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Rheumatic Fever

Peak incidence 5-15yrs Q


Occur due to pharyngeal infection with Lance field Group A Beta haemolytic streptococci Q triggers rheumatic fever 2-4wks Q later, carbohydrate cell wall of the streptococcus cross reacts with valve tissue (antigenic mimicry Q) and may cause permanent damage to the heart valves.


Extra Edge:

  1. Rheumatic fever is not a communicable disease.
  2. It is more common in Low socioeconomic people.
  3. Primary attack rate is 3%
  4. Secondary attack rate is 15 to 50%

Diagnosis revised Jones criteria.


(Revised Jones Criteria)        (Ref. Hari.  18th ed,. Pg- 2755)
Diagnostic Categories Criteria
Major manifestations:
1. Carditis
2. Polyarthritis
3. Chorea              
4. Erythema marginatum
5. Subcutaneous nodules
Minor manifestations Clinical:
1. Fever,
2. Polyarthralgia
1. Elevated ESR
2. Leukocytosis
3. ECG- Prolonged P-R interval
Supporting evidence of a preceding streptococcal infection within the last 45 days 1. Elevated or rising ASO or other streptococcal antibody, or
2. A positive throat culture, or
3. Rapid antigen test for group A streptococcus, or
4. Recent scarlet fever


  1. Hallmark is McCallum patch.
  2. Patient may have Aschoff’s nodule which has Anitschkow myocyte.

Important points: (Pathology of rheumatic fever)

  1. Aschoff nodules
  2. MacCallum patch
  3. Fibrinous pericarditis


  1. Benzylpenicillin 0.6-1.2g IM stat then penicillin V 250mg/6h orally
  2. Analgesic for carditis/arthritis. Aspirin 100 mg/kg/d in divided doses. For 6wks. Toxicity causes tinnitus, hyperventilation, Metabolic acidosis  
  3. Steroids Q. Are specially used if carditis is there with or without CHF. 
  4. Valproate, carbamazepine for the chorea

Secondary prophylaxis Penicillin V 250mg/12h PO until no longer at risk (>30yr Alternative: sulfadiazine, erythromycin.

Table 322-3 American Heart Association Recommendations for Duration of Secondary Prophylaxis* (Ref. Hari. 18th ed., pg - 2757,Table 322-3)
Category of Patient Duration of Prophylaxis
Rheumatic fever without carditis For 5 years after the last attack or 21 years of age (whichever is longer)
Rheumatic fever with carditis but no residual valvular disease For 10 years after the last attack, or 21 years of age (whichever is longer)
Rheumatic fever with persistent valvular disease, evident clinically or on echocardiography For 10 years after the last attack, or 40 years of age (whichever is longer). Sometimes lifelong prophylaxis.

Important Points:

  1. Surgical replacement of mitral and/or aortic valve during acute rheumatic fever results in a rapid control of CCF and decrease in heart size, despite investigational evidence for ongoing active rheumatic fever. (AIIMS May 11)
  2. The surgical findings thus indicate that it is the acute hemodynamic overload secondary to valvar regurgitation, which is responsible for CCF and the morbidity and mortality of acute rheumatic. 

Other important conditions associated with streptococcal infection.

  1. Post streptococcal reactive arthritis.
  2. PANDAS (Pediatrics autoimmune neuropsychiatry disorder associated with Streptococci)

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