Rheumatic Fever

All about Rheumatic Fever

1. What is Rheumatic fever?

Rheumatic fever is usually seen in children between 5 and 15 years where, after an episode of fever and sore throat, child again develops fever, joint pain and joint swellings along with heart disease. There is a strong relationship with the throat infection caused by the bacteria Streptococcus.

2. What kind of children develops rheumatic fever?

Both male and female children are equally affected. In India this disease is rarely seen in children below 5 years. This disease is common in children of poor socioeconomic condition leading to unhygienic and over crowded living conditions. In the above mentioned scenario, the streptococcal bacteria producing sore throat which lead on to rheumatic fever develop commonly and spreads from one child to the other. Along with this, poor nutrition decreases the child’s resistance power to infection. In India when the rate of rheumatic fever in children between 5 and 15 years is around 6 per 1000, in Kerala it is 2 per 1000. Rheumatic heart disease contributes to 40 – 50 % of cardiac patients in a hospital. In S.A.T. hospital, every year, around 100 children get admitted due to rheumatic fever.

3. How does sore throat predispose to rheumatic fever?

Not every child with streptococcal infection of the throat develops rheumatic fever. Some children are genetically susceptible. The antibodies (molecules produced by the body to counter the infection) produced against streptococcal bacteria unfortunately react with the heart muscle, joints and sometimes the nervous system resulting in the manifestations of rheumatic fever.

4. What is the clinical picture of rheumatic fever?

At the onset, please remember that all the manifestations of rheumatic fever may not be seen in a single patient. Diagnosis is often made with the help of certain clinical features and other laboratory investigations.
The main clinical features consist of heart disease, arthritis (inflammation of the joints), chorea (purposeless jerky movements), subcutaneous nodules (swelling seen beneath the skin) usually seen on bony prominences like elbows, shin, back of the head and spine which are non tender and a peculiar rash (erythema marginatum). The rash is faintly reddish, non-itching, which appear as a red spot or as serpigenious. But it is difficult to recognize the rash in Indian children due to the dark complexion of the skin.
Patients who have subcutaneous nodules almost always have heart disease. In India, these swellings are seen only about 5% of patients.

5. How does rheumatic fever affect the heart?
Rheumatic fever affects all the three layers of the heart (pericardium, myocardium and endocardium). It is seen in 50-75 % patients of acute rheumatic fever. Almost 80% of the patients who develop heart disease do so within the first two weeks of the onset of rheumatic fever. In pericarditis there is swelling of the pericardium covering the heart and fluid collection beneath the pericardium. Myocarditis leads to heart failure. In endocarditis, the heart valves are damaged and results in rheumatic valvular disease. Rheumatic valvular disease can be long lasting and it can even cause death of the patient.

6. What are the special features of joint pain due to rheumatic fever?
Knee joint, ankle joint and elbow joint are the commonly affected joints. Rarely smaller joints like joints in the fingers and toes are also involved. Because of the pain and swelling in the joint it is difficult to bend and straighten the joints. 50-70% of rheumatic fever patient’s joint problems are seen within the first few days itself.

7. What is this abnormal movement called Chorea?
Chorea is a late feature usually occurring 3 months after the onset of rheumatic fever. The affected child is emotionally disturbed and drops things he or she is carrying and also there is a deterioration of handwriting. This shivering spontaneously disappears in 6 weeks.

8. Is it necessary to do blood test, E.C.G., Echo test?
Yes. ASO, ESR and WBC Count are elevated. ECG and Echo test are necessary to find out the status of the heart.

9. What is the treatment of rheumatic fever?
Complete bed rest is advised for some period. If there is heart disease, restrict salt intake. Drugs like Penicillin, Aspirin and Steroid are used for the treatment

10. How can we prevent Rheumatic fever?
Do not ignore your child’s sore throat. Consult your doctor. Proper treatment of sore throat can go a long way in preventing the first attack of rheumatic fever. Once the child develop rheumatic fever penicillin treatment is a must because it prevents the development of heart disease due to rheumatic fever.

11. How long does the penicillin treatment to be continued?
(a) Rheumatic fever, no heart disease
Penicillin treatment for 5 years from last attack or 21 years which ever is later.
(b) Rheumatic fever, had heart disease but now there is no sequelae.
Penicillin treatment for 10 years or till 25 years for the child which ever is later.
(c) Rheumatic fever, rheumatic heart disease existing.
Penicillin preferably life long or at least till 40 years of age.

11. Does penicillin treatment has any side effect?
Penicillin injection some times produces pain and fever. So it is better to take injections on holidays. Rarely penicillin injections produce severe allergy and sudden death. But parents should understand that such allergy is very rare and if penicillin is not used, heart valves of the child will get severely damaged. So before every penicillin injection test dose is taken. But test dose may be negative and allergy can come on injection. So any allergy is noted and parent should be immediately reported to the doctor and it requires emergency treatment.
Tablets can substitute injections. Penicillin tablets 250 mg two times a day to be taken and to be continued irrespective of the age of the patient.

12. Is there a chance of infection to heart valves due to rheumatic fever?
Definitely yes. There is increased chance of infection to heart valves in those with rheumatic fever than those without it. Due to rheumatic fever, infection can occur to normal heart valves and those with heart disease at birth.

(1) What are the symptoms of infections to heart valves?
Prolonged fever, reduction in weight, body pain, joint pain, head ache etc. The efficiency of the heart decreases. Spleen enlargement, red spots appearing in the skin, bleeding inside the brain, pus inside the brain, paralysis of the body parts can occur.

(2) How does a heart valve get infected?
Usually after dental extraction or after dental surgical treatment, heart valves can get infected.

(3) Does this infection has treatment, if so, how long?
Yes. At least 6 weeks treatment is necessary.

13. How can we prevent this disease to heart valve?
Those with rheumatic heart disease should have their teeth very clean. Very good personal hygiene. Inform the dentist about your heart disease. And while treating dental problems, a good cover of antibiotic treatment is necessary to prevent infection to heart valves.

14. (1) How does this heart valvular damage occurs?
Mainly the mitral valve connecting the two left sided chambers of the heart and the aortic valve connecting the aorta with the left side of the heart are involved. These diseases are called mitral stenosis (constriction of valves), mitral regurgitation (enlargement of the valve ring producing leak of blood while the heart pumps), aortic stenosis, and aortic regurgitation respectively.

(2) What are the symptoms for the child if the heart valves are damaged?
In the beginning there need not be any symptoms. But once the disease progresses, child will develop tiredness, breathlessness, palpitation, difficulty in playing etc.

(3) What treatment to be done once heart valves are damaged?
Once rheumatic fever comes (even if there is no heart disease) penicillin treatment should be continued to prevent the recurrence of rheumatic fever. Recurrence of rheumatic fever causes severs heart valvular damage. Dental treatments should be done under antibiotic cover to prevent infections (infective endocarditis). If the heart function is poor, drugs like Digoxin is necessary and anemia (pallor) should be prevented.

(4) Is surgery is necessary for heart valvular damage?
Surgery may be necessary when there are symptoms like sever tiredness or breathlessness or when heart function decreases irrespective of treatment. Surgery is mainly Valvotomy or valve replacement. Balloon treatment for valve construction is now available and is cheaper nowadays.

(5) Can a child with heart valvular damage go to school and play?
A child with good heart function can go to school, play like any other child. But penicillin treatment to be continued.

(6) A Girl child had rheumatic fever— can she get married, get pregnant and deliver?
If there is no heart valvular damage, there is no problem for marriage or delivery, but penicillin to be continued. If heart valves are damage, special care should be taken during pregnancy and if there is no severe damage to valves, pregnancy can be continued. But delivery for such a lady should be in a hospital with all the facilities. Mitral stenosis can be corrected before pregnancy through surgery. So a lady can undergo surgery and then get pregnant. But somebody who has severe damage to heart valves, better not to get pregnant as during pregnancy or delivery heart disease can get worse or even death can occur.

15. Be Careful
If your child is having any symptoms of rheumatic fever, consult a doctor, take treatment. If you are careful, no need to get worried.

Strep throat a Major risk factor for Rheumatic Fever

Strep throat is very common among kids and teens. Symptoms of strep throat include fever, stomach pain, and red, swollen tonsils.
Strep throat usually requires treatment with antibiotics. With the proper medical care — along with plenty of rest and fluids — your child should be back to school and play within a few days.

How Strep Throat Spreads

Anybody can get strep throat, but it's most common in school-age kids and teens. These infections occur most often during the school year when big groups of kids and teens are in close quarters.
The bacteria that cause strep throat (group A streptococcus) tend to hang out in the nose and throat, so normal activities like sneezing, coughing, or shaking hands can easily spread infection from one person to another.
That's why it's so important to teach kids the importance of hand washing — good hygiene can lessen their chances of getting contagious diseases like strep throat.

Strep Throat vs. Sore Throat

Not all sore throats are strep throats. Most episodes of sore throat — which can be accompanied by a runny nose, cough, hoarseness, and red eyes — are caused by viruses and usually clear up on their own without medical treatment.
A child with strep throat will start to develop other symptoms within about 3 days, such as:

red and white patches in the throat
difficulty swallowing
tender or swollen glands (lymph nodes) in the neck
red and enlarged tonsils
headache
lower stomach pain
fever
general discomfort, uneasiness, or ill feeling
loss of appetite and nausea
rash

Diagnosis

If your child has a sore throat and other strep throat symptoms, call your doctor. The doctor will likely do a rapid strep test in the office, using a cotton swab to take a sample of the fluids at the back of the throat. The test only takes about 5 minutes.
If it's positive, your child has strep throat. If it's negative, the doctor will send a sample to a lab for a throat culture. The results are usually available within a few days.

Treatment

In most cases, doctors prescribe about 10 days of antibiotic medication to treat strep throat. Within about 24 hours after starting on antibiotics, your child will probably no longer have a fever and won't be contagious. By the second or third day after taking antibiotics, the other symptoms should start to go away, too.
Even if your child feels better, he or she should finish the antibiotics as prescribed. If your child stops taking antibiotics too soon, bacteria can remain in the throat and the symptoms can return.
If your child is not treated for strep throat, he or she is most infectious when the symptoms are the most severe but could remain contagious for up to 21 days. Lack of treatment — or not finishing the prescribed course of antibiotics — also could put your child at risk for other health problems, such as rheumatic fever (which can cause permanent damage to the heart), scarlet fever, blood infections, or kidney disease.
To prevent your sick child from spreading strep throat to others in your home, keep his or her eating utensils, dishes, and drinking glasses separate from those that everyone else is using. Wash them in hot, soapy water after each use. Also, make sure your child doesn't share food, drinks, napkins, handkerchiefs, or towels with other family members.
Make sure your child covers his or her mouth and nose during a sneeze or a cough to prevent passing infectious fluid droplets to someone else. Also, throw out your child's toothbrush after the antibiotic treatment has been started and he or she is no longer contagious, and make sure your child uses a new one.

Caring for Your Child

You can help your child feel better while battling strep throat. Provide plenty of liquids to prevent dehydration, such as water or ginger ale, especially if he or she has had a fever. Avoid orange juice, grapefruit juice, lemonade, or other acidic beverages that can irritate a sore throat. Warm liquids like soups, sweetened tea, or hot chocolate can be soothing.
As recovery progresses, talk to your doctor about when your child can return to school and other routine activities.

How to treat sore throats in your child ?

If your child or anyone in your family gets a sore throat:

Visit your doctor and ask for a throat swab
Have a throat swab done and check if it is a "strep" throat
Your doctor will either give:
- a course of penicillin tablets. These tablets must be started straight away and taken for ten days (even if the sore throat feels better after two to three days). Erythromycin will be given to people who are allergic to penicillin.
- or one injection of penicillin

All about Scarlet fever

Rheumatic fever can occur as a Complication of Scarlet fever

What causes scarlet fever?

Scarlet fever is due to a throat infection caused by a bacterium (germ) called streptococcus. There are various strains (types) of streptococcus. They cause various infections, and one strain causes scarlet fever.

What are the symptoms of scarlet fever?

Sore throat and fever (high temperature) are the typical first symptoms.
A bright red (scarlet) rash soon develops. This is caused by a toxin (poison) that is made by the streptococcal bacteria. The toxin gets into the blood from the infected throat. The rash starts as small red spots, usually on the neck and upper chest. It soon spreads to many other parts of the body. The face may become quite flushed. The rash blanches (goes white) if you press on it.
The tongue may become pale but coated with red spots ('strawberry tongue'). After a few days the whole tongue may look red.
Other common symptoms include: headaches, vomiting, being off food, and feeling generally unwell.

Most children will recover fully within a week or so, even without treatment. (However, it is best to have treatment - see below.) The sore throat and fever last a few days, and then usually ease. The rash lasts about six days, and then usually fades away. As the rash fades, some of the skin may peel, mainly on the hands and feet (a bit like after being sunburnt).

What is the treatment for scarlet fever?

Treatment is to speed recovery and to prevent possible complications.

Antibiotics. A 10 day course of penicillin is usually advised. Other antibiotics are advised if you are allergic to penicillin. Symptoms usually go in a few days, but it is important to finish the course of antibiotics. This makes sure all the bacteria are killed and reduces the chance of complications.
Other treatments aim to keep the child comfortable until the illness goes.
- Paracetamol (Calpol, Disprol, etc) reduces fever and eases aches and pains. Ibuprofen is an alternative.
- Keep the child cool. If the room is warm then take all their clothes off.
- Give lots of cool drinks. This helps lower the fever and prevent dehydration.

What are the possible complications of scarlet fever?

Complications are uncommon, but can be serious. They include the following.

Serious infection such as throat abscess, sinusitis, and spread of infection to the lungs which can cause pneumonia.
Late complications sometimes develop 2-3 weeks after the infection has gone. These are rheumatic fever (which can damage the heart) and kidney damage (glomerulonephritis). These are due to immune reactions in the kidneys, heart, joints and other organs following infection with streptococcal bacteria.

Treatment with antibiotics reduces the chance of complications. Complications now rarely occur.

Is scarlet fever infectious?

Yes. Coughing, sneezing, and breathing out the bacteria can pass it on to others. It takes 2-4 days to develop symptoms after being infected. Keep children with scarlet fever off school, and away from others, for five days after starting antibiotics.

In summary

Scarlet fever is an infectious illness.
Full recovery is usual.
Serious complications are now rare, probably due to antibiotic treatment.
Finish the full course of antibiotics, even if symptoms soon go.

What other Conditions or Diseases can Mimic Rheumatic Fever ?

Differential Diagnosis of Rheumatic fever

Arthritis consider:
- Rheumatoid arthritis (including Still's disease in children)
- Henoch-Schonlein purpura
- Reactive arthritis
- Erythema nodosum
Heart disease consider:
- Cardiomyopathy
- Kawasaki disease
- Infective endocarditis
Rash (erythema marginatum) consider:
- Drug reactions
- Lyme disease
Chorea consider:
- Drug reactions (especially in young people) to:
  metoclopramide, oral contraceptives, phenytoin, haloperidol or amitriptyline.
- Huntington's chorea. This does not usually present until at least 30 (peak age 35-45).
- Chorea gravidarum may occur in pregnancy.
- Wilson disease

Can my child develop rheumatic fever again after the first attack? ?

Yes, although the chances are reduced because of the use of prophylactic antibiotics after the initial disease process. The greatest chance of recurrence is during the first three years. The chance of developing the disease again decreases with age and time since the first attack.

After having rheumatic fever, your child will need prophylactic medications to help decrease the chance of developing rheumatic fever again.(Daily Oral penicillin or Long acting Penicillin injections every 3 weeks). The duration of prophylactic medications depend on the severity of initial attack and will be decided by your doctor.

Strep throat; a Major risk factor for Rheumatic Fever in Children

Strep throat is very common among kids and teens. Symptoms of strep throat include fever, stomach pain, and red, swollen tonsils.

Strep throat usually requires treatment with antibiotics. With the proper medical care — along with plenty of rest and fluids — your child should be back to school and play within a few days.

How Strep Throat Spreads

Anybody can get strep throat, but it's most common in school-age kids and teens. These infections occur most often during the school year when big groups of kids and teens are in close quarters.

The bacteria that cause strep throat (group A streptococcus) tend to hang out in the nose and throat, so normal activities like sneezing, coughing, or shaking hands can easily spread infection from one person to another.

That's why it's so important to teach kids the importance of hand washing — good hygiene can lessen their chances of getting contagious diseases like strep throat.

Strep Throat vs. Sore Throat

A child with strep throat will start to develop other symptoms within about 3 days, such as:

red and white patches in the throat
difficulty swallowing
tender or swollen glands (lymph nodes) in the neck
red and enlarged tonsils
headache
lower stomach pain
fever
general discomfort, uneasiness, or ill feeling
loss of appetite and nausea
rash

Diagnosis

If it's positive, your child has strep throat. If it's negative, the doctor will send a sample to a lab for a throat culture. The results are usually available within a few days.

Treatment

Even if your child feels better, he or she should finish the antibiotics as prescribed. If your child stops taking antibiotics too soon, bacteria can remain in the throat and the symptoms can return.

If your child is not treated for strep throat, he or she is most infectious when the symptoms are the most severe but could remain contagious for up to 21 days. Lack of treatment — or not finishing the prescribed course of antibiotics — also could put your child at risk for other health problems, such as rheumatic fever (which can cause permanent damage to the heart), scarlet fever, blood infections, or kidney disease.

To prevent your sick child from spreading strep throat to others in your home, keep his or her eating utensils, dishes, and drinking glasses separate from those that everyone else is using. Wash them in hot, soapy water after each use. Also, make sure your child doesn't share food, drinks, napkins, handkerchiefs, or towels with other family members.

Make sure your child covers his or her mouth and nose during a sneeze or a cough to prevent passing infectious fluid droplets to someone else. Also, throw out your child's toothbrush after the antibiotic treatment has been started and he or she is no longer contagious, and make sure your child uses a new one.

Caring for Your Child

As recovery progresses, talk to your doctor about when your child can return to school and other routine activities.

What is Rheumatic fever ?

1. What is Rheumatic fever?

3. How does sore throat predispose to rheumatic fever?
Not every child with streptococcal infection of the throat develops rheumatic fever. Some children are genetically susceptible. The antibodies (molecules produced by the body to counter the infection) produced against streptococcal bacteria unfortunately react with the heart muscle, joints and sometimes the nervous system resulting in the manifestations of rheumatic fever.

4. What is the clinical picture of rheumatic fever?
At the onset, please remember that all the manifestations of rheumatic fever may not be seen in a single patient. Diagnosis is often made with the help of certain clinical features and other laboratory investigations.
The main clinical features consist of heart disease, arthritis (inflammation of the joints), chorea (purposeless jerky movements), subcutaneous nodules (swelling seen beneath the skin) usually seen on bony prominences like elbows, shin, back of the head and spine which are non tender and a peculiar rash (erythema marginatum). The rash is faintly reddish, non-itching, which appear as a red spot or as serpigenious. But it is difficult to recognize the rash in Indian children due to the dark complexion of the skin.
Patients who have subcutaneous nodules almost always have heart disease. In India, these swellings are seen only about 5% of patients.

8. Is it necessary to do blood test, E.C.G., Echo test?
Yes. ASO, ESR and WBC Count are elevated. ECG and Echo test are necessary to find out the status of the heart.

(2) How does a heart valve get infected?
Usually after dental extraction or after dental surgical treatment, heart valves can get infected.

(3) Does this infection has treatment, if so, how long?
Yes. At least 6 weeks treatment is necessary.

(5) Can a child with heart valvular damage go to school and play?
A child with good heart function can go to school, play like any other child. But penicillin treatment to be continued.

15. Be Careful
If your child is having any symptoms of rheumatic fever, consult a doctor, take treatment. If you are careful, no need to get worried.

How will you treat Rheumatic Heart Disease?

Although having rheumatic fever leaves one more susceptible to heart damage, rheumatic fever does not always permanently damage the heart. However, when the inflammation caused by rheumatic fever leaves one or more of the heart valves scarred, the result is rheumatic heart disease. The mitral valve and the aortic valve are usually the ones damaged by the disease. Years later, the mitral valve may become narrowed, a condition known as mitral stenosis.

Treatment of acute rheumatic fever includes antibiotics to treat the strep infection and additional medications to ease the inflammation of the heart and other symptoms. Usually aspirin is given in large doses until the joint inflammation goes away; rarely steroids are needed. Once the acute illness has gone away, patients need to take penicillin, or an equivalent antibiotic, for many years to prevent recurrences. This is a very important treatment because the risk of heart valve damage increases if rheumatic fever recurs.

Treatment of rheumatic heart disease involves treating the damaged heart valves. Most often the valve leak caused by the disease is mild and does not need treatment. If the leak is severe enough to strain and enlarge the heart, surgery may be needed to eliminate the leak. This surgery may involve repair of the damaged valve. Sometimes the valve is too badly damaged to repair, in which case it must be replaced by an artificial valve.

How will you Diagnose Rheumatic Heart Disease?

The first step in diagnosing rheumatic heart disease is establishing that your child recently had a strep infection. The doctor may order a throat culture and/or a blood test to check for the presence of strep antibodies. However, it is likely that signs of the strep infection may be gone by the time you take your child to the doctor. In that case, the doctor will need you to try to remember if your child recently had a sore throat or other symptoms of a strep infection.

The doctor will do a physical examination and check your child for signs of rheumatic fever, including joint pain and inflammation. The doctor also will listen to your child's heart to check for abnormal rhythms or murmurs that may signify that the heart has been strained.

In addition, there are a couple of tests that may be used to check the heart and assess damage, including:

Chest X-ray -- This allows your child's doctor to check the size of the heart and to see if there is excess fluid in the heart or lungs.
Echocardiogram -- This test uses sound waves to measure the heart's size and shape and creates an image of the heart.

How can I prevent rheumatic heart disease?

The best defense against rheumatic heart disease is to prevent rheumatic fever from ever occurring. By treating strep throat with penicillin or other antibiotics, doctors can usually stop acute rheumatic fever from developing.

People who've already had rheumatic fever are more susceptible to attacks and heart damage. That's why they're given continuous monthly or daily antibiotic treatment, maybe for life. If their heart has been damaged by rheumatic fever, they're also at increased risk for developing bacterial endocarditis, an infection of the heart's lining or valves.

What are the symptoms of rheumatic heart disease?

Symptoms vary greatly. Often the damage to heart valves isn't immediately noticeable. A damaged heart valve either doesn't fully close or doesn't fully open.

Typically, symptoms of rheumatic fever appear about two weeks after the onset of an untreated strep throat infection. Apart from the sore throat caused by the strep infection, children have a fever and feel ill. Commonly, the child will have a very painful, swollen and red joint -- usually a large joint like a knee, ankle, elbow or shoulder -- that goes away after a day or two only to be replaced by the same findings in another joint. Short-lived skin rashes may occur, but are not common. Even if the heart is affected, it is usually not sever enough to cause symptoms, and occasionally the child may be short of breath.

Most cases of strep throat, including untreated infections, do not cause rheumatic fever. However, if rheumatic fever affects the heart valves, it can disrupt normal blood flow through the heart and cause damage to the heart.

Eventually, damaged heart valves can cause serious, even disabling, problems. These problems depend on how bad the damage is and which heart valve is affected. The most advanced condition is congestive heart failure. This is a heart disease in which the heart enlarges and can't pump out all its blood.

What is Rheumatic Heart Disease ?

Rheumatic fever is an inflammatory disease. It can affect many of the body's connective tissues — especially those of the heart, joints, brain or skin.Rheumatic heart disease is a condition in which the heart valves are damaged by rheumatic fever. Anyone can get acute rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic heart disease that results can last for life.