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AM Report
March 5, 2010
Amy Auerbach
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Typically preceded by group A streptococcal
tonsillopharyngitis (two to four weeks prior to
ARF)
? Whether GAS skin infections could also
predispose
Most frequent in children between 4 and 9
years of age
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Migratory arthritis (involving large joints)
Carditis and valvulitis
Central nervous system involvement
(Sydenham chorea)
Rash
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Typically migratory arthritis- knees, ankles,
elbows, wrists most commonly
Often earliest manifestation
May see monoarticular arthritis if patient has
received salicylates or other NSAIDs
Joint analysis demonstrates steril
inflammatory fluid
Minimal changes in serum levels of
complement
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Pancarditis affecting the pericardium,
epicardium, myocardium, and endocardium
Symptoms may be subtle or non-existent
May see mitral regurgitation early on
Mitral stenosis is manifestation of late
scarring and calcification
Echocardiography always indicated to assess
for valvular disease
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Sydenham chorea- abrupt, purposeless,
nonrhythmic involuntary movements,
muscular weakness, emotional disturbances
Commonly more marked on one side and
cease during sleep
Emotional disturbances typically manifest as
inappropriate behavior, crying, restlessness
Can see diffuse hypotonia
Often has longer latent period than other
manifestations
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Firm and painless, typically a few milliliters to
one to two centimeters
Typically located over bony surface or near
tendon
Present for 1-2 weeks but rarely more than a
month
Least common manifestation (in the US)
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Typically occurs early in the disease
May persist or recur even when all other
manifestations have disappeared
Typically occurs only in patients with carditis
High probability of ARF if the following criteria
are met:
1)
Evidence of preceding group A streptococcal
infection
2)
Two major manifestations OR
One major and two minor manifestations
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Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
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Arthralgia
Fever
Elevated ESR or CRP
Prolonged PR interval
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1)
2)
3)
Three settings in which diagnosis can be
made without Jones Criteria
Chorea as only manifestation
Indolent carditis months after acute
infection
Recurrent rheumatic fever in patients with
history of rheumatic fever or rheumatic
heart disease
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Symptomatic relief
Eradication of GAS
Prophylaxis against future GAS infection to
prevent recurrent disease
Primary prevention most important: prompt
diagnosis and treatment of group A
streptococcal tonsillopharyngitis
1)
2)
3)
Polyarthritis is typically the first
manifestation but may present weeks after
GAS tonsillopharyngitis
Patients already treated with aspirin and
NSAIDs may not meet criteria for ARF
despite having the disorder
Carditis is most severe manifestation and
can be prevented by prompt treatment of
GAS