RHEUMATIC FEVER ; RECOMMENDATIONS 2009

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Information about RHEUMATIC FEVER ; RECOMMENDATIONS 2009
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Published on July 1, 2009

Author: praveenks

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Slide 1: M. Zulfikar Ahamed Professor & HOD , Pediatric Cardiology GMC, Thiruvananthapuram CARDIOLOGY UPDATE 2009CURRENT RECOMMENDATIONS ont r e a t i n gRHEUMATIC FEVER Slide 2: CONSENSUS GUIDELINES on PEDIATRIC ACUTE RHEUMATIC FEVER & RHEUMATIC HEART DISEASE Working Group on Pediatric RF and Cardiology Chapter of IAP WRITING COMMITTEE Anitha Saxena R.Krishnakumar S.Radhakrishnan Rani Gera Smitha Mishra M.Zulfikar Ahamed INDIAN PEDIATRICS, JULY 2008 Slide 3: GUIDELINES ON Diagnosis & Treatment of Streptococcal Throat infection Diagnosis & treatment of RF Treatment of Complications Issues like IE Prophylaxis Secondary Prophylaxis Slide 4: RF in INDIA 0.5/1000 3/1000 1.4/1000 6.4/1000 3.4/1000 0.9/1000 Slide 5: 2 Decades , RF - SATH 64 96 87 103 100 Slide 6: RF 6 0 % KD 19% DCM / Myocarditis 11% Others 10% ACQUIRED HEART ILLNESS IN CHILDRENSATH, Tvpm ( 2006 ) Slide 7: 0 < 5 5-14 15-24 25-34 > 34 yrs RHD EPIDEMIOLOGY of RF / RHDit bites & maims RF Slide 8: DIAGNOSIS of RF Mature clinical judgment Laboratory support Echo cardiography FRAME WORK - DJC ’92 / WHO 2OO4 Slide 9: MODIFIED DJC 1992 Major Minor Carditis Polyarthritis Chorea Subcutaneous Nodule Erythema Marginatum Clinical fever polyarthralgia Laboratory Elevated Acute Phase reactants ESR CRP Prolonged PR Positive throat culture / Rapid antigen / Elevated streptococcal antibody titer Supporting evidence of GABS infection Slide 10: WHO 2002-2003 DIAGNOSIS OF RF / RHD DIAGNOSIS Primary RF Recurrence RF No Valve Disease Recurrence RF RHD Chorea Insidious Carditis How ? AHA Recommendations. 2 Major or 1 Major + 2 Minor + antecedent strep infection 2 Major or 2 Minor + 1 Major + antecedent strep infection 2 Minor + antecedent strep infection Other Major criteria not required Slide 11: INCIDENCE OF MAJOR CRITERIA (JONES) MAJOR MANIFESTATIONS- RF : MAJOR MANIFESTATIONS- RF Then and now 1985 – Kerala - 2003 72 77 13 10 5 0 0 2 61 60 Slide 13: ARTHROPATHIES Infectious RA SLE Malignancies Vasculitis Reactive Slide 14: Downgraded to ‘minor’ in 1956 An important finding in high RF incidence area More useful in rheumatic recurrence/ rheumatic carditis POLYARTHRALGIA Slide 15: Short latent period Sluggish response to Aspirin Involves older children, young adults Can persist longer POST STREPTOCOCCAL REACTIVE ARTHRITIS Is it Benign ? CARDITISChild With A Recently Acquired Cardiac Problem : CARDITISChild With A Recently Acquired Cardiac Problem Rheumatic Carditis Myocarditis Inf. Endocarditis DIAGNOSTIC DILEMMAS IN RHEUMATIC CARDITIS, MYOCARDITIS & INF ENDOCARDITIS : DIAGNOSTIC DILEMMAS IN RHEUMATIC CARDITIS, MYOCARDITIS & INF ENDOCARDITIS Resolved by :- History Physical examination Lab results ECG ECHO Slide 18: 1. Recurrence : A new episode of RF following another GAS infection; occurring > 6 - 8 wks following stopping treatment 2. Rebound : Manifestations of RF occurring within 4-6 wks of stopping treatment or while tapering drugs 3. Relapse : Worsening of RF while under treatment and often with Carditis TERMINOLOGY RF - LAB DIAGNOSIS : RF - LAB DIAGNOSIS APR ESR CRP Preceding Strep ASO ( Throat swab) ADNA se B Rapid Ag Blood Counts Hb .TC , DC. Smear Cardiac status CXR .ECG Others ANA. Blood C & S. Etc Echocardiography Slide 20: Elevated ESR - > 30 mm/hr Positive CRP - > 8 mg /dl Polymorphonuclear Leukocytosis - less specific ACUTE PHASE REACTANTS Slide 21: Throat swab 10 -25 % Rapid Antigen test Antibodies IDENTIFICATION OF STREP INFECTION ASO Anti DNAse B Anti Hyaluronidase Slide 22: ASO ‘Positive’ ASO ASO is > 320 units in Child > 240 units in Adult Rheumatic Carditis 1995 - 70% All Rheumatic fever 2003 - 73% Chorea Alone 2001 - 30% Tvpm Experience Slide 23: “The Case of Persisting ASO positivity” “The Case of Isolated elevation of ASO” ASO - TWIN SITUATIONS Know the natural history of ASO Know that ASO + vity = Previous throat Inf Un riddling ? Slide 24: 10 AV BLOCK in RF Present in 30% Minor diagnostic laboratory criteria No correlation to Carditis ? No correlation to future RHD Slide 25: ECHO IN Ac RF Severity of Carditis ? Bi valvar involvement ? 2.. Sub clinical Carditis ? 3. Occasionally in confirming the diagnosis of RF Slide 26: ECHO in RF Ejection fraction - Normal Mitral Valve involvement Aortic Valve involvement Slide 27: A Pixel is worth Thousand of words Slide 32: RF DAMAGE to HEART GABS DAMAGE CONTROL MEASURES TREATMENT RF - TREATMENT Past to Present : RF - TREATMENT Past to Present Venesection , Opium, Purgatives 19th century Sanatoria treatment Early 20th Century Aspirin Late 19th century Steroids, Penicillin 20 th Century TREATMENT STRATEGY : TREATMENT STRATEGY Eradicate GAS Anti inflammatory drug therapy General Medical Measures Rest. Diet. CHF . Surgery ? ERADICATION OF GAS choice : ERADICATION OF GAS choice Penicillin V 250 mg 3 - 4 times x 10 days BPG 1.2 / 0.6 mega units IM once Erythromycin 40 mg /kg/day divided x 10 days Slide 36: TREATMENT OF SORE THROAT BPG 0.6 / 1.2 Million units SD Penicillin V 250 mg q i d x IO days 500 mg q i d x 10 days Azithromycin 12.5 mgm / kg / OD x 5 days Cephalexin 50 mgm /kg /day BD x 10 days Slide 37: COST OF TREATING STREP THROAT Per course (INR) Oral Penicillin (10 D) - 135 Erythromycin (10 D) - 135 Azithromycin (5 D) - 65 Cephalexin (10 D) - 220 Slide 38: WHEN TO TREAT RFWith Anti Inflammatory Drugs ? Occasion Treat Typical Polyarthritis Carditis SC Nodules ( + Carditis) Chorea; CRP / ESR + ve Chorea; CRP / ESR - ve + + + +? - Slide 39: TREATMENT OF RF CHOICE OF THERAPY ( Anti inflammatory) Aspirin vs Steroids Aspirin vs Steroids vs IVIG ? Slide 40: TREATMENT OF RF DURATION OF THERAPY Empirical 4 wks - 12 wks Mild Polyarthritis Severe Carditis Slide 41: ASPIRIN vs STEROIDS To Give or Not to Give ? TRIALS Non Randomized 119 117 + Randomized 11 Meta analysis (5) ? Slide 42: Beneficial role in proliferative stage Enhanced role in T- cell mediated Valve injury Definitively prevents death STEROIDS and Rheumatic Carditis in defense of steroids Slide 43: TREATMENTWhen Do We Administer Aspirin/Steroids in Rheumatic Fever ? SAT protocol No Carditis ( Clinical + Echo) Aspirin Carditis ( Clinical / Echo) Significant / Severe Aspirin Mild Steroids RF POLYARTHRITIS : POLYARTHRITIS Aspirin 100 mgm / kg /day 3 -4 divided doses x 2 weeks Followed by 75 mgm/ kg x 2-4 weeks MILD CARDITIS : MILD CARDITIS Aspirin 100 mgm /kg /day 4 divided doses (4 -6 gm) x 2 -3 weeks 75 mgm / kg/ day x 6 -8 weeks Slide 46: WHEN TO SWITCH ? Aspirin to Steroid 1. No response within 3 -4 days * 2. New Cardiac findings develop 3. Child develops CHF/ CE 4. Child intolerant to Aspirin ?? ( Can We Try NSAID ? ) SEVERE CARDITIS Prednisolone : SEVERE CARDITIS Prednisolone 2 mgm /kg /day 2-4 divided doses (max 60mgm /day ) x 2-3 weeks [ ESR < 30mm / 1hr ] Taper off 5 mg / 3 days Add - Aspirin 75 mgm / kg / day x 8 -10 weeks Slide 48: WHAT IS SIGNIFICANT / SEVERE CARDITIS ? 1 . CHF 2. Cardiomegaly 3. Bi valvar Involvement 4. Pericardial Rub Clinically or CXR Clinical Echo Slide 49: RF IN ADULT Polyarthritis is the predominant event Carditis - lower incidence Chorea ; SC Nodes rare Other arthropathies may meet Jones Criteria PSRA is a well defined entity Slide 50: RF IN ADULT Polyarthritis ; No Carditis / Mild Carditis : Aspirin 4-6 gm / day divided doses x 2 wks Taper to 50 mg / kg / or 75 % x 4 -6 wks Slide 51: RF IN ADULT Carditis –Significant Prednisolone 2 mg /kg / day max: 80 mg /day divided x 2 wks Taper Add aspirin 50 mgm/ kg /day divided x 6 -10 wks Slide 52: ADULT DOSES Aspirin 6 gm /day / 4 divided doses tapering dose 75 % initial dose or 50mg/kg/day Prednisolone 2 mgm /kg/ day max: 80 mg /day Slide 53: Naproxen Ibuprofen Possible in Polyarthritis Can We Use other NSAIDS ? Slide 54: Naproxen 10 – 20 mg/ kg/ day BD Methyl Prednisolone 30 mgm / kg / daily x 3 doses NSAID / OTHES Slide 55: CHOREA - DRUGS 1. Haloperidol 0.25 – 0.5 mgm / kg /day 2. Diazepam 0.25 – 0.5 mgm/ kg / day 3. Valproate 15 mgm / kg / day REST Guidelines : REST Guidelines Clinical Rest Ambulation Schooling Polyarthritis 2 wks > 2 wks 6 wks Carditis - No CHF /CE 4 wks > 4 wks 6-12 wks Carditis -CHF0 /CE + 6 wks > 6 wks 12 wks Carditis CHF + /CE+ 6 wks > 6 wks 4 wks - post stopping Slide 57: TREATMENT OF CHF IN RF Issues Use of Digoxin - Needed ? - Modification of dosage Use of ACEI - Standard practice Use of Diuretic - in pulmonary congestion Use of Dobutamine / Nitroprusside - in refractory CHF Slide 58: Ac RF CARDITIS - Severe / Refractory CHF ? Inotrope IV (Dobutamine) NTP infusion - especially in Chordal rupture IVIG ?? Methyl Prednisolone ? Emergency Surgery Repair Replacement Slide 59: NEW MODES OF TREATMENT ? IVIG ?? Valproate for chorea ? Anti- cytokines - adjuvants Methyl Prednisolone 1.Intolerant to oral steroids 2. Fulminant Carditis Slide 60: Primordial Primary Tertiary Secondary PREVENTION IN RF Preventing Strep Throat - Vaccine ? Preventing Rheumatic recurrence by chemoprophylaxis Treating RHD Treating Strep Throat infection SECONDARY PROPHYLAXIS : SECONDARY PROPHYLAXIS Continuous chemoprophylaxis to prevent recurrence in a patient who had an initial attack of RF STRATEGY Chemoprophylaxis Treat breakthrough Infection SECONDARY PROPHYLAXIS -What to Give ? : SECONDARY PROPHYLAXIS -What to Give ? BPG 1.2 million U IM 3 weekly Penicillin V 250 mg BD PO daily Erythromycin 250 mg BD PO daily Sulfadiazine 500 mg OD PO daily 1000 mg Slide 63: COST OF SECONDARY PROPHYLAXIS Per month ( INR) Benzathine Penicillin - 35 Oral penicillin - 210 Erythromycin - 200 Slide 64: RF; No Carditis 5 years from last Episode or till 18 / 21 years RF, Carditis ; No residual RHD 10 years from last episode ; or till 25 years RF, Carditis; RHD 10 years from last episode ; or till 40 years / lifelong HOW LONG TO GIVE ? RHEUMATIC CHOREA : RHEUMATIC CHOREA NO ACCESS TO ECHO ACCESS TO ECHO NO MURMUR TILL 25 YEARS No Valve involv Valve involv Till 18/ 21 years 25 - 40 yrs Post Strep Reactive ArthritisWhat to be done ? : Post Strep Reactive ArthritisWhat to be done ? ECHO Normal Abnormal Secondary Prophylaxis Secondary Prophylaxis as for RF 1 year (LP) 5 years ? (HP) www.pedheartsat.org : www.pedheartsat.org Please visit our Website ! Slide 68: “ The rest is (not) silence ” Hamlet Slide 69: Thank you very much !

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