Generality
Rheumatic fever is a generalized inflammatory process, which affects several anatomical districts of the body; the most affected sites are the large joints, the heart, the skin and the nervous system. The disorder has a curious origin: due to a bacterial infection, sustained by group A streptococcus, the immune system begins to function incorrectly and to act against the organism to be defended.
Figure: rheumatic fever affects children the most and arises after streptococcal pharyngitis. From the site: www.stuff.co.nz
From this, various symptoms arise, including joint pain and swelling, heart problems, fever, etc.
To avoid complications, it is important that diagnosis and treatment are timely. The cure consists in alleviating the symptoms and preventing the onset of other infections.
What is rheumatic fever?
Rheumatic fever is a generalized inflammatory disease, which represents a posthumous complication of group A streptococcal infections. The main sites affected by the inflammatory process are the large joints, the heart, the skin and the central nervous system.
Healing can also take place without treatment, however, in this case, there is a high risk that the disease will leave permanent damage to the patient.
GROUP STREPTOCOCCO A
The bacterium involved in the onset of rheumatic fever is group A streptococcus ( Streptococcus pyogenes ), which causes pharyngitis ( sore throat ) or scarlet fever .
Rheumatic fever can therefore be considered a complication of these infectious diseases.
Epidemiology
Rheumatic fever, in industrialized countries, is very rare: in fact, one person for every 100, 000 inhabitants gets it. On the contrary, it is much more common in overcrowded and poorly hygienic-sanitary countries, such as some regions of Africa, the Middle East and South America.
Worldwide, annually, cases of rheumatic fever are just under half a million.
The most affected individuals are young people (males and females in equal measure), aged between 5 and 15 years. In adults, however, this inflammatory disease is very rare.
Causes
At one time, it was believed that rheumatic fever was caused exclusively by streptococcus in group A of pharyngitis or scarlet fever.
Today, however, we are quite convinced that the pathological mechanism is another, more complex and with more protagonists. It seems, in fact, that to determine the inflammation is a malfunction of the immune system, activated to defend the body from streptococcus bacterial infection.
SOME MORE DETAILS ™
The immune system, once activated against the bacterium in question, exchanges some physiological molecules of the human body (they seem to be proteins) for molecules of bacterial origin, attacking and destroying them. This triggers the inflammatory process in all those tissues containing this molecule recognized as foreign and dangerous.
It remains to explain why the immune system, at some point, goes "on tilt"; in this regard, some possible risk factors have been identified, but further scientific investigations are needed.
RISK FACTORS
The known risk factors, with a role in the malfunctioning of the immune system, are:
- Environmental factors . Living in an overcrowded environment, lacking from a hygienic-sanitary point of view, exposes every single individual to repeated bacterial infections caused by streptococcus of group A; this means that the probability of developing rheumatic fever is higher than in countries where sanitary measures are at the forefront. This theory is supported by statistical data.
- Genetic factors . Some people are naturally predisposed to develop rheumatic fever, as this predisposition "is written" in their genes. Compared to the environmental component, the theory of genetic factors presents different points of question.
Symptoms and Complications
To learn more: Rheumatic Fever Symptoms
The symptoms and signs that characterize rheumatic fever are numerous.
heart, large joints, skin and central nervous system ; moreover, rheumatic fever can cause a series of manifestations similar in some respects to those of influenza, such as fever and sore throat . However, it is worth remembering that each patient represents a case in itself, with symptoms that can sometimes be different from the most common.
A list of the main symptoms is as follows:
- Arthritis in the large joints (knees, hips, wrists and ankles)
- Heart problems, due to inflammation of the myocardium (the heart muscle)
- Skin rash
- Sydenham Korea (it is a particular inflammation of the nervous system)
- Chest pain
- Medium-high fever
- Abdominal pain
- Subcutaneous nodules
- Enlarged throat lymph nodes
ARTHRITIS
Arthritis is probably the most common symptom of rheumatic fever: in fact, joint pain and swelling affect three in four people.
Figure: Rheumatic fever causes pain and swelling in the large joints of the human body. From the site: www.dinf.ne.jp
The joints involved are usually those of the knees, hips, wrists and ankles, which appear painful on both sides of the body.
The onset of this disorder is quite rapid, so that in some individuals the arthritis can occur even after just one week of bacterial infection.
HEART PROBLEMS
Cardiac problems, due to inflammation of the myocardium (the heart muscle), are perhaps the most important symptom of rheumatic fever. This importance is not due to the percentage of affected patients (about 30-60%), but rather to the serious complications that could arise.
An inflamed myocardium impairs the contraction of the heart and, with it, the blood circulation. All this is manifested by shortness of breath (both after exertion and at rest), a persistent sense of fatigue, chest pain and tachycardia .
If not treated properly, cardiac inflammation can cause permanent damage to the anatomical structures of the heart (see complications).
SYDENHAM KOREA
Sydenham's chorea is an inflammatory condition that affects the nervous system. It manifests itself principally with involuntary click movements and uncontrollable body contortions; secondly, it can cause a lack of balance, an inability to coordinate hand movements and sudden mood swings.
Sydenham's chorea appears, almost exclusively, in young patients (one in four cases) and, once rheumatic fever is exhausted, leaves no permanent brain damage.
Figure: the skin rash. The redness usually starts from the neck and spreads, then, over the whole trunk. From the site: www.iahealth.net
RASH CUTANEOUS
The skin rash, or rash, that accompanies rheumatic fever is also called marginal epithelium . It is a non-painful reddening of the skin, not itchy (that is it does not itch) and characterized by a jagged edge.
It is rare, as it affects one young patient every 10, and tends to run out and reappear spontaneously.
WHEN TO REFER TO THE DOCTOR?
The signals to keep under observation, because they could indicate that rheumatic fever is in progress, are:
- Severe throat inflammation (pharyngitis), without the classic symptoms of a cold
- Enlarged lymph nodes in the neck
- Appearance of skin rash, first between head and neck, then in the trunk
- Difficulty in swallowing due to pharyngitis
- Intense red tongue and small growths
- Fever between 38 ° C and 38.5 ° C
COMPLICATIONS
If not treated properly, rheumatic fever can cause permanent damage to the heart, specifically altering the heart valves . Heart valves regulate the flow of blood into and out of the heart and, clearly, their malfunction can alter blood circulation.
Most common cardiopathies caused by rheumatic fever:
- Valvular stenosis
- Aortic insufficiency or mitral insufficiency
- Damaged and weaker myocardium
- Atrial fibrillation
- Heart failure
Figure: the heart and its main anatomical structures. Cardiac complications often involve valves, all mitral and aortic.
THE RETURNS
Those who have already suffered from rheumatic fever are prone to relapses, especially if they are infected again by the bacterium Streptococcus Pyogenes .
Diagnosis
To establish the diagnosis of rheumatic fever, an objective examination of the patient, an accurate blood test and, finally, instrumental tests are required.
EXAMINATION OBJECTIVE
During the physical examination, the doctor asks the patient how the symptoms started and how long he has been hearing them. For example, knowing if an individual has spent time in a country where it is easier to get rheumatic fever can be very important.
Next, evaluate first hand the condition of large joints, the presence of fever and signs of Sydenham's chorea, heart rate and throat appearance.
BLOOD ANALYSIS
The blood of a patient with rheumatic fever has particular characteristics, which can be evidenced by certain tests.
So-called erythrocyte and C-reactive protein ( PCR ) sedimentation tests show whether inflammation is taking place in the body (high values) or not (normal values).
The antistreptolysinic titer, on the other hand, is a test that aims to investigate the presence of anti-streptococcal antibodies. If these are actually present, it means that there has been a bacterial infection in the recent past.
INSTRUMENTAL DIAGNOSTICS
The instrumental examinations consist of the electrocardiogram (ECG) and the echocardiogram .
The ECG measures the electrical activity of the heart, showing whether or not there are changes in the heart rate.
The echocardiogram, on the other hand, is an ultrasound, which provides detailed images of the main anatomical structures of the heart (valves, atria and ventricles).
In both cases, these are tests that are harmless to the patient, which the doctor advises to repeat periodically, because rheumatic fever heart problems do not appear immediately.
CRITERIA OF JONES
Below is a table with the so-called Jones criteria, useful for the doctor to determine whether or not it is rheumatic fever. The criteria are divided into major and minor: one speaks of rheumatic fever when the patient has at least two major criteria or two minor and at least one major criteria.
The major criteria
- Obvious cardiac abnormalities (chest pain, arrhythmia, shortness of breath, etc.)
- Severe pain and joint swelling
- Involuntary body movements (Sydenham Korea)
- Non-itchy and painless skin rash
- Subcutaneous nodules
The main minor criteria
- Medium-high fever
- Blood tests in favor of ongoing inflammation
- Slight joint pain
- Mild arrhythmia
Treatment
There is no specific cure for rheumatic fever; we must wait for it to heal spontaneously. However, there are therapeutic countermeasures that have the following objectives:
- Relieve symptoms and reduce the risk of permanent damage
- Completely remove the streptococcus from the body
- Protect against future bacterial infections
THE ANTI-INFLAMMATORS
Anti- inflammatories are administered to the patient to alleviate and moderate the symptoms of rheumatic fever: above all, pain and swelling in the large joints and inflammation of the myocardium.
The most frequently used drugs are: NSAIDs ( ibuprofen or naproxen ), aspirin and, in the most serious cases, prednisolone .
Aspirin and prednisolone require special care when taking it, as they can trigger serious side effects. The first, in young patients, can cause Reye's syndrome ; the second is a corticosteroid, a powerful anti-inflammatory capable of promoting osteoporosis, hypertension, increased body weight, etc.
ANTIBIOTICS
The antibiotics ( penicillin and derivatives) are taken by the patient to eliminate streptococcus altogether and to protect it from future bacterial infections (prophylaxis), which could cause the reappearance of rheumatic fever.
The best way to prevent a relapse is to have intravenous antibiotic injections every two or three weeks for several years.
THE ANTICONVULSIVERS
Anticonvulsants, such as valproic acid, are given to patients showing signs typical of Sydenham chorea.
To learn more: Medicines for the treatment of Rheumatic Fever »
THE REST
The doctor advises to stay at rest in order not to tire the patient and to shorten the healing time. It is indicated, in particular, if the individual with rheumatic fever suffers from serious heart problems.
Refraining from physical activity allows easier resolution of myocardial inflammation.
Prognosis and prevention
The prognosis related to rheumatic fever depends, in large part, on starting treatment.
If diagnosis and therapy are both timely, recovery is fast and, probably, uncomplicated.
Conversely, late diagnosis and therapy impair the healing path, as there is a greater risk of complications appearing and the patient is subject to relapses.
PREVENTION
To prevent the onset of rheumatic fever, it is very important to carefully treat group A streptococcal infections. With the necessary therapies, the risk of worsening the situation is minimal, especially in countries with state-of-the-art health measures.
As regards, instead, those who have already contracted rheumatic fever, the best recommendation is to undergo periodic checks and prophylaxis.
