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Acute Rheumatic Fever

  1. Rheumatic Fever Is An Inflammatory Disease which occurs as a delayed sequel of pharyngeal infection (not skin), caused by group A β hemolytic Streptococcus. Antibodies produced against some streptococcus cell wall proteins and sugar react with heart, connective tissue of body, joints, result in rheumatic fever.
    1. There is no single sign, symptoms or laboratory test for the confirmation of diagnosis.
  2. Age 5-15yrs.
    1. Mitral valve and chorea more common in females
    2. Aortic valve involvement is seen more often in males 


  1. Due to group A beta hemolytic streptococcus.
  2. Following streptococcal sore throat there is a latent period of 10 days to several weeks, before onset of rheumatic fever.
  3. M protein is believed to be the virulence factor of the streptococcusQ 

Clinical features

Two major or one major and two minor criteria are required in the presence of essential criteria to diagnose acute rheumatic fever.


Criteria for diagnosis of rheumatic fever


Major criteria

  1. Carditis
  2. Arthritis
  3. Subcutaneous nodules
  4. Chorea
  5. Erythema marginatum

Minor Criteria                                                                                                 

  1. Clinical
    1. Fever
    2. Arthralgia                   
  2. Laboratory
    1. acute phase reactant
       CRP. I ESR , Leucocytosis
    2. prolong PR interval

Essential criteria


Evidence of recent streptococcal infection as indicated

  1. increased antistreptolysin `O’ titer
  2. positive throat culture
  3. recent scarlet fever

Criteria for diagnosis of:


Primary episode of RF

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

RFrecurrence in a pt. without RHD

2 major or 1 major plus 2 minor plus evidence of preceding strep. Infection

RF recurrence in a pt. with RHD

2 minor plus evidence of preceding strep. Infection

Chorea or indolent carditis

No other criteria or evidence of preceding strep. Infection needed.

  1. Carditis- rheumatic carditis is pancarditis; Aschoff bodies in the atrial myocardium are believed to be characteristic of rheumatic carditisQ.  
    1. ​​Pericarditis -
      1. precordial pain
      2. Pericardial friction rub
      3. ST and T changes
      4. Always has additional mitral or aortic regurgitation murmur
    2. ​​Myocarditis-
      1. Cardiac enlargement
      2. Soft first sound
      3. CHF                                            
      4. Disproportionate tachycardia                                      
      5. Gallop rhythm                                       
      6. Carrey Coombs murmur
        [delayed diastolic murmur due to valvulitis] 
    3. endocarditis represented by a pansystolic murmur of MR with or without AR murmur 
  2. Arthritis
    1. Migratory polyarthritis (usually large joint involved)
    2. There is no residual damage to joint
    3. Dermatic response to NSAID 
  3. Subcutaneous nodules - Appear on bony prominences
                                            Non tender
                                           Pts. having subcutaneous nodules almost always have carditis 
  4. Chorea - late manifestationQ
    ASLO titre returns to normalQ
    Triad of abnormal movements, hypotonia & emotional lability Q
    Jerky speechQ 
  5. Erythema marginatum
    1. evanescent pink rash (Erythematous serpiginous rash).
    2. present on trunk or extremeties, never on face
    3. transient migratory may be brought out by application of heat
    4. it is non pruritis and blanch on pressure 

Minor Criteria

  1. Clinical
    1. Fevers, abdominal pain, epistaxis          
    2. Arthralgia    
    3. Previous rheumatic fever 
  2. Laboratory manifestation
    → Acute phase reactant
    1. Leucocytosis
    2. Raised ESR  
    3. Raised CRP

If CHF appear it brings the ESR down towards normal


 prolong PR interval


Arthralgia or a prolonged PR interval cannot be used as a minor manifestation in the presence of arthritis or carditis respectively.


Essential Criteria


Includes evidence for recent streptococcal infection

  1. Elevated ASLO titres
    1. 250 Todd unit in adult considered to be elevated
    2. 333 Todd unit in children     
  2. Positive throat culture for streptococci which is relatively uncommon.
  3. Residua of scarlet fever

The desquamation of skin of palm and sole indicate that pt. has had scarlet fever with in two weeks. Scarlet fever rare in India.



  1. Inj. Benzathine penicillin is given to eradicate streptococci (single dose)
    Inj. Procaine penicillin twicw daily for 10 days.
  2. when diagnosis of acute rheumatic fever is confirmed one must educate the patient/ parent about continuous antibiotic prophylaxis.
  3. Bed rest
  4. Therapy with anti inflammatory agent
    If pt. has carditis with CHF use steroids
    If carditis without CHF, use either steroids/ aspirin (steroid preference)
    If pt. has no carditis -  use aspirin
  5. Treat CHF 

Duration of secondary prophylaxis

  1. No carditis: 5 years/18yrs of age, whichever is longer.
  2. Mild to moderate carditis and healed carditis:10 yrs/25 yrs of age, whichever is longer.
  3. Severe disease or post intervention patients:
    1. Life long. One may opt for secondary
    2. Prophylaxis up to the age of 40 years

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