Rheumatic fever is a immune response to a group A streptococcus  (GAS) infection. 3% of all untreated strep infections lead to the development of rheumatic fever. If not caught early, it can lead to permanent heart damage. Recurring rheumatic fever can cause further damage to the heart.

It is rare to see rheumatic fever within most developed countries. Within New Zealand, those at a higher risk of developing it are Maori and pacific people aged between 4-19, having a familial history of rheumatic fever, housing overcrowding, and deprivation. It can also be seen between 3-35 years old. There is a higher incidence of rheumatic fever in Northland.

 

Pathophysiology

An untreated strep throat infection can lead to the development of rheumatic fever and rheumatic heart fever. 10% of those whom develop rheumatic fever will also go on to develop rheumatic heart disease

The bacteria directly affects the endocardium. The resulting inflammation ends with the scaring of the heart valves. The scaring leads to mitral regurgitation and aortic stenosis (narrowing of the aortic valve in the heart, restricting blood flow). Surgery to replace the damaged valves may be needed.

 

Signs and Symptoms

  • History of sore throat wihtin 5 weeks
  • Febrile
  • Joint pain
  • Stomach pain
  • Fatigue
  • sore or swollen joints (monoarthritis or polyarthritis) knees and ankles mainly
  • rash (erythema marginatum)
  • small painless lumps under the skin (subcutaneous nodules) elbows, knees, wrists, ankles spine
  • jerky or uncoordinated movements (Sydenham’s chorea).

 

 Jones criteria

 

 

Treatment

  • NSAIDs to reduce joint inflammation and pain
  • Antibiotic treatment for 10 days forsuspected GAS
  • Bed rest to reduce extent of carditis
  • Mouth, teeth and gums checked by a dental health professional to prevent infective endocarditis (IE is a bacterial infection translocated from the mouth to the heart)
  • Mitral/aortic valve replacement

 

Long term management

Antibiotic Route Dose
benzathine penicillin G (BPG, also known as Bicillin LA) intramuscular injection

every 21 or 28 days

Children <30kg: 450mg (600,000 units)

Adults and children ≥ 30kg: 900mg (1,200,000 units)

For those who have an allergy to amoxicillin or penicillin, use:
erythromycin ethyl succinate oral daily 40mg/kg/day in two to three divided doses

 

In general, the antibiotic is given every 28 days (or every 21 days in some cases) for a minimum of 10 years, or until the individual is 21 years old (for no or mild carditis) or 30 years old (for more severe carditis), whichever is longer.

 

Nursing interventions

  • Swab all high risk patients throats (avoid teeth, tongue, uvula and lips)
  • Start prophylaxis antibiotic treatment immediately
  • Educate on the importance to complete full course of antibiotics
  • Follow up on AB use on the 3rd and 7th day to encourage adherence
  • Educate the family about the risk factors of rheumatic fever and encourage family members to get help with sore throats
  • Provide education on the risk of children sharing beds encourage the use of bunks of top and tailing.
  • Support to access services such as ministry of socil development and housing NZ

 

 

 

References

Hogarth, K., & Rapata-Hanning, M. (2015). Maori health in Aotearoa New Zealand. In J. Craft & C. Gordon (Eds.), Understanding pathophysiology (2nd ed., pp. 1179–1198). Sydney, Australia: Mosby Elsevier.

Ministry of Health. (2017). Rheumatic fever. Retrieved February 15, 2017 from http://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever

 

 

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