Rheumatic Fever

Fanny Budiman
Bullpoopers & SOCA BOBOK
2019
Etiologi
• The famous Strep A
• Streptococcus pyogenes
Rheumatic Fever
• Autoimmune reaction to infection by Group A strep resulting
multisystem disease that affects the heart, joints, brain, and skin
• Merupakan komplikasi strep throat / scarlet fever yang tidak diobati
• Gejala menetap : rheumatic heart disease
Epidemiologi
• Disease of poverty
• 95% cases and deaths occur in developing countries
• Children 5-14 years old (ARF)
• 25-40 years old for RHD
Virulence : M protein
• M protein  resist
phagocytic killing in
human blood
• M protein binds with
plasma fibrinogen 
interferes complement
Virulence (Hyaluronic acid)
• Hyaluronic acid capsule  • This capsule binds to CD44 di
resist phagocytes ingestion human pharyngeal epithelial
and killing cell  colonisation
• Weak immunogen compared
to M protein WHICH IS
AWESOME  why?
Pathogenesis
• Cross reactive antibodies attaching at the cardiac valve endothelium
 CD4+ T cells  inflammation
Strep M protein and N-acetylglucosamine of group A Strep
carbohydrate
similar to :
Human myosin, tropomyosin, keratin, actin, laminin, vimentin, N-
acetylglucosamine
Clinical Features
• Latent period between Strep A and ARF
• Most common symptoms : HIGH GRADE fever, polyarthritis, chorea,
erythema marginatum, subcutaneous nodule
• Multisystem :
1. Heart
Valvular damage (mitral, aortic)  regurgitation  calcification , stenosis,
thickening
P-R interval prolongation (first degree AV block), S1 softening
2. Joint
Polyarthritis, arthralgia (pada large joints pindah pindah)  Resolves with
salicylates / NSAID
Clinical Features
3. CNS
Sydenham chorea
https://www.youtube.com/watch?v=V74h6e
Fpk-8
4. Skin
Erythema marginatum (macula, gapernah
muncul di muka)
Subcutaneous nodules (delayed, berhub
dngan carditis)
Diagnosis
• Swab culture, Rapid Antigen Test  mostly negative
• Serologi :
1. ASO (anti streptolysin O)
2. Anti DNase B (ADB) titer
• JONES criteria
DD/
• PSRA (post streptococcal reactive arthritis)
- Small joint involvement is symmetric
- Short latent period following Strep infection (< 1 week)
- Bisa disebabkan nongroup A beta hemolytic Strep infection
- Slower responsiveness to salicylates
- Absence of ARF

• Myocarditis
• Pharyngitis
• Scarlet fever
Treatment & Prevention
• Long term penicillin
• Benzathine penicillin G 1,2 juta IU atau 600,000 IU (<27 kg) setiap 4
minggu
• Kalo high risk bisa lebih sering 2-3 minggu
• Alternatif : Oral penicillin V (250 mg)  less effective
• Primary prevention : obati strep throatnya 