Think ARF video
Video transcript
Speaker 1 Acute rheumatic fever is a preventable complication of a group A streptococcal infection. Unfortunately, this condition is difficult to diagnose and contributes to health inequity in high risk populations in Queensland. This video aims to support health staff working in Queensland to recognise, investigate and notify acute rheumatic fever. Acute rheumatic fever, also known as ARF, causes significant disease in Aboriginal and Torres Strait Islander, Māori and Pasifika people in Queensland.
Speaker 1 The highest rates of ARF are seen across North Queensland, with children aged between 5 and 14 years old most at risk. Prevention, early detection and treatment of ARF is critical, as ARF is a precursor to rheumatic heart disease, which can cause lifelong heart damage, cardiac failure, and premature death. ARF is an important public health issue and is a notifiable condition in Queensland.
Speaker 1 Health care professionals working with high risk groups should adopt a high index of clinical suspicion for ARF. ARF can occur following an untreated group A streptococcal infection, most commonly sore throats and skin sores. Following an infection, some people will develop an abnormal autoimmune inflammatory response that can affect the joints, skin, brain, and heart. While most of the inflammatory responses seen in the body are temporary, the effects on the heart can be permanent. This is known as rheumatic heart disease, or RHD.
Speaker 1 When someone is diagnosed with ARF, secondary prophylaxis should be commenced, which aims to protect the heart from further strep A infections, causing recurrent ARF episodes. Long term administration of intramuscular Benzathine benzylpenicillin G, known as BPG, or Bicillin every 21 to 28 days, reduces the risk of recurrent ARF and cumulative heart valve damage, which may lead to heart failure, stroke, and premature death.
Speaker 1 ARF can be difficult to diagnose as there is no specific diagnostic laboratory test. ARF is a clinical diagnosis based on a pattern of clinical features using the revised Jones Criteria and evidence of a recent group A strep infection. Resources such as the Queensland Suspected ARF Clinical Pathway and HealthPathways, are quick reference tools that assist clinicians to recognise and manage patients with suspected ARF. These resources support Australian ARF and RHD Guidelines and outline a number of potential differential diagnoses. In high risk populations, ARF should continue to be considered until an alternative diagnosis is made. Where a diagnosis remains uncertain, seek clinical support from a senior medical officer or the public health unit.
Speaker 2 The clinical features of ARF, referred to as manifestations, may include joint pain, carditis, Sydenham’s chorea, erythema marginatum, subcutaneous nodules, fever, raised inflammatory markers, or a prolonged PR interval on ECG. Presentations of ARF are highly diverse, they're often subtle, and they may evolve over time. Manifestations of ARF, as per the Jones Criteria, are divided into major and minor based on prevalence and specificity, with the presence of major criteria making a diagnosis more likely and minor criteria considered suggestive.
Speaker 2 Arthritis is the most common presenting symptom of ARF. Major manifestations include aseptic monoarthritis, polyarthritis, or polyarthralgia, with monoarthralgia considered a minor manifestation. The large joints are most commonly affected, often asymmetrical and migratory in onset, with a pain impacting joint movement and use. Rheumatic carditis primarily refers to acute inflammation of the endocardium, mainly impacting the mitral and aortic valves.
Speaker 2 A new significant murmur may be detected clinically, however, reliance on auscultation alone is not recommended. Carditis is often asymptomatic unless moderate or severe, and a diagnostic echocardiogram is recommended for all suspected cases of ARF. Sydenham’s chorea is the only absolute diagnostic feature of ARF. It is characterised by jerky, uncoordinated movements which disappear during sleep. Clinical signs may include a milkmaid’s grip, spooning, and the pronator sign.
Speaker 2 Erythema marginatum is a non itchy and painless pink rash occurring in irregular circular patterns and which blanches under pressure. Subcutaneous nodules are small, round, firm and painless nodules which occur over bony processes. Erythema marginatum and subcutaneous nodules are very rare, occurring in less than 2% of ARF cases, and while they're highly specific for ARF, they can also be difficult to diagnose accurately.
Speaker 2 For more detailed information on diagnostic characteristics of manifestations, please refer to the Australian ARF and RHD guidelines. Minor manifestations and supporting evidence of a preceding strep A infection form an important part of developing a patient's whole clinical picture. Convalescent strep serology to confirm recent acute infection may be required for patients with a high background exposure to strep A. When applying the Jones Criteria, it's important to note that major and minor manifestations affecting the same body system can only be used as one manifestation per ARF notification. For example, polyarthritis and monoarthralgia are only one manifestation.
Speaker 2 Each time a patient has a suspected episode of ARF, the recommended workup includes a careful assessment and history taking around symptom evolution, blood tests for strep A serology markers antistreptolysin and anti-DNase B titres, as well as inflammatory markers ESR and CRP. Throat or wound swab for bacterial culture using a swab with a clear gel based medium, an ECG to assess for cardiac involvement, and referral for echocardiogram and specialist review.
Speaker 2 This is necessary to not only assess for acute subclinical carditis, but also to assess for the presence of RHD and to determine the need for ongoing cardiac surveillance. Admission to hospital should be carefully considered to adequately assess and diagnose a patient, particularly children and young adults. The final diagnosis and age of the patient will determine subsequent management recommendations outlined in the Australian ARF and RHD Guidelines, and this includes the need for and duration of secondary prophylaxis with BPG, the frequency of follow up echocardiograms and the frequency of primary care and specialist reviews.
Speaker 2 Managing patients with suspected ARF involves treating any persisting strep A infection and its symptoms. Sore throats and skin sores should be swabbed and treated empirically with penicillin as a first choice unless contraindicated. Joint pain associated with ARF often responds promptly to salicylates or NSAIDs, so alternative analgesia is preferable to avoid masking symptom evolution. Treat any complications as per local protocols and admit to hospital if clinically indicated. When needed, involve cultural support early to assist with communication, education, engagement and follow up appointments. Give or arrange for the first dose of long acting BPG to be given. For ongoing management, refer the patient to their nominated GP, and where available, to the local RHD team.
Speaker 1 In Queensland, every episode of ARF needs to be notified to public health under the Public Health Act. This includes all suspected and confirmed cases as well as any recurrent episodes. Notification forms are available online on the Queensland Health RHD page. Results of an echocardiogram or specialist review are not required before submitting a suspected ARF notification. Additional information, such as echo findings or repeat serology results, can be later incorporated to further support ARF diagnosis and determine the presence of carditis or established rheumatic heart disease.
Speaker 1 When it comes to diagnosing and treating acute rheumatic fever, the key points to remember are; Think ARF in young Aboriginal, Torres Strait Islander, Māori and Pasifika patients with joint pain and fever. Refer to diagnostic tools and complete all recommended investigations for every suspected episode of ARF. For suspected or confirmed ARF give recommended BPG, request an echocardiogram and specialist review, complete a notification form and notify your local public health unit. Involve culturally appropriate health workers or local RHD team when necessary. And prevent ARF by empirically treating sore throats and skin infections in people at high risk of ARF. More information and resources can also be found on the Queensland Health ARF and RHD web page.