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Rheumatic Fever

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References:

  1. Lecturer (Cambel, V)

An infection involving the heart, CNS, joints, subcutaneous tissue, and the skin caused by Group A Beta-hemolytic Streptococcus.

  • Risk Factors: children with dental caries (check-up once every 6 months), those who have had recent or recurrent strep throat, immunocompromisation

Jones Criteria

In Rheumatic Fever, the child presents with two major manifestations or one major with two minor manifestations.

  1. Major: heart carditis, CNS chorea, joint polyarthritis, subcutaneous nodules, skin erythema marginatum.
  2. Minor: fever, history of strep. infection (ask for sore throat), elevated laboratory findings (anti-streptolysin O titer [ASOT]), arthralgia
    • ASOT Lab Findings:
      • 150 to 250: (inc.)
      • >250 to <500: Dormant RF
      • >500 to <5000: Active RF
      • >5000: Rheumatic Heart Disease
    • ESR, increased during hyperemia.
    • CRP, produced by the liver in response to inflammation and tissue damage. This is used to determine both the presence of inflammation and response to treatment.

Pathophysiology

  1. Spread of GABHS to the pulmonary system, through pulmonary circulation, to the mitral valve (proliferation) of the heart results in the major manifestations:
    • Carditis
    • CNS Chorea
    • Polyarthritis: inflammation
    • Subcutaneous Nodules
    • Erythematous Marginatum
  2. Mitral Valve Stenosis: damage to the mitral valve from GAHBS. Left ventricular hypertrophy occurs for compensation. This backs up to the left atrium and pulmonary circulation, resulting in LSCHF. Crackles and moist coughing occurs from pulmonary edema.
    • Lanoxin (Digitalis) increases heart contraction, while decreasing heart rate. This results in bradycardia. Do not administer Lanoxin if heart rate is less than (adult) 100 (infant), 90 (toddler, 80 (preschooler), 70 (school-age), 60 bpm (adolescent/adult). Decreased cerebral perfusion alters LOC.

Nursing Management

  1. Fever, Pain (polyarthritis), Inflammation, Thrombotic Formation
    • Aspirin fulfills all of these problems within a child (antipyretic, analgesic, antiinflammatory effect, thrombolytic effect). The main purpose is for its antiinflammatory effect on polyarthritis.
  2. Diet: high calorie, high fiber, low sodium, and soft diet. If polyarthritis affects the temporomandibular joint, NGT/OF may be required.
  3. Polyarthritis: pain may be produced even by thin linens. A bed cradle is created and formed as a tent, to maintain thermoregulation without placing weight on the patient directly.
    • Fractured TSB may be required to reduce discomfort. Avoid the joints, and only pat the patient. Place a moist towel on the forehead, torso, and axillary areas.

PARAFI

The PARAFI mnemonic denotes the interventions for a child with rheumatic fever:

  1. Pain Control
  2. Antibiotics for an active infection by GABHS
  3. Rest
  4. Aspirin as an antiinflammatory and as an antithrombotic
  5. Follow-up Care is necessary to detect progression or complication of the disease.
  6. Infection, specifically respiratory infection is prevented and immediately managed to prevent flareups of rheumatic fever.

Treatment

Penicillin is the drug of choice, combined with erythromycin and benzathine penicillin. 2. Oral: Erythromycin with Penicillin 3. Monthly injection of 1 gram benzathine penicillin (twice a month, 500 mg per dose).

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