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8/10/2019 Rheumatic Fever
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Rheumatic
fever
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Rheumatic feveris acute systemic disease of
the connective tissue immune
inflammatory genesis,characterised mainly by
arthritis, carditis, chorea,
subcutaneous nodules and
erythema marginatum.
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Rheumatic fever(RF)
is common world-wide and is
responsible for many causesof damage heart valves.
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Etiology:
Group A, hemolytic streptococcus(strains 3,5,18,24,28,49 ) is the maine
etiologycal factor. RF occurs about 2weeks after exudative tonsi l i tis
(quinsy,soa throat), scar let
fever,streptodermia or otherstreptococcus infections, if it goes
without treatment.
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Person who has high hyperensitivi ty toimmune system on streptococcus
suffered more frequently. This
hypersensibil i ty of immune systemgenotype determinate with HLA system
antigen A11, B
27, B
35, CW
2, CW
5, DR
5,
DR7.
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Pathogenesis:
On the basis of pathogenesis RF is
immunoinflamatory reaction
(reaction antigen-antibody) with
edema,
hyperemia,
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lymphocyte infiltration of
connective tissue heart (valvule,endocardium, myocardium,
pericardium), brain, vessels,
synovial membrane of joints,skin,
other organ and formatione
rheumatic granuloma (Aschoffsnodule) in connective tissue.
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Immunoinflamatory reaction (react ion
ant igen-ant ibody) is always
accompanied by elimination ofinflammatory mediators: histamine,
bradikinin, prostaglandin E2 and
other.Histamin is dilated capillares andbring on oedema, hyperemia,
infiltratione connective tissue with
cells of immune response
(lymphocytes, plasmatic cells, mast
cells, eosinophils, basophils).
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Prostaglandin E2 - causeincrease to C.
Cluster circulate immune
complex in connective tissue
is cause formation ofpointing necroses in
particular area.
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during immunoinflamatory
reaction morphologically we are
different 4 stages:
mucoid swelling;fibrinoid swelling;
granulomatosis;sclerosis and hyalinosis.
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Outcome of the
immunoinflammatory reaction
are sclerosis,hialinosis,deformation,calcification
valvulas and formatione
anatomical defects (valvula
heart d isease) .
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Sclerosis of myocardium -
myocard iosc leros is(cardiacinsufficiencyheart failure,
arrhythmias, blockades).
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Clinical PICTURE
symptoms and signs ar ise 2 weeks
after pharyngitis or tonsi l l i tis (soa
throat) or scarlet fever.
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major cr i ter ia (manifestation)of RF are:
1.Migratory polyarthritis
2.Carditis
3.Chorea
4.Subcutaneous nodules
5.Erythema marginatum
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m ino r cr i ter ia o f RF are:
high toC;abdominal pain, anorexia;
heart failure;
epistaxis;
pneumonia;
asthenia;malaise;
fatigue.
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Migratory polyarthritis is the most
common clinical manifestation,monoarthritis can also occur. Joints
become painful and tender ,red, hot,
swollen, sometimes with effusion.
Knees, elbows or wrists are most
commonly involved. It leaves nopermanent joint deformility.
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Cardit is
(involves 2 or 3 wall of heart)endocarditis+myocarditis=
rheumocard i t is :
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Rheumatic myocarditis, mature Aschoff nodule
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CLINICAL SIGNS OF CARDITIS:
Cardiac failureChanges heart sounds
Cardiac enlargement
Murmurs;
1. systolic myocardial murmur;
2. murmurs of VS, MI, AS, AI.
pericardial rub.
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ChoreaSydenhamS chorea
emotional instability,muscular weakness and
rapid, uncoordinated jerky
movements affecting
primarily the face, foot and
hands.
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Subcu taneus nodu les
These are firm,
colorless, painlessnodules 1-2 cm in size,
near the tendens orbony prominences of
joints, especially elbow.
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Subcutaneous nodules (rheumatic fever
nodules/Aschoff nodules)
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Erythema marg inatum
This is a nonpruritic, flat,
circular or serpigious rash
on thoraxic trunk and near
joints.
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DIAGTOSTICS
For diagnostic we use:
* major and minor rheumatic criterias* rheumatic anamnesis
* markers of streptococcus infection
* laboratory findings* ECG
* Doppler USG of heart.
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2 major criteria or one major criteria
and 2 minor criteria with markers of
streptococcus infection are basement
for support the diagnosis of RF.
NB!
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LABORATORY FINDINGS:
General blood analysis (blood test)anemia, leycocytosis, shift in leycocyt formulaleft, accelerated erythrocyte sedimentation rate(ESR);
biochemical blood analysis:
reumoprobs:
Level of C-reactive protein;
Level of Seromucoids
Level of Glycoproteins
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positive throat culture;
elevated level of antistreptolisin O,
antistreptokinaze or other streptococcalantibody.
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ECG findings:
PQ prolongation more than 0,18-0,20 sec;
Signs of enlargement of atria or
ventricules;
Signs of pericarditis.
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Doppler USG heart:
Thickening of walls
Patological blood flows
(regurgitatione)
Enlargement atrium or ventricles;
Signs of effusion in pericardium.
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Treatment regimenthe patient must take rest
before normalizaton of his temperature ;
Diet N10;
Ethyologycal treatment: :- ant istreptoc cocal ant ib iot ics
- Benzilpenicillini-natrii 1,21,5 million U
per day,
- Benzathine penicillini G 1,2 million U perday
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Or Amoxicillin 0,5 - 4 times per day;
Ampicillin 0,5 - 4 times per day
If the patient have allergic to penicillinwe use:
Erytromicinum Cephalexin 50mg/kg
Cephadroxil 50mg/kg
2 times per day
Azithromycin 15mg/kg
Clarithromicin 15mg/kg
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One of this ant ib iot ics adm inister
du r ing 10 day, than we change
ant ib io t ic and prescr ibe pro longate
ant ib iot ics:
Bicillinum-3 (1,5 million U forone injection weeks;
Or Bicillinum-5 (1,5 milliom U
one jnjectione for 3 weeks
during the year)
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4. Anti-inflammatory drugs:(NONSTEROID ANTI INFLAMMATORY
DRUGS)NSAID This drugs
blocked Pr a2.NONSELECTIVE:
1) Sal icy l ic Ac id:Acetylsalicylic acid;Sodium salicylate;Mg salicylate.
2) A t l i id
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2) An tray l ic ac id-Mefenamic acid 0,250,5;
- Flufenamic acid;
- Meclofenamic acid.
3) A ry lbenzene ac ids-Diclofenac Sodium ( Voltaren,
ortofen ) - tablets 0,0250,05;
-ampules 0,075; suppository 0,05;
gel 1 %;-Alclofenac;
-Fenclofenac;
- Fentiazak.
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4) Prop ion ic acids :
Ibuprofen ( brufen )Dragee 0,2;
FlorbiprofenDragee 0,05;
Ketoprofen;
Naproxen;
Fenoprofen;
Fenbufen;
Piridofen.
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INDOL DERIVATIVES :
Indomethacin ( Metindol, Indosid )Dragee 0,025 Suppository 0,05;
SulindacTablets 0,2.
PYRAZOLE DERIVATI VES :
Butadion ( Phenylbutazone );
Analgin;
Amidopirin.
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SELECTIVE COX2
BLOKERS:OXICAMSPiroxicam ( Felden ) Tablets 0,01
Izoxicam
Sudoxicam
Meloxicam ( Movalis )
COXI BS :Celecoxib ( Celebrex, Rancelex
Rofecoxib ( Rofica )
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5. Cort icos teroid therapy :
Prednizoloni 0,5-1 mg/kg orally 3times daily(during 3-5 week) with
decrease dose step by step on
regime 5 mg for weeks.
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6.Symptomatical therapy:
If the patient have signs of carditis and
heart failure we administrate:
diuretic drugs:
furosemid 20-40 mg orally daily in the
morning before meal;
Hypothyazidi 50-100 orally daily.
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- Cardiotonic drugs such as
Digoxin 0,0001 1-2 times orally
daily.
If the patient has arrhythmiasahtiarrhythmic drugs.
If the patient has signs vasculitis we
are administed ac. Ascorbinici 0,53times orally daily.
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Prognos is :
In case of initial RF with advantage arthritisand initial carditis prognosis will be favourable
if the patient receive adequate therapy.
In cases severe RF with arthritis, severe
carditis, chronic rheumatic disease, heartvalvule diseases are observed.
If RF is not treated, chronic rheumatic disease
and heart valvule diseases are always occur. Arthritis, chorea, subcutaneous nodulus
erythema marginatum have favorable outcome.
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Prophylaxis (prevention):
Primary prevention:is prevention from
streptococcal infection (tonsilitis,
pharingitis, scarlet fever).
Secondary prevention:
---Antistreptococcal prophylaxis should
be conducted after attack of acute RF in
order to prevent recurrence.
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---Bicillini-5 1,5milliom U (or Benzilinepenicillin 6 1,2 million) one injection for
month due to 3 month
---Aspirini 0,54 times daily
orally during 3 weeks or other
NSAID.
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