#infectious_diseases See: [ARF and RHD australian guidelines](https://www.rhdaustralia.org.au/arf-rhd-guidelines) - [devonthink link](x-devonthink-item://93496C54-9F55-4C34-A109-A6FAC2665420), [cameron paeds acute rheumatic fever](x-devonthink-item://E383FFBD-9FD8-4DE9-B350-0F6F60D3E600?page=529), [Dunn - Rheumatic fever](x-devonthink-item://19B52D8D-19D0-4223-BA30-0F4F631FF0E5), [Rheumatic fever - RACGP 2012](x-devonthink-item://15C392C0-9AA8-41B5-AFB4-1D9CFF742BB1) - [online link](https://www.racgp.org.au/afp/2012/january-february/rheumatic-fever) > [!key points] > 1. Acute rheumatic fever (ARF) is a systemic inflammatory response to group A streptococcal throat infection. > 2. The major complication is progressive *damage of cardiac valves* leading to chronic **rheumatic heart disease** (RHD). > 3. Although uncommon in developed countries, very high rates occur amongst [[Aboriginal health|Indigenous Australians]], New Zealand Māori and Pacific Islanders. > 4. Diagnosis is based on the presence of clinical features (carditis, arthritis, chorea, and rarely skin rashes and nodules) with evidence of systemic inflammation and recent group A streptococcal infection. > 5. Treatment of ARF is supportive and involves controlling joint pain and managing carditis, heart failure and chorea. > 6. Long-term antibiotic prophylaxis with intramuscular benzathine penicillin prevents further attacks of ARF and improves cardiac outcomes. > 7. Antibiotics are recommended prior to dental procedures to prevent infective endocarditis. Mnemonic:: JONES, CAFE PAL # Diagnosis **JONES** major criteria: Joint involvement ♥ myocarditis, valvular disease (often mitral or aortic) Nodules, subcutaneous Erythema marginatum [Sydenham's Chorea](https://www.youtube.com/watch?v=wTCnbga3sqg) (rapid, uncoordinated jerking movements primarily affecting the face, hands and feet) Minor criteria  *CAFE PAL* CRP elevated ≥ 30 Arthralgia, polyarthritis Fever elevated ESR ≥ 30 (if ↑ risk group) Prolonged Pr interval anaemia of rheumatism leukocytosis > **A definite initial episode of ARF** requires: > - 2 major manifestations + evidence of preceding Strep A infection, **OR** > - 1 major + 2 minor manifestations + evidence of preceding Strep A infection Preceding Strep A infection is indicated by an elevated or rising antistreptolysin O or other streptococcal antibody, or a positive throat culture or rapid antigen or nucleic acid test. *Arthritis* is the most common presenting manifestation. The arthritis of ARF  is classically described as a **migratory polyarthritis of the large joints**; however, a much wider spectrum of joint manifestations can occur including monoarthritis and arthralgia. **Carditis** manifested as valvulitis, myocarditis, or pericarditis occurs in 80% of cases. mitral valve > aortic valve. New murmur sometimes, but need ECHO for inaudible regurg. # Treatment - *analgesia* - paracetamol first line 15mg/kg - NSAIDs eg naproxen - Tramadol immediate-release 50 to 100 mg (child 1 to 2 mg/kg) orally, 4- hourly up to a maximum of 400 mg/day - Oxycodone - *antibiotics* - Benzathine benzylpenicillin G (BPG) 1,200,000 units (child <20 kg: 600,000 units; ≥20 kg: 1,200,000 units) IMI single dose - **or** Phenoxymethylpenicillin 500 mg (child: 15 mg/kg up to 500 mg) orally 12- hourly for 10 days - **Penicillin hypersensitivity** (non-severe): cefalexin 1 g (child: 25 mg/kg up to 1 g) orally, 12-hourly for 10 days - **Immediate penicillin hypersensitivity**: azithromycin 500 mg (child: 12 mg/kg up to 500 mg) orally daily for 5 days - *Carditis* - Furosemide (frusemide) 1 to 2 mg/kg orally as a single dose, then 0.5 to 1 mg/kg (to a maximum of 6 mg/kg) orally, 6- to 24-hourly - Spironolactone 1 to 3 mg/kg (initially) up to 100 mg orally, daily in 1 to 3 divided doses. Round dose to a multiple of 6.25 mg (a quarter of a 25-mg tablet). - Enalapril 0.1 mg/kg orally, daily in 1 or 2 divided doses increased gradually over 2 weeks to a maximum of 1 mg/kg orally, daily in 1 or 2 divided doses, other ACE inhibitors (captopril, lisinopril, ramipril, perindopril) - *Sydenham’s chorea* - Usually no treatment requires - carbamazepine 3.5 to 10 mg/kg per dose orally, twice daily or sodium valproate 7.5 to 10 mg/kg per dose orally, twice daily if symptoms are debilitating - *Severe disease* - Prednisone/prednisolone 1 to 2 mg/kg up to a maximum of 80 mg orally, once daily or in divided doses - Considered for use in selected cases of severe carditis, despite meta-analyses in which overall benefit was not evident.