Throat Throat infection infection Rheumatic Rheumatic fever fever Rheumatic Rheumatic heart heart disease disease

MIRI .S.R,MD,FACC Pediatric cardiologist Interventional Cardiologist

Diagrammatic structure of the group A beta hemolytic streptococcus Capsule Cell wall Protein antigens Group carbohydrate Peptidoglycan Cyto.membrane Cytoplasm

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Body produce antibodies against streptococci ,cross react with human tissues because of the antigenic similarity between streptococcal components and human connective tissues

There is no direct invasion to the tissue but its an auotoimmune disease that involves Ag-Ab interaction.

Pathogenesis Pathogenesis





Delayed immune response to infection with group.A beta hemolytic streptococci. After a latent period of 1-3 weeks, antibody induced immunological damage occur to heart valves,joints,

subcutaneous tissue & basal ganglia of brain

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It involves group A beta hemolytic streptoccocus throat infection

that involves tonsils & pharynx, so tonsillectomy will not immune the patient against R.F.

R.F cause permanent damage to the heart but not to the joint (only arthritis) thus its said “R.F.leaks the joints but bites the heart” •

Rheumatic -epidemiology Rheumatic fever fever-epidemiology •3% in epidemics of exudative streptococcal pharyngitis in closed community(school,army) • 0.3% in sporadic streptococcal throat infection • 50% if there is a past history of rheumatic fever(thus secondary prophylaxis is important) •

Epidemiology Epidemiology








Ages 5-15 yrs are most susceptible Rare boys Environmental factors-- over

crowding, poor sanitation, poverty, Incidence more during fall ,winter & early spring ١٢

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Microorganism variables: only certain strains that can produce the immunologically active Ag. Host variables: some of human will produce large amount of Abs after each infection but others don’t

Rheumatic -epidemiology Rheumatic fever fever-epidemiology

1.Throat infection may or may not be symptomatic 2.Infection of sufficient duration to produce antibody 3.Genetic predisposition

SO:


Every patient with sore throat and risk factor ,should be managed as streptococcal infection

RF presented in many ways a. arthritis without cardiac involvement b. rheumatic chorea without arthritis nor carditis c. carditis with or without arthritis

heart will be involved in 50% of the cases inflammation, fibrosis & shrinkage of the valves, patients will come with valve stenosis.

Rheumatic -diagnosis Rheumatic fever fever-diagnosis Major manifestations

•Carditis •Polyarthritis •Chorea •Subcutaneous nodules •Erythema marginatum

Rheumatic -diagnosis Rheumatic fever fever-diagnosis Minor manifestations •Clinical findings•Arthralgia(joint pain without swelling ) •Fever •Laboratory findings•Elevated acute phase reactants raised ESR raised CRP •Prolonged P-R interval

Jones Jones criteria criteria for for initial initial attack attack of of rheumatic rheumatic fever fever Evidence of preceding streptococcal infection

+ 2 major manifestations or one major manifestation and 2 minor manifestations

Criteria Criteria for for diagnosis diagnosis


RF recurrence in a patient without RHD

2 major or 1 major plus 2 minor plus evidence of preceding strep infection


RF recurrence in a patient with RHD

2 minor plus evidence of preceding strep infection

Chorea or indolent carditis No other criteria or evidence of preceding strep infection needed




Evidence Evidence of of preceding preceding streptococcal streptococcal infection infection

• Positive throat culture (in 25% ) • Elevated or rising streptococcal antibody titer anti-streptolysin Anti DNAseB anti-hyoluronic acid If these antibodies ( >300 in children >200 in adults) suggest previous infection.

Laboratory Laboratory Findings Findings ASO titer : 1.

2.

at 3 wks then comes down to normal by 6 wks Peak value attained

Arthritis Arthritis

1. Polyarthritis 2. Migratory 3. large joints 4. no residual deformity 5. rapid response to aspirin: if aspirin given,24 to 48hrs joint pain will disappear ;thus used as diagnostic test)

Chorea Chorea





Spasmodic, unintentional, jerky choreiform movements speech affected, fidgety, late manifestation

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Rheumatic -diagnosis Rheumatic fever fever-diagnosis

1. Murmur (MR / AR: endocardium involved) 2. Heart failure (Cardiac nlargement :myocardium involvement)

3. Pericardial rub or effusion pericardium involvement

Rheumatic -diagnosis Rheumatic fever fever-diagnosis


Chest x-ray – cardiomegaly, pulmonary venous congestion

Rheumatic -diagnosis Rheumatic fever fever-diagnosis





ECG- heart block, T wave changes, low voltage QRS Echocardiogram – cardiac dilatation, valve involvement, pericardial effusion

Subcutaneous nodule

Rheumatic -diagnosis Rheumatic fever fever-diagnosis

Subcutaneous nodules (nodules of rheumatoid arthritis are larger)

Subcutaneous nodules










Occur in 10% Painless,palpable nodules Mainly over extensor surfaces of joints,spine,scapulae & scalp Associated with strong seropositivity Always associated with severe carditis ٣٤

Erythema Erythema marginatum marginatum

• Erythematous, ring or crescent shaped, transient patches over trunk and limbs

Rheumatic -diagnosis Rheumatic fever fever-diagnosis Erythematous patches with central clearing

Erythema marginatum

Erythema Marginatum

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05/05/1999

Dr.Said Alavi

Erythema Erythema Marginatum Marginatum









Occur in