Autoimmune Disease

Acute Rheumatic Fever
Definition
• An inflammatory disease of childhood resulting
from untreated Streptococcus pyogenes (group A streptococcus) pharyngeal
infections.
It refer to Group A Beta hemolytic streptococcus , this group of streptococcus

has antigen lump into group called Group A that produce enzymes streptolysis
RBC lysis (Beta hemolysis)
• Peak incidence 5 to 15 years; more

common in females.
• This bacteria has protein in their cell wall called M protein which is
highly antigenic leading to antibodies production.
• This antibodies cross react with protein on some our body own cell
like heart, joint, ms, skin and brain thus attach body own cell.
• Once bound to cardiac tissue it activate nearby immune cell
cytokine mediated immune response tissue destruction
Treatment
• Aim to suppress inflammatory response  minimize cardiac damage
- symptomatic relief (anti inflammatory meds)
- eradicate pharyngeal streptococcal infection (antibiotic)
• Bed rest.
- Restrict activity until acute phase reactants return to normal.
• Anti-streptococcal therapy:
- IV C. Penicillin 50 000U/kg/dose QID or Oral Penicillin V 250 mg QID (30kg) for 10 days
- Oral Erythromycin for 10 days if allergic to penicillin.
• Anti-inflammatory therapy
- mild / no carditis:
Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over 4 weeks.
- pericarditis, or moderate to severe carditis:
Oral Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks, taper with addition of aspirin as above.
• Anti-failure medications
- Diuretics, ACE inhibitors, digoxin (to be used with caution).
Prophylaxis
Secondary Prophylaxis of Rheumatic Fever
• IM Benzathine Penicillin 0.6 mega units (<30 kg) or 1.2 mega units (>30 kg) every
3 to 4 weeks.
• Oral Penicillin V 250 mg bd.

• Oral Erythromycin 250 mg bd if allergic to Penicillin.
Duration of prophylaxis
• Until age 21 years or 5 years after last attack of ARF whichever was longer.
• Lifelong for patients with carditis and valvular involvement.
Infective Endocarditis
Definition
• Infective endocarditis is defined as infection of the endocardial
surface of the heart which frequently involves the heart valves.
• Early and accurate diagnosis is crucial to allow appropriate treatment
to improve outcomes and reduce mortality.
Symptom
Symptom
• Immune reaction to bacterial protein antibodies bacterial
antigen-antibodies complexes deposit in different part of body.
Diagnosis
• A high index of suspicion in any patients with with
unexplained fever (90%), loss of appetite and weight loss.
• Heart murmurs (85% of patients). Some may present

With complications such as heart failure (up to 58%) and
embolic events (25%).
• Young infants and immunocompromised patients

may not have fever.
• Pre-existing risk factors:

• Congenital heart disease; (unrepaired or repaired)
• Prosthetic heart valves and intracardiac devices
• Previous history of infective endocarditis
• Native valvular heart diseases such as rheumatic heart disease
• Presence of chronic intravenous access such as indwelling
central venous catheters, chemoports and haemodialysis catheters
• Immunocompromised patients
• The diagnosis of IE requires combination of clinical features,
microbiological findings, endocardial involvements and
extracardiac complications by imaging tools.
Blood culture
• it is cornerstone of diagnosis of IE
• At least 3 sets (to increase yield and reduce
false positive rate by skin contaminants)
• There is no necessity to wait for spikes of
fever (due to continuous nature of bacteraemia)
• taken at 30 mins intervals between samples
• obtained from peripheral veins (not from
central venous catheter) using aseptic technique
• Should be taken before commencement of
antibiotics
• Each set should include 1 aerobic and 1 anaerobic
bottle with minimal of 3 ml of blood
Echocardiography
• Transthoracic echocardiogram (TTE) should be
performed as soon as possible when IE is suspected
• Findings suggestive of IE include vegetation, abscess,

pseudoaneurysm, new dehiscence of prosthetic valve,
fistula, valve leaflet perforation and aneurysm
• If clinical suspicion of IE remains high despite an initial

negative TTE, do repeat TTE or transoesophageal
echocardiogram (TEE) is recommended within a week.
- In children, TEE requires general anaesthesia and risk versus

benefit must be carefully considered
- TEE is advisable in cases with prosthetic valves, prosthetic
cardiac material and those with poor TTE acoustic window
- TTE is recommended at completion of antibiotic treatment
to assess treatment response
Imaging Modalities
• Cardiac CT: detection of intracardiac abscesses, pseudoaneurysms
and degree of para-valvular extension, splenic abscesses and
intracranial mycotic aneurysms.
• Brain MRI: detection of ischaemic lesions, microbleeds and

mycoticaneurysms
• Nuclear Imaging: supplementary roles in difficult cases such as

prosthetic valve endocarditis.
Modified Duke Criteria
Modified Duke Criteria
Management
Antimicrobial Therapy
• Main problem is vegetation are poorly vascularize thus its hard to
treat with antibiotic to reach site of infection through blood.
• Infective endocarditis is biofilm infection where bacteria embedded
deep within matrix that is full with sugar and water.
• To maximize diffusion into vegetation it is typically treated with Initial
high dose iv abx to achieve high bactericidal effects for adequate
duration to ensure complete eradication (4 to 6 weeks).
Antibiotic Regimens for Initial Empirical
Treatment
• The backbone of empirical antibiotic involves 2 broad spectrum
antibiotic that cover staphylococci (methicillin susceptible and
methicillin resistant), streptococci and enterococci.
• Its given based on types of valves.
Community-acquired native valves or late
prosthetic valves endocarditis
• IV Ampicillin 200 – 300 mg/kg/day in 4 – 6 divided dose (max 12 g/day)
+
• IV Gentamicin (1 mg/kg) 8 hourly
+
• IV Cloxacillin (200 mg/kg/day) in 4 – 6 divided dose (max 12 g/day)
(allergic to penicillin)
• IV Vancomycin (40 mg/kg/day) in 2 – 3 divided dose (max 2 g/day)
+
Early prosthetic valve endocarditis
• IV Vancomycin (40 mg/kg/day) in 2 – 3 divided doses (max 2 g/day)
+
+
• Oral Rifampicin (20 mg/kg/day) divided in 3 doses (max 900 mg/day)
Nosocomial and healthcare associated
endocarditis
• IV Vancomycin (40 mg/kg/day) in 2 – 3 divided doses (max 2 g/day)
+
±
• IV Cefepime (50 mg/kg) 8 hourly (max 6 g/day)
• Once the causative microorganism is identified and sensitivity pattern

obtained, the empirical regimen should be switched to definitive
regimen
SURGICAL INTERVENTIONS
Surgical intervention is indicated in the following cases:
• Heart failure: severe valvular regurgitation, obstruction or fistula causing
refractory pulmonary oedema, cardiogenic shock or severe heart failure
symptoms.
• Uncontrolled infection: infection caused by fungi, local extension of

infection (abscess, pseudoaneurysm, fistula, enlarging vegetation),
persistent positive blood cultures despite appropriate antibiotic therapy
and prosthetic valve endocarditis caused by staphylococci or non-HACEK
gram-negative bacteria.
• Prevention of embolism: Left-sided vegetation > 10 mm after 1 or more

embolic episode, very large vegetation > 30 mm.
Prevention
Procedures which require IE prophylaxis
• Under most circumstances, the
pre-procedural antibiotic prophylaxis
as per routine surgical practice is
adequate as IE prophylaxis.
• If pre-procedural antibiotic is not

routinely given, the following
recommendations should be used:

Autoimmune Disease

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Acute Rheumatic Fever

It refer to Group A Beta hemolytic streptococcus , this group of streptococcus

• Peak incidence 5 to 15 years; more

• Oral Penicillin V 250 mg bd.

• Heart murmurs (85% of patients). Some may present

• Young infants and immunocompromised patients

• Pre-existing risk factors:

• Findings suggestive of IE include vegetation, abscess,

• If clinical suspicion of IE remains high despite an initial

- In children, TEE requires general anaesthesia and risk versus

• Brain MRI: detection of ischaemic lesions, microbleeds and

• Nuclear Imaging: supplementary roles in difficult cases such as

• Once the causative microorganism is identified and sensitivity pattern

• Uncontrolled infection: infection caused by fungi, local extension of

• Prevention of embolism: Left-sided vegetation > 10 mm after 1 or more

• If pre-procedural antibiotic is not

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