Heart Diseases in Children

8/13/2019 Heart Diseases in Children

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Acute rheumatic fever


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Introduction

Inflammatory diseases that involves heart, joint,CNS, skin and subcutaneous tissues


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Epidemiology

Most common cause of acquired heart disease inchildren

Mainly in under developed countries

First infection is usually btw 5-15 years old

More common in girl > boy


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Aetiology

Streptococcus pyogenes (Group A hemolyticStreptococcus) pharyngeal infection

This genetic susceptibility is inherited as an

autosomal recessive gene


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Pathogenesis

Streptococci trigger autoimmune reaction

inflammation

- Not direct infection of the bacteria to the heart

- Antibody produce by the infection showed to cross

react with host tissue in the valvular tissue,myocardium, joint, subthalamic & caudate nuclei

- Valvular damage in mitral and aortic, less in triscupid

and pulmonary


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Revised Jones criteria

Major criteria- Sydenhams chorea (10%)

- Subcutaneous nodules (rare)

- Migratory polyarthritis or polyathralgia(80%), or

aseptic monoarthritis

- Carditis (50%)

- Erythema marginatum (


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Erythema marginatum


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Minor criteria- Fever (temperature > 38 C)

- Raised actue phase reactants, ESR > 30 mm/h or

CRP > 30 mg/L

- Prolonged PR interval


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Recurrent attack of ARF

- 2 major criteriaOr

- 1 major criteria + 2 minor criteria

Or

- 3 minor criteria

PLUS

evidence of a preceding group A streptococcalinfection


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ECG CXR

Echo


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Management

Acute phase1. Bed rest

2. Anti-streptococcal therapy

IV C. Penicillin 50 000U/kg/dose 6H

or oral Penicillin V 250 mg 6H (30kg) for 10 days

oral Erythromycin for 10 days if allergic to penicillin.


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3. Anti-inflammatory therapy

Mild / no carditis:

- oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4

weeks, taper over 4 weeks

Pericarditis, or moderate to severe carditis:- oral Prednisolone 2 mg/kg/day in 2 divided doses for

2 - 4 weeks,

- taper with addition of aspirin as above.


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4. Anti-failure medications - diuretics, ACE inhibitors, digoxin (to be used with

caution).


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Secondary Prophylaxis

IM Benzathine Penicillin 0.6 mega units (30 kg) every 3 to 4 weeks

oral Penicillin V 250 mg twice daily

oral Erythromycin 250 mg twice daily if allergic to

Penicillin


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Duration of prophylaxis- until age 21 years or 5 years after last attack of ARF

whichever was longer

- lifelong for patients with carditis and valvular

involvement.


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Infective endocarditis


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Introduction

Microbacteria infection which cause exudative andproliferative inflammatory alteration of the

endocardium or vascular endothelium

An uncommon condition in children but has a high

morbidity and mortality if untreated


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Risk factors

congenital heart disease repaired congenital heart defects

congenital or acquired valvular heart diseases

immunocompromised patients with indwelling central

catheters


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Aetiology

1. Bacteria- Streptococcus viridans

- Staphylococcus aerues

- Community acquired enterococci

- HACEK group

Haemophilus spp

Actinobacillus actinomycetemcomitan

Cardiobacterium hominis Eikenella corrodens

Kingella kingae


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2. Fungus

- Candida

- Aspergillus- Histoplasma

3. Others

- Libman-Sacks endocarditis (SLE)


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Clinical features

Fever + new murmur is IE until proven otherwise


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Symptoms

Fever Lethargy

Loss of appetite

Loss of weight

Arthralgia


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Signs

Peripheral stigmata- Splinter haemorrhage

- Oslers node

- Janeway lesion

- Necrotic skin lesion

- Clubbing (late)

- pallor


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Oslers node


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Oslers node


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Janeway lesion


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Janeway lesion


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Rothss spot on funduscopy

Neurological signs from cerebral infaction

New/changing murmur

Splenomegaly

Haematuria (microscopic)

Arthritis


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Modified Duke Criteria

Major criteria

1. blood culture positive:

typical microorganisms from two separate blood

cultures:

- Viridans streptococci,- Streptococcus bovis,

- HACEK group,

- Staphylococcus aureus- community-acquired enterococci


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2. evidence of endocardial involvement on

echocardiogram

- vegetation, abscess or dehiscence of prosthetic valve


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Minor criteria

1. Predisposing heart condition, prior heart surgery,

indwelling catheter

2. Fever, temperature > 38C

3. Vascular phenomena:- major arterial emboli

- septic pulmonary infarcts

- mycotic aneurysm

- intracranial hemorrhage,

- conjunctival hemorrhages

- Janeways lesions


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4. immunologic phenomena:

- glomerulonephritis- Oslers nodes

- Roths spots

- rheumatoid factor

5. microbiological evidence:

- positive blood culture not meeting major criterion


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Diagnosis Definite IE

Pathological criteria1. microorganisms by

- Culture

- histological examination of vegetation or intracardiacabscess specimen

2. pathological lesions with active endocarditis

Clinical criteria:

2 major or1 major + 3 minor or

5 minor


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Possible IE

- 1 major + 1 minor criteria

or- 3 minor


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Investigation

Blood

- FBC

- ESR

- CRP

- BLOOD C&S

- LFT

- C3/C4


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UFEME

CXR

ECG

ECHO


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Management

Ensure 3 blood cultures taken before antibiotic

therapy.

Do not wait for echocardiography.

Use empirical antibiotics,until culture results

available


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Guidelines on prophylaxis of IE

Endocarditis prophylaxis recommended

High-risk category

- prosthetic cardiac valves

- previous bacterial endocarditis

- complex cyanotic congenital heart disease

- surgical systemic pulmonary shunts


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Moderate-risk category

- other congenital cardiac malformations (other thanabove and below)

- acquired valvar dysfunction (e.g rheumatic heart

disease)

- hypertrophic cardiomyopathy

- mitral valve prolapse with regurgitation

Endocarditis prophylaxis not


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Endocarditis prophylaxis not

recommended

Negligible-risk category

isolated secundum ASD

repaired ASD & VSD

patent ductus arteriosus (after 6 mths)

mitral valve prolapse without regurgitation

functional, or innocent heart murmurs

previous Kawasaki disease without valvular

dysfunction

previous rheumatic fever without valvular dysfunction

cardiac pacemakers and implanted defibrillators


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Common procedures that require IE prophylaxis

Oral, dental procedures

- extractions, periodontal procedures

- placement of orthodontic bands (but not brackets)

- intraligamentary local anaesthetic injections

- prophylactic cleaning of teeth


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Respiratory procedures

- tonsillectomy or adenoidectomy

- surgical operations involving respiratory mucosa

- rigid bronchoscopy

- flexible bronchoscopy with biopsy


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Gastrointestinal procedures

- sclerotherapy for esophageal varices

- oesophageal stricture dilatation

- endoscopic retrograde cholangiography

- biliary tract surgery

- surgical operations involving intestinal mucosa


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Genitourinary procedures

- Cystoscopy

- Urethral dilation


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Standard general prophylaxis

Oral Amoxicillin 50 mg/kg (max 2 Gm) one hour before

procedure

Or

IV/IM Ampicillin 50 mg/kg (max 2 Gm)


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Penicillin allergy

Oral Clindamycin 20 mg/kg (max 600 mg)

Or

Oral Cephalexin 50 mg/kg (max 2 Gm)

Or

Oral Azithromycin/clarithromycin 50 mg/kg (max 500 mg)

Or

Oral Erythromycin 20 mg/kg (max 3 Gm)

Or

IV Clindamycin 20 mg/kg (max 600 mg)


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Kawasaki disease


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Introduction

Also known as mucocutaneous lymph node

syndrome

Systemic febrile condition affecting children usually

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Heart Diseases in Children