Diagnosis and Management

Of
Acute Rheumatic Fever (ARF)
Keith Edwards
Primary Prevention
 Strep Skin Infection
BUT ?? Secondary to Scabies
Pathogenesis - primordial
Poverty and overcrowding
poor sanitary conditions
lack of education
limited access to medical care for adequate
diagnosis and treatment are recognised as
contributing factors to this disease in
Australia (and the rest of the world)
AIHW 2003
 IN Houses
Overcrowding OF
We are NOT preventing ARF

So…for now..we have to

DIAGNOSE
and
Manage ARF
Effectively!!!
Importance of Accurate Diagnosis
• If wrong and patient has not had ARF
–unnecessary injections for 10 years

• If wrong and patient has had ARF

–recurrence of ARF and early death
 Difficulties with Diagnosis
• 40% of RHD patients had no record of ARF
– Delay/atypical Presentation
– Importance of admitting to hospital
• Need to increase awareness in broader
community
• Train health staff
– Rapid turnover
– Downsouth recruits
 What Can We
Do?

Think ARF
–Diagnose Better
–Treat Better
–Prevent Recurrences Better
 Diagnosis
Reminder Posters
ARE

ON THE WALL

NOT IN OUR HEADS

Clinic wall chart
Is it rheumatic
fever?
the signs & symptoms can be mild.

Any child (> 5 years) or adult who has:

 One or more new painful joints..OR

 Onset of unusual movements……..OR

 A new heart murmur …………………..OR

 Low-grade fever

CONSIDER RHEUMATIC FEVER

See new CARPA Manual - page 308

OR
contact the DMO on call
Think ARF
Beware the Red Herring Story
 Painful Joint?
• “I bumped it on a wall”
• “I fell off my bike”
• “I fell out of a tree”
• “My brother hit me with a stick”

NO
ACUTE RHEUMATIC FEVER
 RHD Australia
Have come to the rescue!!

• National Guidelines
• Quick Reference Guides
• On Line Modules for Clinicians
• Phone App
 Approach to Diagnosis
• No diagnostic test
• Score system based on clinical features – Jones
– 1944
• Modified to suite high and low prevalence
areas - 2006
• Important that all clinicians are aware and
abide by the score
• Important to rule out other possible causes
Beware
of
Septic
Arthritis
Mono-arthritis – swollen and hot
Chorea Video
Prolonged PR Interval
Evidence of a recent Streptococcal Infection

• Throat Swab (+ve 5%)

• ASOtitre / Bdnase Serology

 Acute Rheumatic Fever
First Episode and Recurrences by Year
Secondary Prophylaxis Coverage by Year - NT
2007 – 2013
 How to eliminate Days at Risk

LA Bicillin RECALL LAST DAY

LA Bicillin

DAY DAY DAY

1 21 4th Week 28

Reset Recall
To 21 days
 Some Key Points
• Early treatment of Strep throat within 7 days
from onset can prevent ARF
• ARF occurs around 6 weeks after the Strep
Infection
• The first ARF episode may be mild and “sub-
clinical”
• There is no single diagnostic test for ARF
• Prevention of further Streptococcal infections
is paramount to prevent heart damage (RHD)
 Take Home Messages

What Can Make a Difference

1. Preventing ARF in the first place

2. Diagnosing ARF early and accurately
3. Preventing Recurrent ARF
END --- ARF and RHD