Rheumatic Fever

Presenter :
M. Faqih Lazuardi (100100076)
Fadila Safira(100100099)
Supervisor :
dr. Selvi Nafianti Sp.A (K)

Introduction
-Definition
Acute rheumatic fever (ARF) is a
multisystem disease resulting from
an autoimmune reaction to infection
with
group
A
streptococcus.
Although many parts of the body
may be affected, almost all of the
manifestations resolve completely.
-Epidemiology
ARF is mainly a disease of children
aged 514 years.
Recurrent episodes of ARF remain
relatively common in adolescents
and young adults. This pattern
contrasts with the prevalence of
RHD, which peaks between 25 and
40 years.
RHD
more
commonly
affects
females, sometimes up to twice as
frequently as males

Etiology

Pathophysiology

Clinical Manifestation

Diagnosis
Evidence of
Streptococca
l Pharyngitis

Diagnosis

2 Major
Criteria
Or
1 Major or 2
Minor
Criteria

Treatment

Prognosis
Untreated, RF lasts on average 12
weeks.
With treatment, patients are usually
discharged from hospital within 12
weeks.
Cases with more severe carditis
need
close
clinical
and
echocardiographic monitoring in the
longer term

Prevention
Primary Prevention
Eliminated
of
the
major risk factors for
streptococcal
infection, particularly
overcrowded housing.
This is difficult to
achieve in most places
where ARF is common.
Secondary
Prevention
The
mainstay
of
controlling ARF and
RHD
is
secondary

Case Report
Name
:MS
Age
: 12 years 10 month
Sex
: Male
Date of Admission : July, 20th 2014

Chief Complaint

: Involuntary movement

History: Involuntary movement has been

happened by the patient 2 weeks ago, first
the patient suddenly cant walk, and the patient
cant speak from 1 day before entering the
hospital.
Fever was happened this 2 weeks, the fever was
up and down, the temperature was high when
night and low if he was given the fever
medicine, patients had a history of sore throat 1
month ago and recovered after being given
antibiotics.
Seizures (-), a history of seizures (-), a history of
trauma (-), History sore throat (-), cough (-), cold
(-).
A history discharge from the right ear was found
since 1 week ago, color, smell (-)
Previously, the patient had been taken to
hospital for treatment Vita Insani and performed
a CT-scan and the patient's family says no
abnormalities (results not taken) and there is an
enlarged heart on chest x-ray results (results

Pregnant History

There is no history of fever, hypertension,

diabetic mellitus, and consumed herbal
medicine.
Birth History

Spontaneous; attended by midwives; BW

3200 gram; BL 50 cm, cyanotic (-).
Immunization History

Not complete, BCG I, DPT III, Polio III.

Campak I, Hepatitis III
Feeding History
From birth to 3 months
: Breast milk only
From 3 months to 1 year 3 months: Breast milk
only and rice porridge
History of Growth and Development
Sitting: 4
Crawling
Standing
Walking

months
: 7 months
: 12 months
: 12 months

History of previous illness

The patient had no history of previous

disease. however, the patient was
taken to the hospital family vita
human in Khajuraho and the patient
perform a CT scan examination and
chest x-ray, the patient's family said
the results of the CT scannya not have
the disorder, there is a chest x-ray and
cardiac enlargement but looks normal
in the lungs, but the patient's family to
bring results.

History of previous
medications : -
History of Family Disease

:-

Pysical Examination
Generalized status
Body weight: 20kg, Body length: 127 cm
BW/BL: 20/25 x 100% = 80 %
BW/age: 20/28 x 100% = 71,42 %
BL/age : 127/133 x 100% = 93,49 % (Normal)
Presens status
Consciousness: Apatis , Body temperature: 37,0 oC.
Anemic (-); Icteric (-); Cyanosis (-); Edema (-).
Dyspnea (-).
Localized status
Head :
Large crown closed. Black hair, normal.
Right Eye: Pupil diameter 3 mm. Inferior palpebra
conjunctiva pale (-). Icteric sclera (-). Light
reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra
conjunctiva pale (-). Icteric sclera (-). Light reflex (+).
Ear, nose and mouth were within normal limit.
Neck :
Lymph node enlargement (-).

Thorax:
Symmetrical fusiformis. Chest retraction
(-)
epigastrial,
intercostals,
suprasternal. HR: 90 bpm, regular,
murmur (+) sistolik grade III/6 LMCS ICR
III-IV.
RR: 22x/i, reguler, rales (-).
Abdomen:
Rapid turgor. Normoperistaltic. Liver,
spleen and renal unpalpable.
Extremities:
Pulse 90x/i, regular, adequate p/v, warm
acral , CRT < 3. BP: 100/80 mmHg.
Urogenital:
Male; within normal limit.

Laboratory Findings (July 20th 2014):

Parameters

Value

Normal Value

Hemoglobin

12,00 gr%

11,1 14,4 gr%

Hematocrite

35,70 %

35 41%

4,62 x 106 /mm3

3.71 4,25 x 106

3,20 x 103 /mm3

/mm3
6.0 17.5x 103

341.000 /mm3

/mm3
217.000

MCV

77,30 f

497.000 /mm3
82 100 f

MCH

26,0pg

24 30 pg

MCHC

33,6 gr%

28 32 gr%

RDW

14,80 %

14.9 18.7 %

MPV

9,40 f

7,0 10,2 f

PCT

0,32%

PDW

10,3%

Complete Blood Count

Erithrocyte
Leucocyte
Platelet

Carbohydrate Metabolism

Hitung Jenis

Blood Glucose

Neutrofil

40,40

37-80

Limfosit

34,00

20-40

Monosit

19,20

2-8

Eosinofil

6,20

1-6

Basofil

0,200

0-1

Neutrofil

2,10

1,9-5,4

Limfosit

1,77

Monosit

Ureum
Creatinine

< 50

0.14 mg/dL

0,17 0,42

6,6 mg/dL

9,2 110

136 mEq/L

mg/dL
135 155

4,1 mEq/L

meq/L
3,6 5,5

102 mEq/L

mEq/L
96 106

Elektrolit
Kalsium

Kalium

1,00

10 mg/dL

3,7-10,7

absolute
0,3-0,8

Klorida

absolute

Eosinofil

mEq/L

0,32

0,2-0,5

absolute

Basofil
absolute

< 200

ad random
Renal Function Test

Natrium

absolute

83,00 mg/dL

0,01

0-0,1

Imunoserologi
ASTO

<200

CRP Kualitatif

Positif

Procalcitonin

0,31 ng/mL

<0,05

Radiologic imaging

Chest x-ray interpretation;

Mardani Sibarani , 12 year 10 mounth,
July 20th 2014.
KV strong. Less Inspiration, middle tracha
both costophrenicus angel were sharp
on right but at left isnt visible, smooth
diaphragm, Cardio Thoracic Ratio is har
to defined, bones and soft tissues in
good condition, There were found
pleural effusion in the left lung field
Result : Effusi Pleura

EKG
Interpretasi:
SR, Reg, HR :100x/i
NormoAksis, Pwave
interval PR 0,14 s
Q patologis (-)
QRS interval 0,08s
LVH, T inverted
(I,AVL,V1,V2,V3)
ST elevation (-), ST
depretion (-)

Management:
Differential Diagnosis:
Rheumatic Fever
Rheumatic Heart
Disesase
Working Diagnosis:
Rheumatic Heart Disease

Bed rest
Nasal Canul 1L/I
IVFD D5% NaCl 0,45%, 4
gtt/mikro
Haloperidol 0,5 mg/8 jam/oral
Depakene syr
Diet MB 1600 kkal + 40 gr Protein

Diagnostic Planning:
Urinalysis
Liver function test
Head CT-scan
Nutrition consult
Foto Thorax

Follow Up

July , 21 th 20121
S
O

Involuntary movement (+)

Sens: Alert, Temp: 39,2oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (+)
Body weight: 20 kg, Body length: 127
Head :
Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-).
Light refex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-).
Light refex (+)..
Neck: Lymph node enlargement (-)
Thorax: Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal. HR: 92
bpm, reguler; murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 24 x/i, regular, rales (-)
Abdomen: Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities: Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital: Male; within normal limit.

A
P

Rheumatic Akut Fever

Management:
Bed Rest
IVFD Dext 5% NaCl 0,45% 4gtt/i
Nasal Kanul 1 L/i
Inj. Benzatin penisilin 600.000 iv
Haloperidol 8,5 mg/8 jam /oral
Paracetamol 3x250 mg
Diet MB 1600 kkal + 40 gr protein
Diagnostic Planning:
-

Echokardiografi

July 22th 2014

S
O

Involuntary movement (+)

Sens: Alert, Temp: 37oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (+)
Body weight: 20 kg, Body length: 127
Head :
Right Eye : Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light refex
(+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light refex (+)..
Neck: Lymph node enlargement (-)
Thorax : Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal. HR: 96 bpm, reguler;
murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 22 x/i, regular, rales (-)
Abdomen : Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities : Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital : Male; within normal limit.

A
P

Rheumatic Heart disease

Management:
Bed Rest
Nasal Canul 1L/i
IVFD Dext 5% NaCl 0,45% 4gtt/i
Haloperidol 8,5 mg/8 jam /oral
Depakene syr
Diet MB 1600 kkal + 40 gr protein
Diagnostic Planning:
Echocardiografi :
Moderate MR
Moderate AR
Trivial TR
Mild PR

July 28th 2014

S
O

Involuntary movement (+)

Sens: Alert, Temp: 37oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Body weight: 20 kg, Body length: 127
Head :
Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light
refex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera (-). Light
refex (+)..
Neck: Lymph node enlargement (-)
Thorax: Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal. HR: 100 bpm,
reguler; murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 20 x/i, regular, rales (-)
Abdomen: Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities: Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital: Male; within normal limit.

A
P

Rheumatic Heart disease

Management:
Bed Rest
IVFD Dext 5% NaCl 0,45% 4gtt/i
Haloperidol 8,5 mg/8 jam /oral
Depakene syr
Diet MB 1600 kkal + 40 gr protein
Diagnostic Planning: -

Discussion
The patient has been diagnosed with Rheumatic Fever, based
on Jones criteria, there was found the presence of 3 mayor
symptomps on these patients are: chorea syndenham,
arthritis and carditis. When the results of lab tests found
elevated levels of ASO
In these patients was also diagnosed with Rheumatic Heart
Disease, based on the history of existence, fever, pain in the
throat, and based on the echocardiography examination
found
a Moderate MR, Trivial TR, Mild PR
In these patients has also been given treatment for his disease
rheumatic fever is the provision of as many as 600,000 units of
penicillin benzitin iv, and is in monitoring for 28 days, while to
treat symptoms of his chorea has given Haloperidol 8.5 mg / 8h