Rheumatic Fever Workup

Introduction
Rheumatic fever is mainly a clinical diagnosis No specific confirmatory laboratory tests exist for acute rheumatic fever. However, several laboratory findings indicate continuing rheumatic inflammation. Some are part of the Jones minor criteria. Investigations : RECOMMENDED FOR ALL CASES : o Evidence of systemic illness o Evidence of preceding Streptococcal inf. o Evidence of carditis TESTS FOR ALTERNATIVE DIAGNOSES, DEPENDING ON CLINICAL FEATURES

Evidence of systemic illness

(non specific) Acute phase reactants: White blood cell count leukocytosis Erythrocyte sedimentation rate inc. C-reactive proteininc. *Anemia blood cultures if febrile helps to exclude other infectious causes

Evidence of preceding Streptococcal infection

(specific) Rapid antigen detection tests are not as sensitive. Throat swab: GABHSC , also from family members & contacts (preferably before giving antibiotics) Anti-streptococcal serology: o anti-streptolysin O titre ( not specific for any poststreptococcal diseases ) (repeat 1014 days later if first test not confirmatory) o anti-DNase B titres if available ( more sensitive but results are too variable , performed along with ASO) o Streptozyme test (screening test for Abs to s.c Ags NADase , DNAase , SK , SLO , Hyaluronidase) Specific for post Streptococcus pyogenes infection, such as rheumatic fever. N.R : less than 100 streptozyme units

Evidence of carditis
Chest x-ray cardiomegaly ,pulmonary congestion Electrocardiogram repeat in 2 weeks and 2 months if prolonged P-R interval (nonspecific finding ) or other rhythm abnormality) o 1st & rarely 2nd degree HB o features of pericarditis o T wave inversion o reduction in QRS Voltage Echocardiogram (consider repeating after 1 month if negative) o cardiac dilatation o suspected valve damage & its useful for grading the severity of carditis.

TESTS FOR ALTERNATIVE DIAGNOSES

Various other studies may be needed to rule out other illnesses in the differential diagnoses. Repeated blood cultures if possible endocarditis Joint aspirate (microscopy and culture) for possible septic arthritis Lyme serology ,evaluation of gonorrhea , RF , anti-nuclear antibody, drug screen for choreiform movements Serology and auto-immune markers for arboviral, autoimmune or reactive arthritis