Rheumatic Fever Symptoms, Clinical Signs, Evolution And Treatment
Rheumatic fever is an inflammatory rheumatic disease, which occurs as a result of pharyngeal infection with group A streptococcus and affects the entire body’s connective tissues, but especially the joints, heart and central nervous system. Although rheumatic fever damage highlights, as a rule, joint damage , rheumatic fever is so important by affecting the heart, which can be severe, even fatal, in the acute stage, or may lead to rheumatic heart disease characterized by scarring and deformation of the heart valves, with multiple clinical and hemodynamic consequences.
In developed countries the incidence of rheumatic fever has declined over the past decades, due to the prompt treatment of steptococcal pharyngitis. The most commonly affected age is between 5 and 15 years.
Rheumatic Fever Causes
Rheumatic fever is a disease caused by streptococcus group A, located exclusively in the pharynx. The relationship between this bacterium and rheumatic fever is based on multiple arguments.
- Demonstrating active streptococcal infection in the patient’s recent past (ASO growth and other antistreptococcal antibodies).
- Prevention of rheumatic fever and its relapses by prompt treatment of the streptococcal infection (primary and secondary prevention).
- Rheumatic fever occurs at a certain period of time after pharyngitis.
The mechanism by which streptococcal infection leads to rheumatic fever is still imcompletely known. Two hypotheses are probable: imnuo-allergic and autoimmune.
- Imnuo-allergic mechanism, which consists of a hypersensitivity reaction to one or more antigens (parts of microbes) or metabolites, argued by high ASO antibody titers.
- Autoimmunity. Certain streptococcal antigens cause a cross-immune reaction with the cardiac and vascular structures, due to antigenic similarity between some components of streptococcal membrane ( such as M protein) and several heart ”antigens” (like myosin). In simple terms some streptococcal components resemble the structure with that of human cell components (the body makes no difference, and immune system reacts against its own cells and attacks them)
Rheumatic Fever Risk Factors
- Environmental factors seem to be important in promoting streptococcal infection, such cold climates, high humidity climates and human congestion (schools, barracks, large families, urban communities) are conditions that favor transmission of strep throat.
- The genetic predisposition to react in a certain way, against streptococcal infection, which results in rheumatic fever.
Rheumatic Fever Signs And Symptoms
The disease progresses in stages in the attacks of 8-12 weeks, spontaneous self-limited. Prodromal stage, represented by erythematous angina, may be absent in 20-50% of cases. Latent stage of rheumatic fever covers the period of 1 to 5 weeks, from the occurrence of angina and the onset of rheumatic fever. It may be asymptomatic or have nonspecific symptoms: fever or low grade fever, joint pain, fatigue, poor appetite, sweating, palpitations, weight loss, epistaxis, abnormal behavior, and alterations in laboratory tests. State period characterized by various symptoms and signs, major (arthritis, carditis, chorea, subcutaneous nodules) and other minor signs.
Migratory arthritis is very common manifestation of rheumatic fever, present in over 75% of cases, and has the following characters:
- Three large joints simultaneously affected with, pain, swelling, functional limitation of movement, redness and local heat.
- Affects large joints of the limbs (knee, elbow, radio-carpal, shoulder, hip), but in general can affect any joint.
- Migratory character, appearing again at the same joint.
- Heals quickly without deformation after treatment with salicylates (eg aspirin) or corticosteroids (Methylprednisolone, Prednisone.
- Lasts for 1-3 weeks, and heals spontaneously within 4-5 weeks maximum.
The worst aspect of rheumatic fever is carditis, which is present in 40-60% of cases. In time, this complication occurs especially in the first two attacks, between 5th day and 15th after the onset of arthritis (arthritis rarely before).
The intensity of the manifestations of carditis varies from a fulminant evolution – fatal to a mild inflammation, inconspicuous, up to fulminant heart failure.
- Cardiomegaly (enlargement of the heart cavities) is caused by myocarditis – very common.
- Pericarditis (5-10% of cases) may be dry, manifested by friction and pain, or exudative.
- Heart failure is the worst manifestation of carditis, involving, in varying proportions, associating manifestations of endocarditis with those of myocarditis and pericarditis.
Syndeham chorea (chorea minor) is a neurological manifestation of rheumatic fever which occurs in less than 10% of cases at 2-7 months after the acute episode, when most or all clinical and biological manifestations of rheumatic fever have disappeared.
Rare clinical manifestations
- Rheumatic pneumonia, which is associated with severe carditis
- Pleurisy (4-5% of cases), with small amounts of liquid, corticosteroids will lead to healing without sequelae.
Overall symptoms of rheumatic fever
- Fever is always present, can occur suddenly or gradually (3-6 days), has a moderate intensity (up to 38 degrees Celsius), fades after salicylates (aspirin), intensity depends on the severity of carditis.
- Sweating is abundant, continuous, especially overnight.
- Pallor, more pronounced than the degree of anemia is caused by infection, anemia, neuro-vegetative disorders.
- Asthenia is very pronounced in the case of carditis
- Epistaxis (nosebleeds), rarely present in 10% of cases, can be discreet or abundant.
Rheumatic Fever Evolution And Prognosis
Rheumatic fever evolution is varied and difficult to apreciate at the onset of disease. Approximately 75% of rheumatic attacks resolve in 6 weeks, 90% in 12 weeks and persist for over 6 moths in less than 5% of the cases. The latter are cases of severe rheumatic carditis with rebel attacks or prolonged Sydenham chorea symptoms.
Once rheumatic fever is remitted and more than two months have passed after interrupting treatment with salicylates or cortisone, rheumatic fever symptoms do not occur again. Only the presence of a new streptococcal infection can trigger the onset of symptoms.
The prognosis depends entirely on carditis severity. During attacks, death can occur through severe myocarditis, or heart failure, and later due to valve damage. The main causes of death in adults are: heart failure, bacterial endocarditis, systemic and pulmonary embolism.
Rheumatic Fever Treatment
Although there is no specific treatment for rheumatic fever and there are no measures that may influence the intesity of an attack, treatment is mandatory.
- Bed rest and diet. Bed rest at the hospital, it is mandatory for all patients, at least for three weeks, during which carditis usually occurs. Duration must be greater for those with medium and severe carditis (2-6 months, depending on the evolution) . Limiting physical activity depends on the carditis severity. Resumption of normal activity is done after 3 months (mild carditis), 6 months (avreage severity carditis) and much later or never in case of severe carditis.
- Antibiotic treatment. Administration of antibiotics is one essential part of the conventional treatment of rheumatic fever and aims for the eradication of group A streptococcal throat infection. Penicillin is administrated, amoxicillin for children. If the patient is allergic to penicillin, erythromycin or second generation cephalosporins are recommended.
- Anti-inflammatory treatment (suppressive, anti-rheumatic). It represents the treatment of clinical manifestations, which aims to fight inflamation. It does not heal and does not prevent long-term evolution of rheumatic Fever. Generally, aspirin and corticosteroids (prednisone) are used to treat rheumatic fever
Prevention of rheumatic fever is represented by early and correct treatment of throat infection and prevention of further attacks.