Treatment of acute attack and importance of secondary prevention

Treatment: There is no specific for rheumatic fever, and no know measure change the course of the attack.

Good supportive therapy, however, can reduce the mortality and morbidity of the disease.Antibiotic therapy: After rheumatic fever is first diagnosed, a course of penicillin should be given eliminate group a streptococci.

This course is advisable even if bacteriologic examination yields throat cultures negative for streptococci,since the organisms may be present in area inaccessible to swabs. It is preferable to administer penicillin parenterally.

An effective course is a single injection of 1.2 million units of benzathine penicillin intramuscularly daily for 10days. Attempts to reduce ultimate heart damage by administering larger doses of penicillin early in the acute rheumatic attack have not been successful.

After completion of the therapeutic course of penicillin, continuous protection from reinfection with streptococci should be provided by instituting one of the prophylactic regiments described below.

Suppressive Therapy: For patients with out carditis, treatment with glucocorticoids is unnecessary. Acute arthritis can be relived with codeine or salicylates, the latter being preferable to reduce fever and joint inflammation.

When salicylate is used in the therapy of rheumatic fever, the dosage should be increased until the drug produces either a clinical effect or systemic toxicity characterized by tinnitus, headache, or hyperpnea.

A starting dose of 100 to 125mg\kg per day in children and 6 to 8g in adult given in four or five divided doses is recommended. Of the various salicylate preparations, ordinary aspirin is cheapest and most effective.

Many physicians prefer glucocorticoids to salicylates for the treatment of carditis, despite the lack of a demonstrated advantages of these adrenal hormones in controlled clinical trials.

Glucocorticoids are most potent anti-inflammatory agent but are more likely to be followed by posttherapeutic “rebound” and they are have the additional disadvantage of more frequent side effects, particularly acne, hirsutism, and cushingoid change in facies and habitus.

For this reasons it is preferable to begin treatment of patients who have carditis with salicylates: if these drugs fail to reduce fever and to ameliorate heart failure, therapy with glucocorticoids may be initiated promptly.

Prednisone is administered in doses daily. After the inflammation has been brought under control by either salicylates or glucocorticoids, treatment should be continued until the sedimentation rate approaches near – normal values and should be maintained for several weeks thereafter.

To prevent post steroid rebounds, an “overlap” course of salicylate therapy may be added when steroids are tapered off over a 2-week period. Rebound of rheumatic activity are usually of short duration and when mild, are best managed without resuming anti inflammatory treatment because a second or even a third rebound nay occur when suppressive therapy is discontinued.

About 5% of rheumatic attacks are most likely to occur in patients with cardiac damage and with previous rheumatic episodes. Weekly test for C – Reactive protein in blood and for erythrocyte sedimentation rate are useful in following the healing process, particularly while treatment with glucocorticoids or salicylates is gradually withdrawn.

Treatment of Chorea:

The sings and symptoms of chorea usually do not respond well to treatment with antirheumatic agents. Because the patients with chorea is frequently emotionally unstable, and because the manifestations of chorea may be exaggerated by emotional trauma.

Complete mental and physical rest is essential. Patients with chorea should be kept in a quiet rooms and cared for by sympathetic attendants.

Glucocorticoids or salicylates have little or no effect on chorea. Sedatives and tranquilizers particularly diazepam and chlorpromazine, are useful. Chorea no matter how serve, disappears during sleep.

Which should therefore be ensured by adequate sedation. Padded sideboards for the bed may be necessary to avoid injury to the patients. In the absence of other evidence of acute rheumatic disease,

It is advisable to allow gradual resumption of physical activity when improvement is apparent rather than waiting for all choreiform movement to disappear, which may require many months.

Because of the great variability in the course of chorea, evaluating the effectiveness of various therapeutic measures is difficult. It is well to remember.

That chorea is a self limited disease which is usually not followed by significant neurologic sequelae and that good result are almost invariably obtained by patients, attentive nursing care and conservative medical management.

How to Treat acute attack and importance of secondary prevention