Yulius patimang

1. Immunologic
Streptococcus Beta hemolytic group A

2. Predisposing factors
- Family history
- Socio economic status
- Age 5 -15 years ( peak 8 years)
 Inflammatory lesion : heart, brain, joints,
skin

Aschoff bodies (in atrial myocardium) :

characteristic ?
Central necrosis surrounded by lymphocy
tes, plasma cells, and large mononuclear
and giant multinucleate cell
Aschoof Body : the cells are large, multinucleotide
History
Streptococcal pharyngitis, 1-5 wks ( 3
wks) before onset; chorea
Pallor, easy fatigability, epistaxis, abdo
minal pain

Positive family history

Mayor criteria

1. Arthritis
* Affects 70 % of cases
* Large joints : knee, ankle, elbow, wrist
* Often > 1 joints, simultaneously or
in succession, migratory
* Swelling, heat, redness, severe pain,
tenderness, motion <
* Dramatic response to salicylate
2. Carditis
50 % of cases, usu within first 3 wks
Diagnosis requires presence of 1 of 4:
- organic heart murmur
- pericarditis (friction rub, pericard
effusion,
chest pain, ECG changes)
- cardiomegaly on chest X ray
- congestive heart failure
3. Erythema marginatum
- <10 % of cases
- Non pruritic annular erythematous rashes,
never on face
- Most prominent on trunk and inner proximal
portions
4. Subcutaneous nodules
- 2-10 % of cases, esp in recurrences
- Hard, painless, non pruritic, freely

moveable, swelling 0.2-2 cm

- Usually symmetric on extensor surfaces

of joints, scalp, along spine, has significant

association with carditis
5. Sydenhams chorea
- 15 % of patients, more often in
prepubertal girls.
- begin with emotional lability and personal

ity changes
- spontaneous, purposeless movement
followed by motor weakness
- Dysfunction of basal ganglia and cortical
neuronal components (antineuronal
antibody)
 Positive throat culture or rapid streptococcal
antigen tests for group A :
less reliable (recent and chronic infect)
Streptococcal antibody tests : most reliable
- ASTO : 80%
- Anti-DNA se B
- Anti hyaluronidase
Based on

2 major criteria
or + ASTO
1 major + 2 minor
 Chorea may occur as the only
manifestations of RF
Indolent carditis may be the only
manifestation
Occasionally patients with RF recurrences

may not fulfill the Jones criteria

 Juvenile rheumatoid arthritis
Collagen vascular diseases
Virus associated acute arthritis
 Benzathin penicillin G 0.6 1.2 M units IM
for eradication and prophylaxis
Bed rest
Acetosal for mild cases
Prednison for severe cases
Antiinflammatory agents not needed for

isolated chorea
Recommended anti-inflammatory agents
_______________________________________________________________________________________
Arthritis Mild Moderate Severe
alone carditis carditis carditis
__________________________________________________
Prednisone 0 0 0 2-6 wk*

Aspirin 1-2 wk 3-4 wk# 6-8 wk 2-4 mo

___________________________________________________

* Prednisone should be tapered and aspirin started during

the final week
# Aspirin may be reduced to 60 mg/kg/day
Dosages
Prednisone : 2mg/kg/day, in 4 divided doses
Aspirin : 100 mg/kg/day, in 4-6 divided doses
Bed rest and indoor ambulation
____________________________________
Arthritis Mild Moderate Severe
Alone Carditis Carditis Carditis
__________________________________________________________

Bed rest 1-2 wk 3-4 wk 4-6 wk as long as HF +

Indoor ambulation 1-2 wk 3-4 wk 4-6 wk 2-3 mo
_________________________________________________________

ESR: important for duration of restriction of activities.

Full activity : ESR normal, except significant cardiac involvement _
 Mild carditis : questionable cardiomegaly
Moderate carditis : definite but mild
cardiomegaly
Severe carditis : marked cardiomegaly or

HF (heart failure)
Terima kasih