PE22.4 | Acute Rheumatic Fever — Summary & Reflection

KEY TAKEAWAYS

Acute rheumatic fever is an autoimmune inflammatory disease following Group A streptococcal pharyngitis, caused by molecular mimicry between streptococcal M protein and host cardiac proteins. It affects school-age children (5–15 years) and presents 2–4 weeks after an untreated or inadequately treated GAS throat infection. Diagnosis uses the 2015 Jones Criteria (high-risk for India): two major OR one major + two minor criteria, PLUS evidence of preceding GAS infection. Major criteria: carditis (clinical or subclinical on echo), polyarthritis (or monoarthritis in high-risk), Sydenham chorea, erythema marginatum, subcutaneous nodules. Minor criteria: fever ≥38°C, elevated ESR/CRP, prolonged PR interval, monoarthralgia. Management: GAS eradication (benzathine penicillin G: 600,000 IU <27 kg; 1,200,000 IU ≥27 kg IM once), anti-inflammatory therapy (aspirin 60–100 mg/kg/day; steroids for severe carditis), cardiac failure management, and secondary prophylaxis. Secondary prophylaxis with benzathine penicillin G every 3 weeks: ARF without carditis — 5 years or until 21; with mild resolved carditis — 10 years or until 21; persistent moderate/severe RHD — 10 years or until 40; severe RHD/post-surgery — lifelong. Sydenham chorea is managed with haloperidol or carbamazepine, not aspirin.

REFLECT

Consider the child from the hook scenario: a treatable throat infection, missed by an overwhelmed primary care system, has started a cascade that may scar his mitral valve over the next decade. Reflect: In your future clinical practice, how would you identify the child with a sore throat who needs a throat swab and penicillin versus the one who can be managed symptomatically? What barriers do you foresee in ensuring secondary prophylaxis compliance — a 3-weekly injection for a decade — for a family with limited health literacy and inconsistent access to healthcare? How would you counsel the family in a way that they understand the stakes? Identify one step you could take at the primary care level — even as an intern — to reduce the burden of RHD in your community.