What Is Rheumatic Fever
What Is Rheumatic Fever ?
Rheumatic fever is an inflammatory condition occurring in the joints, heart, and other organs of the body, following a throat infection by streptococcal bacteria.
- Rheumatic fever develops as a reaction to a throat infection caused by the streptococcal bacteria.
- Children developing rheumatic fever usually have joint pain and fever. Rashes and bumps below the skin, palpitations, pain in the chest, and jerky movements, also may be may occur.
- The typical symptoms help diagnose this illness.
- Treating throat infections due to streptococcal bacteria with antibiotics help prevent the development of rheumatic fever.
- Long-term antibiotic therapy is employed to eliminate the infection and aspirin is used as a pain killer.
Rheumatic fever is not an infection, but an illness resulting from an adverse reaction to a streptococcal infection called strep throat. Several parts of the body may develop an inflammation following the streptococcal infection. The joints and the heart are the most affected. The nervous system and the skin are also often involved. Most of the inflammation subsides gradually without causing any permanent damage. However, in some cases, rheumatic fever may cause irreversible damage to the heart.
In developed countries like the US, the occurrence of rheumatic fever has become rarer now because of early detection of strep throat, and the use of antibiotics for treating it. However, it may occasionally appear in certain areas, especially in overcrowded places. A hereditary factor is also found to be responsible. In developing countries rheumatic fever is still very common due to inadequate detection and treatment of strep throat. Not everyone who has a streptococcal infection develops rheumatic fever. For example, in the US only less than 3% of children with untreated strep throat develop this condition. Children who are affected once have a higher chance of developing rheumatic fever a second time, with about 50% of them getting it if a subsequent strep throat is left untreated.
Besides throat infection, the streptococcal bacteria can cause infections in other parts of the body too, including an infection of the skin called impetigo. But these infections are not followed by rheumatic fever.
Symptoms
Rheumatic fever can have various symptoms depending on the parts of the body which are affected by the inflammation. The throat infection may subside within a few days, but the symptoms of rheumatic fever usually start to appear several weeks later. Fever accompanied by pain in the joints and the chest, and palpitations, is the initial symptoms in most cases. The palpitations and chest pain are the result of an inflammation of the heart, referred to as carditis. Other symptoms may include a skin rash, small nodules below the skin, and a condition called Sydenham’s chorea, which is characterized by jerky, unintentional movements. All these symptoms may not be present in every patient.
Joints: Fever accompanied by pain in the Joints is the initial symptom of rheumatic fever. Pain and tenderness may occur in more than one joint at a time. The inflamed joint may be swollen and red in color and may feel hot to touch. Joints of the arms and legs such as elbows, wrists, knees and ankles are the most common sites of inflammation. Hips and shoulders, as well as the small joints of the fingers and toes, also may be inflamed. Migratory pain is a typical feature; wherein pain seems to shift from one joint to another. The pain and inflammation may last for up to four weeks, but they do not cause any permanent damage to the joints.
Heart: Chest pain is the usual indication of heart inflammation, but in many cases, there may not be any external symptoms present, and the inflammation of the heart may go unrecognized for several years, till the damage caused to the heart is detected later in life. The chest pain typically results from the inflammation of the pericardium enveloping the heart. Some people may have an awareness of the heart beat, commonly called palpitations. The damage to the heart can cause heart failure, with symptoms such as nausea and vomiting, shortness of breath, stomach pain, a dry cough and fatigue.
The inflammation of the heart gradually subsides and completely disappears in about five months. However, the damage to the heart, mainly to the heart valves, is irreversible, and precipitates a condition referred to as rheumatic heart disease. The extent of the initial inflammation of the heart determines the severity of rheumatic heart disease. Among those who had only a mild inflammation, about 30% people develop this condition, while severe inflammation often results in rheumatic heart disease in more than 70% of the cases. In 1% of cases, rheumatic heart disease may occur without any heart inflammation. The mitral valve which lies between the left atrial chamber and the left ventricle is the most commonly affected heart valve. The narrowing of this valve, known as mitral valve stenosis, results in leaking around the valve, referred to as mitral valve regurgitation. The heart murmur resulting from valve damage often help the doctor detect rheumatic fever. Valve damage can result in atrial fibrillation and heart failure later on.
Skin: A rash known as erythema marginatum may develop after some of the other symptoms disappear. The rash is painless and is flat with wavy edges. It does not last long; sometimes disappearing the same day it occurred. Those who had inflammation of the joints and the heart may have hard but painless nodules below the skin, often near the joints which were inflamed.
Nervous System: Sydenham’s chorea is a symptom which occurs in children with rheumatic fever if their nervous system is affected. Uncontrollable, jerky movements usually start after other symptoms of the illness have disappeared. The chorea starts gradually, but it steadily increases in intensity. The affected children are often brought to the doctor almost a month after the symptoms first appeared, usually when jerky movements have become rapid flailing of arms and legs. The hand muscles are the first to be affected, but it soon spreads to the feet. Any muscles of the body, except the eye muscles, can be affected. Uncontrolled grimacing results when the facial muscles are affected. However, these jerky movements are absent when the child sleeps. Clumsiness resulting from the lack of control of the muscles can make eating and dressing difficult and clumsy. In some cases, the condition becomes so severe that the children are at risk of injuring themselves. Chorea can last from about four months to eight months.
Diagnosis
The characteristic symptoms help the doctor diagnose rheumatic fever. High levels of the antibody against streptococci bacteria in the blood is an indication of rheumatic fever, but it is not taken as conclusive evidence, as many children without this illness also have these antibodies, although the levels may be lower. An ECG may show abnormal heart rhythms if the heart is inflamed. Damage to the heart valves can be detected by an echocardiogram, which produces an image of the heart with the help of ultra sound.
Prevention and Treatment
Rheumatic fever is best prevented by treating throat infections due to streptococcal bacteria with antibiotics. The treatment should ideally start as soon as the infection occurs, and the antibiotics should be continued till the infection is completely eliminated.
Those who have already had rheumatic fever following a strep throat should continue antibiotic therapy to avoid future episodes. A daily dose of penicillin can be taken orally, or monthly intramuscular injections can be administered. Duration of the treatment depends on how severe the illness is. Most children continue penicillin till they reach adulthood, but in some cases, especially if there is significant heart damage, and if chorea had been one of the symptoms, life-long therapy is recommended. Those who closely interact with children are also required to continue penicillin for life, as children generally have streptococcal infections which can be cause re-infection in adults with a history of rheumatic fever.
The three main aims of the treatment are:
- Completely eliminating the streptococcal infection.
- Reducing joint inflammation and the inflammation of the heart.
- Limiting the stress on the inflamed areas through complete bed rest.
When rheumatic fever is diagnosed, long-acting penicillin injection is given to the children to completely eliminate the infection. The pain and inflammation of the joints and the heart is relieved by high doses of aspirin. Naproxen and other non-steroidal anti-inflammatory drugs are also effective in bringing down the pain and inflammation. If the child has severe inflammation of the heart, corticosteroids like prednisone are also given to reduce it.
When the heart and the joints are in inflamed condition, bed rest is advised to avoid additional stress to the affected parts. Absolute bed rest, except for going to toilet, is essential if the child has inflammation of the heart.
If rheumatic fever has damaged the heart valves, the person always remains vulnerable to endocarditis or an infection of the valves. They should have antibiotics prior to undergoing any surgery or dental procedures as a precautionary measure against developing endocarditis.
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Yasser Elnahas
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