RHEUMATIC FEVER

1. Rheumatic Fever
Asst. Prof. Bhaumika Sharma
Chitwan Medical College

2. Rheumatic fever
• Rheumatic fever is a diffuse inflammatory
disease.
• It is a delayed response to an infection by
group A beta-hemolytic streptococci
• Acute rheumatic fever, which occurs most
often in school-age children.

3. Epidemiological Data
• The incidence of ARF has declined markedly in the
past 50 years in both the United States and
Western Europe.
• In developing countries, the magnitude of ARF is
enormous.
• Recent estimates suggest that 33.4 million people
worldwide have rheumatic heart disease and that
300,000-500,000 new cases of rheumatic fever
(approximately 60% of whom will develop
rheumatic heart disease) occur annually, with
230,000 deaths resulting from its complications.

4. Contd.
• Almost all of this toll occurs in the developing
world.
• The incidence rate of rheumatic fever is as
high as 50 cases per 100,000 children in many
areas.
• Rheumatic fever in the 21st century appears
to be largely a disease of crowding and
poverty.

5. Contd.
• About 60% of the approximately 470,000
patients diagnosed with ARF annually
eventually develop carditis, joining the
approximately 33 million worldwide with
rheumatic heart disease.
• ARF is most common among children aged 5-
15 years.

6. Etiology of the rheumatic fever
• Rheumatic fever develops in relatively small
percentage of people (3%)
• Once rheumatic fever is acquired, the person
becomes more susceptible than the general
population to recurrent infection

7. Contd.
• The Streptococcus is spread by direct contact
with oral or respiratory secretions
• Although the bacteria are the causative
agents, risk factors also present:
– Malnutrition
– Overcrowding
– Lower socioeconomic status ( poverty )
– Poor hygiene

8. Contd..
• As many as 39% of patients with rheumatic
fever develop various degrees of rheumatic
heart disease associated with valvular
insufficiency, heart failure, and death
• The disease also affects all bony joints
producing polyarthritis

9. Contd.
• Rheumatic fever can usually be prevented if
appropriate antibiotic therapy for group A
beta-hemolytic streptococcal infection is
initiated within the first 9 days.

10. Pathophysiology
Presence of group A beta hemolytic streptococcal
infection more than 9 days
Proliferative, inflammatory exudative inflammatory
process in the heart, joint, nervous system, etc.
Abnormal and humoral and cell mediated response
to streptococcal cell membrane cell

11. contd
Permanent and severe heart damage
Rheumatic and myocarditis develop which temporary
weakness the contractile power of the heart
Pericardium also affected and rheumatic pericarditis
occur
Rheumatic endocarditis result in permanent and
crippling side effect

13. Clinical Manifestations
• Fever, weakness, malaise
• Anorexia, weight loss
• Arthritis
• Carditis
• Subcutaneous nodules
• Erythema marginatum
• Chorea
• Abdominal pain

14. Contd.
• Fever: with a temperature of 100.4 C or
higher, alternates with normal temperature.
• Weakness, malaise, weight loss, and anorexia
probably develop as a result of fever and pain

15. Contd.
• Arthritis. It most often affects the larger
joints, such as the ankles, knees, elbows,
shoulder, and wrists.
• The arthritis may or may not be symmetrical.
Joint manifestations may last hours or days

16. Contd.
• Carditis, murmur, cardiomegaly, pericarditis that
produces a significant friction rub, and heart.
• Chest pain due to pericardial inflammation may
be present.
• Sometimes there is myocardial involvement that
produces atrioventricular (AV)conduction defect

17. Contd.
• Subcutaneous nodules are small, painless,
firm nodules that adhere loosely to the
tendon sheaths, especially in knees, knuckles,
and elbows.
• They are usually evident only during the first
week or so and, generally, only in children

18. Contd.
• Erythema marginatum is an unusual rash seen
primarily on the trunk.
• The lesions are crescent-shaped and have
clear centers.

19. Contd.
• Chorea, a CNS disorder, is manifested by
sudden, irregular, aimless, involuntary
movements.
• Chorea disappears without treatment and
produces no permanent sequel.
• Abdominal pain: varies in site and severity.
The pain may be related to engorgement of
the liver.

20. Diagnostic Methods
Jones' Criteria
Major Manifestations
• Carditis
• Polyarthritis
• Chorea (Sydenham's chorea)
• Erythema marginatum
• Subcutaneous nodules

21. Minor Manifestations
• Arthralgia
• Fever

23. contd
Laboratory findings
• Acute phase reactants
- Erythrocyte sedimentation rate
- C-reactive protein
• Prolonged PR interval

24. Contd.
• Evidence of previous group A streptococcal
infection + Throat culture or rapid
streptococcal antigen test
• ↑ streptococcal antibody titer
• Throat swab culture: positive indicates RF

25. Contd.
• Anti-streptolysin O titre: Serological changes may
indicate a recent streptococcal infection.
• Sometimes anti-streptokinase titre, are
performed.
• WBC count: is elevated in RF
• ESR: elevated
• C-reactive protein: elevated
• Cardiac investigation, e.g. ECG, echocardiogram

26. Medical Management
The goals of medical management include
1. eradicating infection,
2. maximizing cardiac output, and
3. promoting comfort

27. Eradicate Infection
• This can be accomplished with oral administration
of penicillin.
• For penicillin-allergic clients, the physician usually
prescribes erythromycin/sulfonamide (e.g.
sulfadiazine).

28. Contd.
• Phenoxymethylpenicillin 500mg four times
daily for 1 week
• The client typically takes prophylactic agents
for rheumatic fever for 5 years after the initial
attack.
• After 5 years recurrences are rare.
• who have had rheumatic fever remain
vulnerable to bacterial endocarditis.

29. Contd.
• In addition, the antibiotics is taken to prevent
RF recurrence.
• They must be referred for evaluation for
possible prophylactic medications before and
after any surgical procedure or dental work

30. Maximize Cardiac Output
• Corticosteroids are used to treat carditis,
especially if heart failure is evident.
• If heart failure develops, treatment, including
cardiac glycosides and diuretics, is effective.

31. Nursing Management
Assessment:
• Baseline subjective and objective data
gathering
• Assess vital signs to reveal fever, tachycardia,
and blood pressure
• Auscultate heart sounds for presence of a
friction rub, and palpate peripheral pulse

32. Contd.
• Baseline ECG
• Assess baseline nutritional and hydration data
• Assess psychological data on the client’s
feelings regarding restrictions of activity,
support systems, coping strategies, level of
discomfort, and knowledge

33. CONTD.
Prednisolone:
• 60-120mg in four divided doses each day until
the clinical syndrome is improved and the ESR
has fallen to normal.
• Steroids are then tapered off over 2-4 weeks

34. Nursing Diagnosis
1. Promote Comfort
• Clients with arthritic manifestations obtain clinical
relief with salicylates.
• These drugs can result in misdiagnosis, a firm
diagnosis should be in place before administration
of salicylates.
• High-dose salicylate (preferably acetylsalicylate,
i.e. aspirin)

35. Bed rest
Best rest until:
• Temp. remains normal without use of salicylates
• Resting pulse remains under 100 BPM
• ECG tracings show no signs of myocardial damage
• ESR returns to normal
• Pericardial friction rub is not present
• Once ambulatory the client must not overdo.

36. Contd.
• Diagnosis: Activity Intolerance related to reduced
cardiac reserve and enforced bed rest.
• Outcomes: The client will progress toward an
optimal level of physical activity tolerance, based on
underlying cardiovascular status and psychosocial
readiness, as evidenced by ability to
(

37. contd
1) pace activity,
(2) verbalize improvement in fatigue,
(3) express acceptance of any imposed activity
restrictions,
(4) steadily increase activity level to include
climbing one flight of stairs without chest pain
or without ECG changes, while heart rate
remains under 90 BPM.
•

38. contd
Diagnosis: Pain related to the inflammatory
response in the joints.
Outcomes: the client will experience increased
comfort, as evidence by
(1) reports of restful sleep and reduced
discomfort,
(2) expression of joint pain relief,
(3) reduced use of pain medications, and
(4) a relaxed body posture and calm facial
expression

39. Interventions:
• Obtain a clear description of the pain or
discomfort.
• Identify the source of greatest discomfort as a
focus for intervention.
• Administer analgesics as needed.
• Balance rest and activity according to the
degree of pain and activity tolerance

40. Contd.
Diagnosis: Altered nutrition: less than body
requirements, related to fever, inflammation,
anorexia, and fatigue
Outcomes: The client will maintain or restore
adequate nutritional balance, as evidenced by
(1) resumption of body weight before the illness or no
further weight loss,
(2) consumption of 75% or more of each meal served,
(3) normal serum albumin or pre-albumin, and
(4) a positive nitrogen balance.

41. Interventions:
• A high-protein, high-carbohydrate diet helps
maintain adequate nutrition in the presence of
fever and infection.
• Hyper-metabolic states (fever and infection) can
induce a catabolic state, thus delaying healing.
Vitamin and mineral supplements may also
benefit the client.

42. Contd.
• Oral hygiene every 4 hours, small attractive
meal servings, and foods that are not overly
rich, sweet, or greasy stimulate the appetite.
• Adequate fluids intake
• Sodium and fluids must be restricted