Acute Rheumatic Fever (Heart Rheumatism)
Acute rheumatic fever (ARA) or heart rheumatism, commonly known as pt rheumatic fever bakteri, usually occurs in individuals between the ages of 5 and 15 years after a throat infection (tonsillitis, pharyngitis) with a bacterial strain called Streptococci. inflammation of the joints, inflammation of the heart, swelling under the skin, involuntary sudden movements called Sydenham Koresi and red colored rashes on the skin, usually feverish. In the initial stage of the disease, death due to heart failure due to inflammation of the heart may occur. ARA is not seen in every child with upper respiratory tract infection, and its incidence is between 1-3 in 100 patients.
It is more common in the years after the initial stage (acute period) and is a valvular heart disease caused by initial cardiac inflammation. Mitral valve is usually affected in girls, whereas aortic valve involvement is more common in boys.
Clinical picture:
Arthritis: inflammation of the joints (wrist, elbow, knee, ankle, etc.), very painful, wandering (usually one to two joints in one joint, while passing another joint), leading to limitation of movement, accompanied by increased temperature and redness. It occurs in 75% of patients. Absence does not exclude ARA. The incidence increases with increasing age. It typically responds very quickly to aspirin treatment. If there is no response to aspirin treatment, the diagnosis should be reviewed.
Carditis (heart inflammation): It is seen more frequently in young children and decreases with increasing age (<3 years 90%, 30% between 14-17 years). The patient may have chest pain, shortness of breath and palpitations. On physical examination, heart murmurs are heard. Heart inflammation can be passed without any clinical findings. Rheumatic heart valve disease usually occurs as a valve stenosis or insufficiency 10-20 years after the first episode (febrile stage). Mitral valve is frequently affected (75-80%) and may be associated with mitral stenosis or insufficiency or both. Aortic valve disease is less common than mitral valve (30%) and tricuspid and pulmonary valves are less affected (<5%).
Sydenham Koresi: It develops in 10-30% of ARA cases. They are involuntary, fast, bouncing movements that often develop on the face, tongue, arms and legs. It is more common in girls. The occurrence of the disease after the febrile stage is usually later than other disease symptoms. This waiting period can be between 6 weeks and 6 months. It is often associated with carditis.
Subcutaneous nodules: 10-20% incidence. Hard, painless, 0.5-2 cm in size, usually seen on the tendons on the outer face of the joints. Coexistence with inflammation of the heart is common.
Skin rash: The most rare finding (5%). They are round, red around, pale middle, slightly raised skin. Coexistence with inflammation of the heart is common.
Laboratory findings
Throat culture must be taken. ASO antibodies are high in 80% of individuals (over 300 units). The sedimentation rate, which is the hourly sedimentation rate of blood, and the levels of CRP secreted from the liver are very high. Increased leukocytes in the blood count in the acute period is a common finding. In patients with cardiac inflammation, x-ray may increase the size of the heart.
Treatment and prevention
Antibiotic treatment: With or without throat infection, benzathine penicillin should be administered in a single dose of 1.2 million units in adults and 600,000 units in children. The faster the penicillin is administered to a child with a throat infection, the less likely it is to develop ARF. This application is called primary prophylaxis.
Anti-inflammatory treatment: Aspirin treatment is standard. Toxic symptoms of the disease are controlled and inflammatory swelling of the joints and heart is suppressed. Aspirin is given in the first 24-36 hours every 4 hours, and then every 6 hours in equal doses. The daily dose is recommended as 80-100 mg / kg in children and 4-8 g / day according to the patient's weight in adults. After two weeks, the daily aspirin dose is reduced to 60-70 mg / kg, and usually within 6 weeks the dose is gradually reduced and discontinued. Steroids are given to patients with severe heart involvement. Glucocorticoid (1mg / kg / day) in the form of diuretic. After 2-3 weeks the dose is reduced and completed in at least one month. When the daily dose is decreased to a total of 10 mg, aspirin should be started.
Prevention of recurrent attacks (secondary prevention)
If the child has a history of cardiac inflammation in the first episode, the likelihood of recurrence is higher in the first 5 years (20%). This treatment should be applied to at least 40 years of age in patients with heart valve damage, and at least 21 years of age in patients without heart damage.
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