Answer 33
Rheumatic fever
False a. is most common in the third decade
True b. is more common in areas of social deprivation
False c. causes erosive arthritis
True d. relapse rate may be reduced by prophylactic antibiotics
True e. is more common following streptococcal pharyngitis than streptococcal cellulitis
The peak age of onset is 5-15 years. Rheumatic fever is rare before the age of 4 years.
Incidence has fallen significantly since the 1940's. For UK children the incidence is less than 0.1 / 1000 / year. The incidence in developing countries is nearer 1 / 1000 / year. Incidence is higher where there is poverty or overcrowding presumably because of increased transmission and because of under-treatment of streptococcal pharyngitis.
The arthritis usually leaves the joints undamaged. Typically it is a migratory arthritis of large joints which settles after 1-4 weeks.
Relapse of rheumatic fever is common (5% per year). It occurs particularly after rheumatic carditis. Relapse can be prevented by giving penicillin V 250mg once or twice daily. Prophylaxis should be continued until age 20 or for at least 5 years after the last attack. Compliance with this oral regimen has been reported to be as low as 10%. Benzathine penicillin 0.9 -1.2MU i.m. every 4 weeks is an alternative.
Streptococcal skin infections are rarely, if at all, complicated by rheumatic fever.
Treatment of acute rheumatic fever consists of penicillin and bed rest. The role of salicylates and steroids is controversial. Emergency valve replacement should be considered if there is progressive cardiac failure and the surgical skills are available.
