Heart Disease caused by infection

a) Acute Rheumatic Fever: autoimmune mediated following Group A Streptococcal pharyngitis. Mainly 6 to 10 year old children. Main symptoms are fever, carditis (75%), arthritis (75%), skin rash, nodules and chorea (all rarer). Most acute RF is miss-diagnosed as malaria or sepsis, but it is the commonest cause of acquired heart disease in Malawian children.

b) Chronic Rheumatic Heart Disease: results from recurrent attacks of acute rheumatic fever causing scarring of mitral and aortic valves. Commonly presents with CCF and mitral regurgitation.

c) Infective Endocarditis: bacterial (strep viridians)/ fungal infection on a pre-existing valve septal defect.

d) Myocarditis: inflammation of myocardium often from viral infection (HIV, coxsackie) causing poor contractility of heart muscle. May result in dilated cardiomyopathy.

Important Points in history

• Symptoms of heart failure.
• Occasionally a history of acute rheumatic fever including:
• Preceding pharyngitis
• Joint pains/ swelling migrating polyarthropathy
• Chest pain
• Skin rashes
• Involuntary movements (Sydenhams chorea)

b) Infective Endocarditis:

Acute: Fever, cough, breathlessness, failure to thrive, sweating.
Subacute: Fatigue, joint pains, weight loss, reduced appetite


More likely with:


• Pre-existing cardiac lesions (congenital or rheumatic heart disease)
• Recent dental work/ operation/ infection

c) Viral Heart Disease:

• Symptoms of cardiac failure
• Fever/ coryza/ diarrhea and vomiting
• Symptoms of immunosuppresion if HIV +ve

Important points on examination

Major Criteria on examination:

• Fever often over 39o, can last 3 weeks
• Carditis (cardiac murmurs, pericardial rub)
• Polyarthritis (asymmetric, migratory)
• Previous history of rheumatic heart disease
• Choreiform movements (particularly girls in early adolescence)
• Erythema marginatum (transient red ring-like rash on torso/inner limbs)
• Aschoff nodules (subcutaneous, over extensor surfaces)

Minor criteria:

• fever
• prolonged PR interval
• raised ESR/ CRP/ WBC

b) Signs of Chronic Rheumatic Heart Disease include:

• Mitral regurgitant murmur
• Mitral snap/ diastolic murmur in mitral stenosis
• Aortic regurgitation murmur left lower sternal edge, diastolic
• Displaced apex beat/ tapping

c) Signs of Subacute Bacterial Endocarditis include:

• A variable heart murmur
• Petechial/ purpural rash
• Splinter haemorrhages (finger and toenails)
• Osler's nodes (red nodules in finger pulps - painful)
• Janeway lesions (haemorrhagic areas in palms and soles painless)
• Roths spots (on fundoscopy haemorrhages with white centres)
• Clubbing
• Subconjunctival haemorrhages
• Splenomegaly
• Pallor

d) Signs of Myocarditis/ Cardiomyopathy:

• A low grade fever
• Other features of a viral infection, e.g. rhinorrhoea
• Signs of HIV or opportunistic infections
• Regurgitant murmurs (e.g. pansystolic murmur of mitral regurgitation)

Relevant Investigations:

• If Rheumatic Heart Disease suspected further Investigations are probably not necessary
• If cardiomyopathy/ myocarditis is suspected: HIV test (HIV cardiomyopathy is a stage 4 disease)
• If Infective Endocarditis suspected:
  • Repeated blood cultures (e.g.1 a day for 3 days) are necessary. Try if possible to coordinate the blood sampling with the fever
  • Urine dipstick: microscopic haematuria
  • (High WBC, ESR)

Indications for Admission

• Admit every child with acute cardiac symptoms or failure.
• It may be possible to manage chronic cardiac symptoms in the Tuesday morning cardiac
  clinic. Discuss with a senior if unsure

Treatment

a) Acute Rheumatic Fever

• STAT dose IM Benzathine Penicillin (600,000 iu IM< 30kg; 1,200,000 iu IM > 30kg)
• 10 days oral Penicillin V or Amoxicillin or Erythromycin
• Aspirin 20 mg/kg QDS for 1-2 weeks (until joint pains resolve) then wean to 15 mg/kg for another 3-6 weeks
• Bed rest
• Severe/ distressing chorea - consider haloperidol or sodium valproate. Most children with chorea do not require specific treatment.
• Consider steroids if ongoing carditis (discuss with consultant)
• If signs of heart failure give Furosemide 1 mg/kg QDS

b) Chronic Rheumatic Heart Disease

• All children should be given Benzathine penicillin IM monthly (through the cardiac clinic see below)
• In proven rheumatic heart disease, this should be continued for life
• May require valve surgery

c) Infective Endocarditis

• IV X-Penicillin (50 000 IU/kg every 4-6 hours, ideally every 4) and Gentamicin (3 mg/kg OD) - both for 4-6 weeks
• Give IV Flucloxacillin 50mg/kg (to max 2g) QDS and Gentamicin (6mg/kg OD) if cultures grow Staph. aureus. (consider IV Ceftriaxone).

• The length of the course is prolonged, and will depend upon the organism and condition of the child.
• minimum 2/52 IV X-Penicillin and Gentamicin, then 2/52 Amoxycillin (15mg/kg PO TDS) for Strep. viridans
• minimum 4/52 IV Flucloxacillin and Gentamicin for Staph. aureus

d) Viral Myocarditis/ Cardiomyopathy

• symptomatic treatment of fever or pain
• begin ART if HIV cardiomyopathy (stage 4 disease)

Complications

Prevention

600,000 iu IM if under 30kg 1,200,000 iu IM if over 30kg

• Continue at least until 18; life-long if significant valve disease
• Follow up in cardiac clinic (Tuesdays 9:00 am)
• THIS MUST BE DOCUMENTED CLEARLY IN HEALTH PASSPORT AND COMMUNICATED TO FAMILY
• Providing monthly prophylaxis for children with previous rheumatic fever is the main raison-dêtre for the paediatric cardiac clinic!

b) Preventing Infective Endocarditis (dental/ surgical prophylaxis):

• All children with structural heart defects (congenital or acquired) are at higher risk
• More turbulent flow = greater risk (VSD, ASD, PDA, TOF, rheumatic valves)
• Gentamicin 7.5 mg/kg IM and Amoxicillin 50mg/kg 1 hour pre-op, and repeat the Amoxicillin 6 hours post-op
  • The value of antibiotic prophylaxis to prevent infective endocarditis is questionable and is no longer recommended in the UK. However, in our context and in the absence of evidence to the contrary, prophylaxis is still recommended.

Follow-up

• Arrange a follow up appointment for children with ongoing cardiac disease in Cardiac Clinic (Tuesdays 9:00 am)

REF:

• WHO Rheumatic fever and rheumatic heart disease Geneva 2001
• Carapetis JR Acute rheumatic fever. Lancet 2005; 366: 155 to 68