300.4 📋 章末速記 Summary

300.4.1 🔑 一句話總結

Acute rheumatic fever (ARF) = GAS pharyngitis 2-4 週後的全身性自體免疫反應；診斷靠 Jones criteria 2015 AHA（2 major OR 1 major + 2 minor + GAS infection 證據）；major 5 項：carditis + migratory polyarthritis + Sydenham chorea + erythema marginatum + subcutaneous nodules；2015 update 接受 subclinical carditis in 中高風險族群；Rheumatic heart disease (RHD) 是慢性後遺症，MS 為全球最常見原因（90%+），MR、AR、AS 可共存；primary prevention = 治療 GAS pharyngitis（penicillin V 10 d 或 BPG IM 單次）；secondary prevention = long-term BPG IM q3-4 wk 預防復發；2024 RHD Action Plan = echo screening + penicillin access + vaccine R&D；台灣 ARF / RHD 已大幅減少，但仍有偶發。

300.4.2 💊 治療精要

  • GAS pharyngitis：penicillin V 250-500 mg PO TID/QID × 10 d 或 BPG 1.2 MU IM 單次
  • acute ARF：ASA / NSAIDs (arthritis)、steroids (severe carditis with HF)、bed rest、GAS eradication
  • secondary prevention：BPG 1.2 MU IM q3-4 wk (preferred)、penicillin V 250 mg PO BID、erythromycin/azithromycin if allergic
  • duration：no carditis 5y or to 21；mild carditis 10y or 21；severe carditis + RHD 終身（或 40 歲）
  • chronic RHD valve disease：MS → PMBV (Wilkins ≤ 8) or MVR；MR/AR → repair > replacement；AS late → TAVR/SAVR

300.4.3 🎯 盧醫師的考前提醒

  1. ARF 是 GAS pharyngitis (not skin) 後 2-4 週 的 immune reaction（vs post-strep GN 可以是 skin or pharyngitis）
  2. Jones criteria 2015: 2 major OR 1 major + 2 minor OR (recurrence) 3 minor + 必須有 GAS infection 證據 (ASO、anti-DNase B、throat culture、scarlet fever)
  3. 5 major manifestations 記憶：Carditis + Arthritis (migratory polyarthritis large joints) + Sydenham chorea + Erythema marginatum + Subcutaneous nodules（CASES）
  4. 2015 update：subclinical carditis (echo positive but no auscultation finding) 在中高風險族群可診斷
  5. RHD globally MS 為最常見（90%+）— commissural fusion + leaflet thickening；Wilkins ≤ 8 → PMBV；rheumatic MS-AF 用 warfarin not DOAC (INVICTUS 2022)
  6. GAS pharyngitis 治療必要：penicillin V 10 d OR BPG single dose；macrolide if allergic
  7. secondary prevention BPG IM q3-4 wk 是金標準；duration 依 carditis + RHD 程度
  8. acute ARF treatment：ASA / NSAIDs for arthritis，steroids 只 for severe carditis with HF；bed rest during active disease
  9. 2024 WHO + WHA RHD Action Plan：echo screening (handheld + AI) + penicillin access + vaccine R&D
  10. arthritis 鑑別：ARF 是 migratory polyarthritis 大關節 asymmetric（vs RA symmetric small joints, reactive arthritis oligoarticular）