACUTE
RHEUMATIC
FEVER
RHEUMATIC
HEART DISEASE
RHD MORBIDITY
(CHF, AF, IE,
CVD)
SECONDARY
PREVENTION
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NO
RHD
Secondary prevention; 2x250mg; every day;
for all people
ERYTHROMYCIN
Secondary prevention; 2x250mg; everyday;
for all people
PENICILLIN V
RHD MORBIDITY (CHF, AF, IE, CVD)
DEATH
CLINICAL MANAGEMENT
CHF MEDICATION
A-COAGULANT
SURGERY/ INVASIVE NON
SURGERY
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SYMPTOMATIC THERAPY
MONITORING INR IN A-
COAGULANT TH/ FOR AF &
POST REPLACEMENT
SURGERY
SURGERY : REPAIR OR
REPLACEMENT
INVASIVE NON SURGERY :
BMV
CHF
AF
IE
CVD
DIURETICS, ACE-I/ARB, DIGOXIN, BB, A-
THROMBOTIC
DIGOXIN, BB, A-THROMBOTIC, A-COAGULANT
ANTIBIOTICS, OPERATION
CARDIAC EMBOLI IN AF/ VEGETATIONS IN IE
(CONTROLED AF, A-COAGULANT, OPERATION);
NEUROLOGIST
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Eritema marginatum = RF
Nodul subkutan = RF