Rheumatic Fever

N C Joshi
Aims of Treatment
- Eradication of initiating streptococcal infection by a therapeutic course of penicillin.
- Treatment of acute carditis
- Treatment of extracardiac manifestations
- Specific treatment of congestive cardiac failure

Eradication of initiating streptococcal infection by a therapeutic course of penicillin: The patient with acute rheumatic fever with whatever manifestations should be given a therapeutic course of antibiotic to eradicate residual streptococci which may be difficult to isolate.

A ten day course of oral penicillin or Inj Benzathine Penicillin in single IM inj 1,20,000 IU in children above 60kg and 600,000 IU in children below 60kg. If patient is sensitive to penicillin - oral Erythromycin 20mg/kg/day in three divided dose can be given for 10 days. Tetracyclines and sulphonamides are not used.

Bed rest:
Recommended duration and strictness of bed rest is variable. Reason for bed rest is to reduce cardiac work and to avoid use of involved joints.

- In those patients with only arthritis 3 weeks, bed rest is advised. Generally patients with polyarthritis or arthralgia become asymptomatic by 2nd or 3rd week and also if at all carditis is going to develop it develops within 3 weeks. After three weeks, ambulatory bed rest is given.

- In those patients with murmur of mitral &/or aortic regurgitant murmur but without cardiomegaly or CHF- two weeks complete bed rest and next two weeks gradual ambulatory bed rest is given.

- In those patients with murmur and cardiomegaly without CHF, 4 weeks strict bed rest followed by 2 weeks ambulatory bed rest is given.

- In those patients with murmur, cardiomegaly and CHF, strict bed rest is given until CHF is completely controlled and ambulatory bed rest is given for 4 weeks after anti-inflammatory therapy has been stopped.

Anti-inflammatory drugs
Aspirin and steroids are the two anti-inflammatory agents of choice for treatment of acute rheumatic fever. Both drugs suppress inflammation, joint manifestations as well as acute phase reactions. There is a little or doubtful effect on erythema marginatum, subcutaneous nodules, chorea as well as on long term complication of arthritis. Aspirin is effective for arthritis but steroids are far superior to Aspirin in case of severe carditis.

Use of anti-inflammatory drugs in acute rheumatic fever:

Silent carditis (Only murmur)
Arthralgia/ Raised ASO & ESR
Steroid zone
Aspirin zone
Analgesics with penicillin

PC - Pancarditis C-CHF - Carditis with failure C-CAR - Carditis with cardiomegaly Silent carditis - ECHO evidence only.
In steroid zone, these conditions require definite steroid treatment.
In Aspirin zone, the use of Aspirin is adequate.
In central zone, either of the drug can be used.

Why Aspirin is not given in severe carditis?
High dosage Aspirin increases O2 consumption of myocardium and increases workload on heart and so precipitates CHF. It has been shown that if only Aspirin is used in carditis, during the course of Aspirin the patient can develop pericardial rub which never happens during steroid course. Aspirin exerts no specific effect on lesion of acute rheumatic process at any site but produces excellent symptomatic relief of arthritis and fever. There is not yet proven evidence that steroids reduce incidence and severity of residual rheumatic heart disease but there is definite impression that death during acute attack of carditis is prevented.

With either drug, duration is 6 weeks or until patient's clinical condition improves and ESR has returned to normal. Both drugs should be given for 4 weeks and then tapered off slowly in next 2 weeks. To avoid or minimize rebounds addition of Aspirin towards the end of steroid treatment is quite useful.

Occasionally, it is necessary to continue the steroid treatment for longer periods of time especially in patients who remain in heart failure with other decongestive measures. If the patient remain in CHF beyond 3 - 4 months of steroid and other decongestive measurers one should seriously think of surgery.

In very severe CHF, Methyl Prednisolone parenterally should be used followed by oral prednisolone.

- Aspirin : 100 - 120 mg/kg/day
- Prednisolone: 2 - 3 mg/kg/day ( maximum 60mg/day. )

Congestive heart failure in patients who present with heart failure, digitalis and diuretics are considered. Digitalis i.e. Digoxin was previously contraindicated since some patients are extremely sensitive to the glycoside. It can be used if one remains on low dosage schedule.

Chorea - Isolated chorea is treated symptomatically since neither Aspirin nor steroids have any effect on the course. The combination of Phenobarbitone and Chlorpromazine works well, if not Haloperidol can be used.

The story of rheumatic fever does not end with the completion of anti-inflammatory treatment and normalization of acute phase reactants. Every patient of acute rheumatic fever is a candidate for continuous prophylaxis as risk of recurrent attack of acute rheumatic fever continue.

The method of choice is monthly intramuscular injection of 1.2 mega units of Benzathine Penicillin and at times every three weeks. In case of genuine penicillin allergy, sulfonamides (0.5gm/daily <25 kg and one gm daily above>25kg) or Erythromycin can be used.

The point of confusion is when to stop prophylaxis. If a patient presents with severe carditis or with recurrent episodes of Acute Rheumatic Fever, prophylaxis is considered for life. For moderate carditis, prophylaxis till 16 years and for mild or no carditis for 3 years from last episode should be given.

Rheumatic Fever Rheumatic Fever 01/24/2001
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