TERIAL AGENTS - Every patient should receive Inj. Procain penicillin 50,000 U/kg for 10 days once a day IM. If sensitive to penicillin give Erythromyc

carditis, prolonged bed rest is not necessary. Patients with definite myocarditis and valvulitis should be kept in bed until: (i) the intensity of heart murmur has diminished or has become stabilized, (ii) heart sounds are of good quality, (iii) sleeping pulse rate is below 100 per minute, (iv) hematocrit is rising or normal and the CRP is negative and (v) there is a true weight gain. Convalescence may often take G months or longer. General acceptable rules for bed rest are - Status 2. Diet - Aim is to maintain nutrition. Only fluids if moderate or high fever. Vitamins and minerals. 3. Drugs - control acute exudative manifestations. (a) ANTIBACTERIAL AGENTS - Every patient should receive Inj. Procain penicillin 50,000 U/kg for 10 days once a day IM. If sensitive to penicillin give Erythromycin 40-50 mg/kg for 10 days. (b) ANTI-INFLAMMATORY AGENTS - (i) Salicylates in the form of Aspirin 100 mg per kg body weight per day in 3-4 divided doses taken in milk or after meals. Continued for 2 weeks then scaled down to 75 mg/kg for 4-6 weeks for both arthritis alone, anchor carditis with or without cardiomegaly Signs of aspirin toxicity are - vomiting, tinnitus, and hyperpnoea. If these occur, the drug should be discontinued for one or two days and then restarted in a lower dose. (ii) Steroids - should be given when there is marked cardiac enlargement, failure, pericarditis. They suppress the activity and allow digitalis and diuretics to work, and if there is only potential failure risk of development of failure is minimised. Rebound phenomena (reappearance of clinical or laboratory signs of rheumatic activity) may occur when steroid medication is stopped or the dosage reduced Dosage - Prednisolone 2 mg/kg/day in divided doses for 2 weeks, gradually decreased over another 2 weeks. Aspirin should be started after 2 weeks of steroids and continued for 4 weeks beyond to prevent steroid rebound 4. Symptomatic treatment - (i) Local treatment - Cradle to lift bed clothing from affected joints. Heat, methyl salicylate and counter irritants. (ii) Cardiac failure - Digitalis - 0.03 - 0.05 mg/kg total dose orally, 3/4 this dose if parenteral digitalisation necessary. Give 1/2 dose stat, 1/4 after 8 hours, 1/4 after another 8 hours. Daily maintenance 1/4-1/5th total dose. Frusemide 2 mg/kg/day with oral pot. chloride, oxygen. (iii) Pain and restlessness - Codein for chest pain and cough. (iv) Anaemia - Iron by mouth. 5: Convalescence - Physical activity not undertaken until clinical and laboratory evidence of rheumatic activity have been absent for at least 2 weeks after stopping of salicylates. Restriction of physical exertion is not necessary where there is satisfactory compensation, and moderate degree of physical activity is desirable, but exercise should be increased gradually. PREVENTION AND PROPHYLAXIS -1. Immediate treatment of every suspected case of sore throat orstreptococcal infection with penicillin or erythromydn for 10 days. 2. Change of environment and improvement of nutrition. 3. Antimicrobial prophylaxis - Oral phenoxymethyl penicillin 200,000 units twice daily, or benzathine penicillin G 1.2 million units IM once every 3 weeks, or sulphadiazine 0 5 gm. twice daily in penicillin-allergic patients. For patients sensitive to sulphonamides and penicillin, Erythromycin 40 mg/kg/day can be used Prophylaxis must be continued till the patient is 25 years old, or for 5 years from the last attack of rheumatic fever whichever is longer. Preferably life-long as adults can get recurrences after many years. Must be used even in chorea. Rheumatic Chorea (Sydenhams Chorea, St. Vitus' Dance): Etiology: Age - maximum incidence at 10th year, rare after puberty. Sex - twice more common in girls. Predisposing factors - Mental strain, e.g. overwork at school, fright or shock, or pregnancy in young females Exciting cause - Majority due to acute rheumatic fever. Rarely scarlet fever, diphtheria, encephalitis, chickenpox. Chorea is regarded as a diffuse meningo-encephalitis affecting the basal ganglia, cerebral cortex and piaarachnoid Clinical features: Triad - of emotional instability, muscular weakness and semipurposeful movements Onset - Chorea may appear several weeks or months (usually more than 6 months) after an attack of acute rheumatic fever or it may be the initial symptom of a rheumatic episode. The onset is usually gradual. The child becomes increasingly nervous, tends to drop things and stumbles frequently. Speech becomes indistinct and characteristic purposeless movements of arms and legs develop. 1. Involuntary movements - (i) Face - constant bizarre grimacing. (ii) Tongue - when protruded it may be impossible to hold it quietly (Jack-in-the-box tongue) and its undulating jerky movements are described as those of a bag of worms. When asked to show the tongue, the child puts it out rapidly and may bite it to keep it out, or may jerk it back rapidly with reptilian speed When talking the tongue produces a clucking sound. (iii) Ocular muscles may rarely participate in the involuntary movements (iv) Extremities -Movements appear first in hands, when arms are outstretched in front, the posture is one of flexion at the wrist and hyper-extension at the metacarpo-phalangeal joints If the upper limbs are held above the head, the palm face outwards (pronator sign). Lower extremities less affected Gait may be clumsy. (v) Muscles of abdomen and neck may be involved (vi) Respiration -