This febrile illness is a complication of inadequately treated Group A streptococcal infection of the throat. There is inflammation of several systems but mainly the joints and heart. It is a major cause of permanent damage to the heart in developing countries. The disease occurs mainly in children of school going age. The onset of symptoms occurs 1-3 weeks after the throat infection.
SYMPTOMS
• Persistent fever
• Joint pain which moves from one joint to another (knees, ankles, wrists, elbows)
• Palpitations
• Tires easily
• Chest pain
SIGNS
• Child looks unwell and is febrile
• Tenderness with or without swelling of any of the joints mentioned above
• Carditis - rapid heart rate (>100/min), murmur, heart failure, pericardial rub
Less commonly,
• Skin rash, subcutaneous nodules over bony prominences
• In our setting this illness may mimic malaria, typhoid fever, sickle cell disease, myocarditis, tuberculosis
INVESTIGATIONS
• Full blood count (raised white cell count)
• ESR - raised
• Sickling status
• Chest X-ray (heart may be enlarged)
• Throat swab for culture
• Antistreptolysin O titre (if available)
• Electrocardiogram
TREATMENT
Therapeutic objectives
• To eradicate streptococcal throat infection
• To prevent recurrent episodes of rheumatic fever and further heart damage
Non-Pharmacological Treatment
• Admit patient. Bed rest until rheumatic activity subsides
Pharmacological Treatment
(Evidence rating: C)
• Eradicate streptococci - give Phenoxymethyl penicillin (Penicillin V), oral for 10 days.
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Adults: |
500 mg every 6 hours. |
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Children: |
|
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1-5 years; |
125 mg every 6 hours |
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6-12 years; |
250 mg every 6hours |
If patient is allergic to penicillin give Erythromycin, oral:
| |
Adults: |
500 mg every 6 hours. |
| |
Children: |
|
| |
1-5 years; |
125 mg every 6 hours |
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6-12 years; |
250 mg every 6 hours |
• Suppress rheumatic activity with:
Aspirin, oral, 100 mg/kg body weight/24 hours in 4-6 divided doses for 2 weeks then 75 mg/kg body weight/24hours for 4-6 weeks then gradually withdraw drug over 2 weeks
or
• If patient has carditis with heart failure or enlarged heart on x-ray, give prednisolone, oral, 2 mg/kg body weight/day for 2 weeks and then gradually taper off. Gradually reduce dose to zero over 2 weeks. When the tapering of prednisolone is started, add Aspirin 75 mg/kg body weight/day for 6 weeks and then withdraw aspirin over 2 weeks
• Treat heart failure initially with diuretics and intranasal oxygen. Digoxin may be required in children in severe heart failure (refer to appropriate text for digoxin doses or refer patient to a specialist)
(See section on heart failure for dosage for diuretics)
• Prevent further episodes of streptococcal infection with Phenoxymethyl penicillin, oral
| |
Adults: |
500 mg every 6 hours. |
| |
Children: |
|
| |
1-5 years: |
125 mg every 6 hours |
| |
6-12 years: |
250 mg every 6 hours |
or
Benzathine Penicillin, IM 1.2 M units monthly for adults; for children more than 30 kg, 900,000 units per month and those less than 30 kg, 600,000 units monthly (more reliable).
or
For patients with penicillin allergy give Erythromycin, oral,
| |
Adults: |
500 mg every 6 hours. |
| |
Children: |
|
| |
1-5 years; |
125mg every 6 hours |
| |
6-12 years; |
250mg every 6 hours |
Continue until age 21 years or indefinite if valvular damage present.
• Patients with rheumatic heart disease will require antibiotic prophylaxis against endocarditis prior to dental and other surgical procedures.
REFER
• Patients who have been treated for heart failure should be referred for further evaluation.
• Suspected rheumatic fever where facilities are not available for basic investigations.
