Rheumatic Fever

Hey everyone, in this lesson we are going to talk about Acute Rheumatic Fever.

Rheumatic fever is an abnormal, autoimmune response to an untreated Group A Strep. Most of the time this is infection is pharyngitis or strep throat. So in this abnormal immune response the immune system attacks the skin, joints, brain and the heart. The effect on the heart is the most concerning because the valves are affected and actually become scarred causing stenosis. This stenosis affects the flow of blood through the heart and if it’s bad enough the heart is damaged and Heart Failure can occur.

It’s really important to do throat cultures so that Strep throat can be identified and treated to help prevent this from happening. If Rheumatic fever is suspected a blood test called an ASO titer (or antistreptolysin O) will be done to see if the patient has streptococcal antibodies in their system.

An echocardiogram will also need to be done to assess for the heart damage we just talked about.

For your assessment of Acute Rheumatic Fever you’ll be focusing on those areas I mentioned it effects, the skin, the joints, the brain and the heart.

For the skin you are looking for a rash that may break out on the trunk.

The joints will become red, hot, swollen and painful.

If the brain is affected the patient may experience something called chorea. This is when the patient moves suddenly, aimlessly and irregularly. They may have involuntary facial grimaces, have difficulty with their speech and be emotionally unpredictable. Seizures can occur as well.

If the heart is affected the patient will have signs of carditis like tachycardia, new murmurs and chest pain. These indicate that the valves have been infected and damaged. The valve most often affected is the mitral valve, which you can see in the photo here.

Treatment starts with taking care of the strep infection with some antibiotics. Penicillin is the drug of choice.

Then we need to treat the inflammation with corticosteroids and aspirin. If you’ve listened to other lessons you may remember that aspirin shouldn’t be given to kids because of the risk for Reye's Syndrome. Well that is definitely true, but in the case of Rheumatic Fever and Kawasaki Disease aspirin is still given because it is thought that the benefits outweigh the risk. We still have to be on the lookout for signs of Reye's syndrome so if you aren’t familiar with them check out our lesson on that topic!

Because of the risk for seizures these patients need to be on seizure precautions and they need close monitoring for signs of cardiac and valve damage.

Long term- if the valves become severely damaged there may be the need for a surgical valve repair. If this is the case, the patient will need to be on long-term anticoagulation therapy to reduce the risk of clots forming.

Preventing future infections is extremely important. The more infections the more likely the heart is to be affected so patients are prescribed prophylactic antibiotics. Most of the time, Penicillin G is given IM every 4 weeks. This is to increase compliance because, let’s be honest, kids and daily gross tasting medication is not a great combo for compliance. There is a lot of different research out there about how long this prophylaxis should go on. Some think for life, others say 5-10 years. This will be provider specific. They will also need extra doses of antibiotics prior to invasive procedures and dental care.

It’s super important to make sure that parents understand the why behind this prophylactic treatment.

Your priority nursing concepts for a pediatric patient with Acute Rheumatic Fever are perfusion, infection control and health promotion.
Acute rheumatic fever is an abnormal immune response to group A strep, usually an infection in the throat.

It affects the skin, joints, heart and brain. The most concerning complication being the damage to the heart. The valves become scarred and this leads to stenosis in the heart causes overworking and can lead to heart failure.

The first step in treatment is to give antibiotics to treat the strep infection. Then the patients will need prophylactic antibiotics for many many years to prevent further infections and further damage.

Anti-inflammatory meds, like corticosteroids and aspirin, are also given to help with the inflammation and pain.

Patient education is a huge part of effective treatment because these patients need to understand why the antibiotics are so important and that they will need lifelong follow up to assess for heart damage.

That's it for our lesson on Acute Rheumatic Fever. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!