Sue Case Study: Pathophysiology and Management of Acute Rheumatic Fever

This paper analyses Sue case, suspected to be suffering from acute rheumatic fever. Learn about the pathophysiology of ARF and the elements to consider during its management. Nurses' role in treating the disease and preventing recurrence is also discussed.

Running Head: SUE CASE STUDY
Sue case study
Student’s Name
Institution
Date

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Introduction
The paper intends to analyse Sue case. She is suspected to be suffering from acute
rheumatic fever. The purpose of the paper is to focus on how nurses should intervene. The
paper is divided into two sections. The first section will focus on the pathophysiology of
acute rheumatic fever and the second section will focus on the elements to consider during
the management of the acute rheumatic fever.
Pathophysiology of Acute Rheumatic Fever
Acute rheumatic fever (ARF) is the consequence of an autoimmune reaction that
occurs after pharyngeal Streptococcus pyogenes infection. The antigenic mimicry between
certain bacterial surface proteins - specific epitopes - and the cells of the host is at the origin
of a cross-immunological reaction occurring on a genetically predisposed terrain. In other
words, Streptococcus M proteins share epitopes (antigenic determinants recognized by Ac)
with synovial proteins, cardiac muscle, heart valves, indicating that molecular mimicry
contributes to the occurrence of arthritis, carditis, lesions valvular (Lennon, 2018). The role
of genetic factors is evidenced by the higher prevalence of acute rheumatic fever and chronic
rheumatic heart diseases (including rheumatic heart diseases) in individual families. In 75-
100% of patients and only 15% of healthy people on B-lymphocytes, there is a specific
alloantigen 883 (D8 / 17), detected with the help of special monoclonal antibodies (Zühlke, et
al 2017). The joints, the heart, the skin and the central nervous system are most often
involved. The pathology varies according to the site.
Concerning the joint, it is important to note that joint involvement resembles
nonspecific inflammation on a synovial biopsy specimen, sometimes with small foci
suggestive of Aschoff bodies (nodules found in the hearts of individuals with rheumatic
fever) (Lennon et al 2017).

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Concerning the heart, cardiac involvement is manifested as carditis, which usually
affects the heart from the inside to the outside, i.e. valves and endocardium, then the
myocardium and finally the pericardium. Characteristic and potentially dangerous valvular
abnormalities may occur. Acute interstitial valvulitis can cause valve edema. If left untreated,
it can lead to edema, thickening, retraction or other destruction of valves and cusps causing
stenosis or valve insufficiency (Kostopoulou, Gkentzi, Karatza & Dimitriou, 2018).
Similarly, tendinous cordage may shorten, thicken or weld, which may increase the
insufficiency of damaged valves or cause valve failure even in the absence of injury (Hanson-
Manful, et al 2018). The dilatation of the valvular rings may also cause regurgitant
insufficiency. The mitral valves are most often affected then the aortic, tricuspid and
pulmonary valves in order of decreasing frequency. Valvar insufficiency and narrowing
usually result from mitral and tricuspid valve lesions (Umapathy & Saxena, 2018).
Concerning the skin, the subcutaneous nodules are indistinguishable from those of
rheumatoid arthritis, but on the biopsy they look like Aschoff nodules (Bozabali, Bayraktar &
Kocabaş, 2017). The erythema marginé differs histologically from other skin lesions of
similar macroscopic appearance e. g, juvenile idiopathic arthritis rash, Henoch-Schönlein
purpura, chronic erythema migrans (manifestation of the onset of Lyme disease), and
erythema multiforme (Sato, Uejima, Suganuma, Takano & Kawano, 2017). At the level of
the dermis, perivascular infiltrates of neutrophils and mononuclear are found.
Initial symptoms usually occur nearly 2 to 4 weeks after streptococcal infection. The
manifestations typically involve an association of the joints, the heart, the skin and the central
nervous system. The migratory arthritis is the most common symptom, seen in about 70% of
children; it is often accompanied by fever. Sometimes, a monoarthritis is observed. The joints
are painful, sensitive, red, hot and accompanied by edema (Khanna & Liu, 2016). The ankles,
knees, elbows and wrists are the joints most frequently affected. The shoulders, hips and

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small joints of the hands and feet can also be reached, but almost never in isolation. In case of
spine injury, another condition should be suspected.
Part 2
The ultimate role of nurses would be to treat the disease and prevent recurrence. The
main objectives are the suppression of inflammation and the control of acute symptoms, the
eradication of group A streptococcal infections and the prophylaxis of a future infection, in
order to avoid recurrent cardiopathy.
Firstly, nurses would be expected to treat streptococcal pharyngitis. Treatment of
streptococcal pharyngitis would decrease the incidence of ARF. The treatment recommended
by WHO (World Health Organization) is based on oral or intramuscular penicillin. Nurses
also have the role to put in place preventing measures. Some teams assign a major role to
primary prophylaxis to control rheumatic heart disease. Evidence of the effectiveness and
value of the cost / benefit of such a strategy remains controversial (Oliver, Foster,
Williamson, Pierse & Baker, 2018). Indeed, streptococcal carriage is frequently
asymptomatic and the existence of potential non-pharyngeal portal of entry, such as the skin,
limits the effectiveness of primary prevention. Nurses should also administer secondary
prophylaxis. Secondary prophylaxis is based on the prevention of ARF relapses (Kevat,
Reeves, Ruben & Gunnarsson, 2017). Regular long-term antibiotic therapy aims to limit the
carriage of the pathogen. It is recommended to administer penicillin intramuscularly (and not
orally) every 3 to 4 weeks by adjusting the dosages to the patient's weight. Duration of
treatment depends on the date of the most recent ARF attack, the age of the patient and the
severity of the valvular lesions (Ralph, et al 2017). Secondary prophylaxis has been shown to
be particularly effective when monitored with specific registers. These regional or national
registers have made it possible to improve treatment compliance and to deal with severe cases
early. Nurses should also offer education. Education of health and population actors,

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combined with primary and secondary prophylaxis, is an effective strategy for controlling the
disease and significantly reducing the economic costs of advanced forms of ARF. Unlike
primary prevention, secondary prevention has proved its effectiveness with an interesting cost
/ benefit ratio
Nurses also has the role of monitoring the dosage and ensuring that the dosage is
adhered to. For example, aspirin is used for controls the fever and pain of arthritis and
carditis. The dose is administered with increasing dosage until clinical efficacy or signs of
toxicity are observed. The initial dosage in children and adolescents is 15 mg / kg 4 times a
day. If the effect of this dose is not maintained the next day, it will be increased to 22.5 mg /
kg 4 times a day the following day and to 30 mg / kg 4 times a day. The systemic toxicity of
salicylates is manifested by tinnitus, headache, or hyperpnea, and may not appear until after 1
week. Salicylate levels are only measured to manage toxicity and should not be measured
until the patient has received aspirin for 5 days. If no therapeutic effect occurs after the 4th
day, which sometimes occurs when carditis or arthritis are severe, nonsteroidal anti-
inflammatory drugs (NSAIDs) should be replaced by a corticosteroid. This clearly shows that
nurses should be always there to monitor dosage and compliance.
It is important to note that the prevalence of rheumatic heart disease increases with
age due to cumulative exposures to infection during childhood and adolescence, with a
female predominance whose reasons are still unknown. The highest figures are for sub-
Saharan Africa and the indigenous populations of Australia (prevalence reaches 50 per
1,000).
Family care
Family care is very important as far as acute rheumatic fever is concerned. The acute
rheumatic fever is primarily related to living conditions: while it has been practically
eradicated from industrialized countries for more than thirty years, its incidence reaches up to

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250 per 100,000 inhabitants in Australia's aboriginal populations. Rheumatic heart disease
still affects between 15 and 20 million people worldwide, mostly children and young adults
living in developing countries. Undernutrition, overcrowding and a low socio-economic level
predispose to streptococcal infections and the resulting episodes of rheumatic fever. Family-
centred care should focus on providing ideal environment to Sue. The family-centred care
should focus on dietary practices and physical activity. It should be noted that the acute
patient with arthritis, chorea or symptomatic heart failure usually has to reduce his activity. In
the absence of carditis, no limitation of the physical activities is necessary after the
disappearance of the initial thrust. In the asymptomatic patient, strict bed rest has no proven
benefit in case of carditis
Effects of hospitalisation of the child, on the child and family
Hospitalization will have positive effects on child because it will enable nurses
monitor the condition and intervene on the right time. It should be noted that acute rheumatic
fever. Considering the treatment plan, it would be better to hospitalize sue. The antibiotic
treatment, lasting 10 days, is based on penicillin G (Benzylpenicillin) at the dose of 2 million
units divided into 2 intramuscular injections per day, or penicillin V
(Phenoxymethylpenicillin) at a dose of 2 million units divided into 3 doses oral.
Intramuscular injections are contraindicated in patients taking anticoagulants. In case of
allergy to penicillin, erythromycin is used at the dose of 50 mg / kg / day in 3 taken orally for
10 days. Anti-inflammatory treatment It is based on corticosteroids or aspirin. Prednisone is
administered at the dose of 2 mg / kg / day without exceeding 80 mg / day. This attack dose is
maintained until the normalization of the SV, which usually occurs on the 10th day, then
gradually decreases the dosage of corticosteroids in steps every 5 days to have a total
duration of treatment of 6 weeks in the absence of heart disease and 3-4 months in case of
carditis. SV is performed weekly and must remain normal. If it increases, we must mention a

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resumption of the inflammatory process. For aspirin, the initial dose is 100 mg / kg / day
without exceeding 6g / day in 4 oral doses. This dose is maintained until the normalization of
SV. The maintenance dose is 60 mg / kg / day maintained for 6 weeks in the absence of
carditis and for 3 months in case of cardiac involvement. Bed rest is part of the treatment of
ARF crisis as well as measures related to corticosteroids (deodized diet, potassium
supplementation, calcium and gastric bandages). Consequently, the treatment plan will expect
Sue to be admitted so that she can get adequate medical attention.
ARF poses a major disease burden among disadvantaged populations globally
(Coffey, Ralph & Krause, 2018). Hospitalization will have negative effects on the family
because the case shows that the hospital offering the services is located 800km away. This
means that it will cost the family a lot of money to meet the transport and hospitalization fee.
Conclusion
Acute rheumatic fever remains a major public health problem in developing countries,
even though effective prevention strategies exist. Ultrasound is able to identify early
rheumatic heart valve lesions and could play a key role in screening for and expanding
secondary ARF prevention measures in areas where the disease is still endemic.

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References
Bozabali, S., Bayraktar, E., & Kocabaş, C. N. (2017). Acute rheumatic fever and acute post-
streptococcal glomerulonephritis rarely seen together. Minerva Pediatrica, 69(1), 83-
85. doi:10.23736/S0026-4946.16.04386-3
Coffey, P. M., Ralph, A. P., & Krause, V. L. (2018). The role of social determinants of health
in the risk and prevention of group A streptococcal infection, acute rheumatic fever
and rheumatic heart disease: A systematic review. Plos Neglected Tropical Diseases,
12(6), e0006577. doi:10.1371/journal.pntd.0006577
Hanson-Manful, P., Whitcombe, A. L., Young, P. G., Atatoa Carr, P. E., Bell, A., Didsbury,
A., & ... Moreland, N. J. (2018). The novel Group A Streptococcus antigen SpnA
combined with bead-based immunoassay technology improves streptococcal serology
for the diagnosis of acute rheumatic fever. The Journal Of Infection, 76(4), 361-368.
doi:10.1016/j.jinf.2017.12.008
Kaminecki, I., Verma, R., Brunetto, J., & Rivera, L. I. (2018). Delayed Diagnosis of Acute
Rheumatic Fever in a Patient with Multiple Emergency Department Visits. Case
Reports In Pediatrics, 20189467131. doi:10.1155/2018/9467131
Kevat, P. M., Reeves, B. M., Ruben, A. R., & Gunnarsson, R. (2017). Adherence to
secondary prophylaxis for acute rheumatic fever and rheumatic heart disease: a
systematic review. Current Cardiology Reviews,
Khanna, K., & Liu, D. R. (2016). Acute Rheumatic Fever: An Evidence-Based Approach To
Diagnosis And Initial Management. Pediatric Emergency Medicine Practice, 13(8),
1-23.

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Kostopoulou, E., Gkentzi, D., Karatza, A., & Dimitriou, G. (2018). Acute Rheumatic Fever,
Kawasaki Disease or Alternative Diagnoses? A Call for the General Paediatrician.
Journal of Paediatrics And Child Health, 54(6), 707-708. doi:10.1111/jpc.14054
Lennon, D. (2018). A Clear-cut Case of Acute Rheumatic Fever After Group G Streptococcal
Pharyngitis in New Zealand. The Pediatric Infectious Disease Journal, 37(4), 376-
377. doi:10.1097/INF.0000000000001834
Lennon, D., Anderson, P., Kerdemilidis, M., Farrell, E., Crengle Mahi, S., Percival, T., & ...
Stewart, J. (2017). First Presentation Acute Rheumatic Fever is Preventable in a
Community Setting: A School-based Intervention. The Pediatric Infectious Disease
Journal, 36(12), 1113-1118. doi:10.1097/INF.0000000000001581
Oliver, J., Foster, T., Williamson, D. A., Pierse, N., & Baker, M. G. (2018). Using preceding
hospital admissions to identify children at risk of developing acute rheumatic fever.
Journal Of Paediatrics And Child Health, 54(5), 499-505. doi:10.1111/jpc.13786
Ralph, A. P., Noonan, S., Boardman, C., Halkon, C., & Currie, B. J. (2017). Prescribing for
people with acute rheumatic fever. Australian Prescriber, 40(2), 70-75.
doi:10.18773/austprescr.2017.011
Sato, S., Uejima, Y., Suganuma, E., Takano, T., & Kawano, Y. (2017). A retrospective study:
Acute rheumatic fever and post-streptococcal reactive arthritis in Japan. Allergology
International: Official Journal Of The Japanese Society Of Allergology, 66(4), 617-
620. doi:10.1016/j.alit.2017.04.001
Umapathy, S., & Saxena, A. (2018). Acute rheumatic fever presenting as complete heart
block: report of an adolescent case and review of literature. BMJ Case Reports,
2018doi:10.1136/bcr-2017-223792
Zühlke, L. J., Beaton, A., Engel, M. E., Hugo-Hamman, C. T., Karthikeyan, G.,
Katzenellenbogen, J. M., & ... Carapetis, J. (2017). Group A Streptococcus, Acute

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Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical
Considerations. Current Treatment Options In Cardiovascular Medicine, 19(2), 15.
doi:10.1007/s11936-017-0513-y