Acute Rheumatic Fever 1.1

• an acute autoimmune disease that occurs as sequelae group A beta-hemolytic streptococcal infection.

  Acute Rheumatic Fever (ARF)
• It is characterized by inflammation lesion of connective tissue and endothelial tissue, primarily affecting the joints and heart.

  Acute Rheumatic Fever (ARF)
• Most initial attacks of ARF

  • Occur 1 to 5 weeks (average 3 weeks) after a streptococcal infection of the throat or the upper respiratory tract
• Peak incidence of ARF

  • Occurs in children ages 6 to 15
  • Incidence after a mild streptococcal pharyngeal infection is 0.3%
  • Incidence after severe streptococcal infection is 1% to 3%
• Family history of rheumatic fever is usually positive
• Streptococcal infection


  1. Abates with or without treatment

  2. Auto antibodies attack the myocardium, pericardium and cardiac valves

  3. Aschoff's bodies (FIBRIN DEPOSITS) develop on the valves, possibly leading to permanent valve dysfunction, especially of the mitral and aortic valves

  4. Severe myocarditis may cause dilation of the heart and CHF
• Inflammation of the large joints

  • Causes painful arthritis that may last 6 to 8 weeks
• Involvement of the nervous system

  • Causes chorea (sudden involuntary movements)
• Major manifestation

  1. Carditis
  2. Polyarthritis
  3. Chorea
  4. Erythema Marginatum
  5. Subcutaneous nodules
• manifested by systolic and diastolic murmur, prolonged PR and QT interval on ECG and possibly by signs of CHF

  Carditis
• Pain and limited movements of two or more joints are swollen, red, warm and tender

  Polyarthritis
• purposeless, involuntary, rapid movements commonly associated with muscle weakness involuntary facial grimaces, speech disturbance and emotional lability

  Chorea
• nonpruritic pink, macular rask mostly or the trunk with pale central areas; migratory

  Erythema Marginatum
• firm, painless nodules over scalp, extensor surface of joints, such as wrists, elbows, knees, and vertebral column

  Subcutaneous nodules
• Minor manifestation

  1. History of previous rheumatic fever or evidence of preexisting rheumatic heart disease

  2. Arthralgia- pain in one or more joints without evidence of inflammation, tenderness, or limited movements

  3. Fever- temperature greater than 100.4 f (38°C)

  4. Laboratory abnormalities – elevated erythrocyte sedimentation rate (ESR), positive C-reactive protein, elevated white blood cell count

  5. ECG changes – prolonged PR interval
• DIAGNOSTIC EVALUATION

  1. Diagnosed clinically through use of the Jones criteria from the American Heart Association – presence of 2 major and 2 minor manifestation

  2. ECG to evaluate PR interval and other changes

  3. Laboratory test listed above. In addition, group A streptococcal culture and/or anti streptolysin-O titer to detect streptococcal antibodies from recent infections

  4. Chest x–ray for cardiomegaly, pulmonary congestion or edema
• Course of antibiotic therapies to completely eradicate streptococcal infection


  1. Usually benzathine penicillin is given I.M in a single dose or a 10-day course of oral penicillin IV

  2. Oral erythromycin maybe used if allergic
• Oral salicylates (aspirin) or nonsteroidal anti-inflammatory drugs (naproxen sodium) usually used to


  Control pain and inflammation of arthritis
• Corticosteroid used in severe cases to


  Try to control cardiac inflammation
• Phenobarbital, diazepam (valium), or other neurologic agent to


  Control chorea
• Bed rest during acute phase

  Until ESR decreases, C-reactive protein becomes negative and pulse rate returns to normal
• Secondary prevention of recurrent ARF

  1. Antibiotic prophylaxis may be continued for 5 years or longer

  2. Benzathine penicillin I.M q 28 days

  3. Penicillin V or erythromycin 250mg twice per day

  4. Sulfisoxazole (periazole) O.5 to 1 g(dosage calculated according to patient's weight) once a day
• Risk of recurrence greatest within first 5 years , with rheumatic heart disease
• For those at low risk for recurrence, antibiotic prophylaxis may be continued for 5 years or longer
• COMPLICATION

  1. CHF

  2. Pericarditis, pericardial effusion

  3. Permanent damage to the aortic or mitral valve which requires valve replacement
• NURSING ASSESSMENT

  1. Assess for signs of cardiac involvements by auscultation

  2. Monitor pulse for 1 full minute to determine heart rate

  3. Assess temperature

  4. Observe involuntary movements

  5. Assess child’s ability to feed self, dress and do other activities if chorea or arthritis is present

  6. Assess pain level using scale appropriate for child

  7. Assess parents’ ability to coop with illness and care for child

  8. Assess need for home schooling while patient is on bed rest
• NURSING DIAGNOSIS:

  ❑ Decreased cardiac output

  ❑ acute and chronic pain

  ❑ risk for injury
• Improving cardiac output

  1. Explain to the child and the family the need for bed rest during the acute phase and as long as CHF is present, for milder cases, light indoor activity is allowed

  2. In severe cases, organize care

  3. Maintain cardiac monitoring if indicated

  4. Administer course of antibiotic and be alert about the adverse effect of drugs

  5. Administer medication for CHF as directed
• Relieving pain

  1. Administer anti-inflammatory medication, analgesics and antipyretic as needed.

  2. Teach family the importance of maintaining dosage schedule, continuing medication until signs and symptoms of ARF have gone

  3. Assist child with positioning for comfort and protecting inflamed joints

  4. Suggest diversional activities that do not require use of painful joints
• Protecting the child with chorea

  1. Use padded side rails if chorea is severe

  2. Assist with feeding and other fine-motor activities as needed

  3. Assist with ambulation if weak

  4. Avoid the use of straws and sharp utensils

  5. Make sure that child consumes nutritious diet

  6. Be patient if speech is affected

  7. Protect the child from stress

  8. Administer Phenobarbital or other medication for chorea as directed and observed drowsiness