Rheumatic fever is an inflammatory disease that occurs as a complication of Group A Streptococcal pharyngitis or sore throat. This disease may occur one to five weeks after an untreated strep throat or a strep throat, which was not treated until ten days or more after the initiation of symptoms. Occasionally rheumatic fever may occur after an unapparent strep throat or may result from treatment that failed to eradicate the streptococci.
There are over one hundred types of Group A Streptococcal bacteria that can cause strep throat and most types do not lead to rheumatic fever. The so-called rheumatogenic strains of Group A Strep appear from time to time. These strains were isolated from a few patients with rheumatic fever and strengthen the concept that only a limited number of strains can cause this disease.
In the 1930s and 1940s rheumatic fever was a serious medical problem for adolescents. Hospitals often had waiting lists for children who needed treatment. The House of Good Samaritan in Boston cared for more than two thousand rheumatic fever patients between 1921 and 1970.
With the discovery of penicillin followed by a plethora of other antibiotics, strep throat could be treated adequately. In 1950, it was proven that proper treatment of Group A strep throat prevented rheumatic fever and its complications.
There was a resurgence of rheumatic fever in the 1980s. At the time, there was a reappearance of the rheumatogenic strains of Group A Strep as well as an increase in the virulence of the bacteria. Some of the children who developed rheumatic fever had no symptoms of strep throat while others took antibiotic treatment and they still developed rheumatic fever. These cases probably represented treatment failures. In the 1990s the incidence of rheumatic fever fell to low levels, but it is still very prevalent in developing countries.
Who is likely to develop rheumatic fever?
To develop rheumatic fever, the adolescent needs to be infected in the upper respiratory tract with a rheumatogenic strain of Group A Strep. Rheumatic fever could develop if the adolescent is not treated for the streptococcal infection, is treated more than nine days after the commencement of symptoms or if the antibiotics fail. The antibiotics could fail if the adolescent does not take the entire prescribed course of medication.
The peak age of incidence for rheumatic fever is in the five- to fifteen-year age group although it can be seen in older adolescents and adults. There is neither a gender nor racial predilection. Rheumatic fever tends to occur in the cooler months in temperate climates or shortly after school opens in September. Crowding favors the spread of strep throat and this may be seen in households, schools or other institutions. Rheumatic fever is rampant in the developing regions including the Middle East, the Indian subcontinent and many countries of Africa and South America. However, during the rheumatic fever outbreak in Salt Lake City between 1985 and 1988, many of the victims were white middle-class children who lived in suburbia.
What are the symptoms of rheumatic fever?
There are many symptoms associated with the various presentations of rheumatic fever since it can involve a number of different organ systems including the heart, joints, skin and nervous system. The time interval between the strep throat and beginning of rheumatic fever varies between one and five weeks with an average of nineteen days. Most adolescents have fatigue and fever. If the joints are affected with arthritis, then the onset is abrupt and this may include aching and swollen knees, ankles, elbows and wrists. The pain may migrate from joint to joint. If the heart is affected it is termed carditis; then the symptoms will be more insidious. The teen may have shortness of breath and weakness. If the nervous system is involved, chorea or St. Vitus’ dance may be seen. This occurs later in the course of the illness and consists of irregular, jerky uncontrollable movements of the face or extremities as well as emotional lability. Less commonly seen are pea to lima bean size bumps under the skin that are termed subcutaneous nodules and a pink rash with clear centers called erythema marginatum that may occur on the body but spares the face. .
About seventy-five percent of new cases of rheumatic fever present with arthritis. Carditis is seen in forty to fifty percent and chorea in fifteen percent. Less than ten percent of new patients have subcutaneous nodules or erythema marginatum.
How is rheumatic fever evaluated?
There is no specific laboratory test that is diagnostic of rheumatic fever. The patient’s history and physical examination are exceedingly important in establishing the diagnosis of rheumatic fever. Physicians will utilize the Jones Criteria, which were updated in 1992 by the American Heart Association as guidelines to assist in the diagnosis of rheumatic fever. Documentation of a recent Group A streptococcal infection is also necessary. An electrocardiogram, echocardiogram or chest x-ray may be ordered if there is a question of carditis.
How is rheumatic fever treated?
Rheumatic fever is treated with anti-inflammatory agents to suppress the symptoms and signs of the disease. These medications, which include aspirin or steroids, do not cure the illness and they do not prevent recurrences in the future. Aspirin reduces fever and joint inflammation. Penicillin or another appropriate antibiotic is needed to treat the streptococcal infection. Most patients need bed rest, which can run from three weeks to three months or sometimes longer. If the patient develops heart failure, then cardiac drugs may be prescribed.
Recurrences of rheumatic fever do occur after subsequent streptococcal infections, so all patients who have been diagnosed with rheumatic fever should receive prophylactic antibiotic therapy to prevent streptococcal infections. This therapy may consist of monthly penicillin injections or daily oral medication. Adolescents who may not be compliant with daily medicine should have monthly injections of antibiotic. Individual decisions between patient, physician and family need to be made as to when the prophylactic antibiotic therapy can be terminated. This important decision should take into account the risk of an individual patient to acquire streptococcal pharyngitis, his or her occupation and ability to recognize symptoms of illness.
How is rheumatic fever prevented?
Accurate diagnosis and appropriate treatment of Group A streptococcal sore throat helps to prevent new cases of rheumatic fever. This may be difficult in a densely populated indigent community where adolescents may not have good access to medical care and treatment. Unfortunately, acute rheumatic fever may occur when a teen has had an unapparent streptococcal sore throat. For those individuals who have been previously diagnosed with rheumatic fever, compliance with antibiotic prophylactic treatment helps to prevent recurrences.
Related topics:
Antibiotics, anti-inflammatory drugs, arthritis, chronic illness, heart disease, strep throat
