Rheumatic fever

Symptoms Of Rheumatic Fever 

Symptoms usually appear 1 to 5 weeks after a bacterial throat infection and they may vary among individuals. Common symptoms include:

• Sore throat

• Swollen, red tonsils

• Fever

• Joint and muscle pain particularly in the knees, and ankles

• Chest pain

• Shortness of breath

• Fatigue

• Small painless lumps under the skin

• Jerky, uncontrollable body movements (Sydenham chorea) — most often in the hands, feet, and face

In severe cases

• Large joints

• Heart failure

• Behavioral disturbance

Know the difference: Scarlet fever vs Rheumatic fever

Scarlet fever is characterized by a pink, bumpy rash, due to group A streptococci infection in the throat or skin and is usually treated with antibiotics. However, if scarlet fever isn't effectively treated, it might progress into rheumatic fever, a more serious condition.

Causes Of Rheumatic Fever

Rheumatic fever can stem from untreated throat or skin infections, mainly caused by group A Streptococcus bacteria, including strep throat, scarlet fever, and impetigo. 

The immune system, responding to the bacterial infection, may mistakenly attack healthy tissues, leading to inflammation and potential damage to the heart, joints, skin, and organs. If the antibodies attack your heart, they can cause your heart valves to swell, which can lead to scarring of the valve “doors” (called leaflets or cusps).

Certain risk factors can increase your likelihood of developing rheumatic fever, as discussed in the next section.

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Risk Factors For Rheumatic Fever

Rheumatic fever is now relatively rare in developed countries, thanks to the widespread use of antibiotics to treat streptococcal infections. The risk factors for  rheumatic fever include:

1. Strep throat infection

The primary risk factor for rheumatic fever is an untreated or inadequately treated streptococcal throat infection (strep throat). Certain strains of streptococcal bacteria, particularly Group A Streptococcus, are more likely to lead to rheumatic fever.

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2. Demographic factors

• Age 

• Gender

• Family history

Note: Rheumatic fever is most common in children between the ages of 5 and 15. Also, rheumatic fever is more common in females with a relative risk of 1.6 to 2.0 compared with males. 

3. Genetic predisposition

Both a person's vulnerability and the specific genetics of streptococcal bacteria play important roles in how these bacteria interact with the body, increasing the risk of infection.

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4. Environmental factors

• Low socioeconomic status

• Poor sanitation

• Crowded living conditions

• Limited access to healthcare

• Undernutrition

Diagnosis Of Rheumatic Fever

The revised Jones criteria serve as a guiding framework for rheumatic fever diagnosis, incorporating diverse clinical and laboratory findings. It includes:

Revised jones criteria

To make a diagnosis, there must be evidence of recent streptococcal infection (confirmed by throat culture or rapid strep test) along with the presence of two major criteria or one major criterion and two minor criteria. The major and minor criteria include:

Major criteria:

• Carditis (inflammation of the heart)

• Polyarthritis (inflammation of multiple joints)

• Chorea (involuntary movements)

• Erythema marginatum (a specific type of skin rash)

• Subcutaneous nodules (small, painless nodules under the skin)

Minor criteria:

• Fever

• Arthralgia (joint pain)

• Elevated acute phase reactants (such as elevated CRP or ESR)

• Prolonged PR interval on ECG

To make a diagnosis of rheumatic fever, there should be either:

1. Two major criteria, or

2. One major criterion and two minor criteria, along with evidence of recent streptococcal infection.

Other key aspects of the diagnostic process include:

1. Clinical evaluation

• Medical history: The doctor will review the patient's medical history, paying attention to recent or past episodes of streptococcal infection, especially strep throat.
  
  

• Physical examination: A thorough physical examination will be conducted to assess symptoms and look for signs of rheumatic fever.

2. Blood tests

• Inflammatory markers: Blood tests like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are commonly used to detect signs of inflammation in the body. Elevated levels of these markers may indicate ongoing inflammation.

• Antistreptolysin O (ASO) titer: This blood test measures the level of antibodies (specifically antistreptolysin O) produced in response to a recent streptococcal infection. Elevated levels may suggest a recent or ongoing strep infection.

3. Throat cultures

• Throat cultures may be performed to identify the presence of streptococcal bacteria. 

• However, it's important to note that the bacteria might no longer be present in the throat by the time symptoms of rheumatic fever develop. 

• This is why antibody tests, like the ASO titer, are often used.

4. Imaging tests

• Electrocardiogram (ECG or EKG): It helps identify abnormal heart rhythms (arrhythmias) and can indicate if there is any damage or enlargement of the heart.

• Echocardiogram: This test can reveal abnormalities in the heart's structure and function, including inflammation of the heart muscle (myocarditis) or damage to the heart valves. 

• Chest X-rays: These may be conducted to assess the extent of cardiac involvement or to rule out other conditions.

Prevention Of Rheumatic Fever

Preventing rheumatic fever primarily involves prompt and effective treatment of streptococcal infections (GAS infections), particularly strep throat. Here are some preventive tips:

1. Consider prophylactic antibiotics 

High-risk individuals are typically recommended monthly injections of penicillin to prevent rheumatic fever.

2. Do not take strep throat lightly

• Strep throat is typically treated with antibiotics (such as penicillin or amoxicillin). 

• Completing the full course of prescribed antibiotics is crucial to eliminate the bacteria.

3. Practice good hygiene

• Encourage regular handwashing to prevent the spread of infections

• Avoid sharing utensils, drinking glasses, or personal items that may harbor bacteria.

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4. Maintain a healthy lifestyle

Encourage a healthy lifestyle with a balanced diet and regular physical activity to promote overall well-being.

Foods to include

• Fish rich in omega-3 fatty acids

• Whole grains

• Fruits and vegetables

• Lean proteins

• Low-fat dairy

• Nuts and seeds

Foods to limit/ eliminate

• Processed foods

• Excessive salt

• Sugary beverages

• Saturated and trans fats

• Supplements that can help

• Omega-3 fish oil

• Vitamin D

• Calcium

• Magnesium

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5. Create awareness

Educate people, especially parents and caregivers, about the symptoms of strep throat and the importance of seeking medical attention.

Doctor To Visit

Suppose you've had rheumatic fever before and you think it's come back or you've had a bacterial throat infection recently and you develop symptoms of rheumatic fever. In that case, you can consult the following specialists:

• General Physician

• Pediatrician (in case of children)

• Cardiologists

• Rheumatologists

• Infectious disease specialist

A general physician can assist with rheumatic fever by providing early diagnosis, coordinating treatment plans, managing symptoms, and referring to the concerned specialists. 

A pediatrician plays a crucial role in the initial diagnosis and ongoing management as rheumatic fever often begins in childhood, 

A cardiologist treats and monitors cardiac complications related to rheumatic fever.

A rheumatologist is a specialist who focuses on autoimmune and inflammatory disorders, including rheumatic fever. They help manage the overall impact on the body.

An infectious disease specialist may be consulted to address the underlying infections.

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Treatment Of Rheumatic Fever

The treatment of rheumatic fever aims to address the infection, alleviate symptoms, manage inflammation, and prevent recurrence. The following approaches are commonly employed:

1. Medications

Antibiotics: These are the first choice to treat streptococcal throat infections. Penicillin is the most commonly used drug. It includes:

• Penicillin V (Phenoxymethylpenicillin) 
• Penicillin G (Benzylpenicillin) 

Anti-inflammatory drugs: Helps to reduce inflammation, fever, and pain. Commonly used medications include:

• Ibuprofen 
• Naproxen
• Aspirin 

Note: Do not administer aspirin to a child without specific instructions from a doctor. It is avoided in children due to the risk of Reye's syndrome (it is a rare but serious condition that causes swelling in the liver and brain, often linked to aspirin use in children recovering from viral infections).

Corticosteroids: Prescribed if the patient does not respond to initial anti-inflammatory medications or if there is inflammation of the heart. Prednisone is most commonly used.

Anti-seizure medications: These medicines are prescribed to manage severe involuntary movements associated with Sydenham chorea. Example include:

• Valproic Acid 
• Carbamazepine
• Haloperidol
• Risperidone
  
  

2. Long-term medication for heart support

• Drug options for managing heart failure may include using angiotensin-converting enzyme (ACE) inhibitors (like Lisinopril and Enalapril) and taking diuretics (like  Furosemide and Spironolactone).

• Depending on the severity, heart surgery may be required to repair or replace damaged valves.

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6. Supportive care

• Bed rest is often recommended during the acute phase of rheumatic fever, especially when the heart is involved.

• Adequate hydration is essential, and maintaining a balanced and healthy diet can support the recovery process.

Home Care For Rheumatic Fever

Home remedies should complement conventional treatments, and their effectiveness and safety may vary. Always consult a doctor before considering anything new. Some of the herbal supplements that can help alleviate symptoms include: 

1. Ginger (Adrak): Has anti-inflammatory and analgesic effects. It may help manage pain and inflammation associated with rheumatic fever.

How to use: Incorporate ginger into your diet through ginger tea or add it to your meals like curry or stir-fry.

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2. Garlic (Lehsun): It is known for its anti-inflammatory properties and is a natural source of quercetin, an antihistamine.

How to use: Consuming raw or crushed garlic a month or two before hay fever season may help reduce symptoms. 

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3. Turmeric (Haldi): Contains curcumin, known for its anti-inflammatory properties. It may help reduce inflammation and alleviate symptoms. 

How to use: It can be consumed by adding it to warm milk or incorporating it into your meals. 

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4. Willow bark: Contains salicin, a compound similar to aspirin, which may help with pain relief and inflammation. 

How to use: It can be used in capsule form, following recommended dosages.

Note: Avoid if you have allergies to aspirin or are taking blood-thinning medications, and consult with a doctor.

5. Green tea: Rich in antioxidants, green tea may have anti-inflammatory properties that could potentially be beneficial.

How to use: Enjoy as a beverage or take green tea extract supplements.

6. Cinnamon (Dalchini): It has anti-inflammatory properties, and may offer mild relief in managing symptoms of rheumatic fever.

How to use: Sprinkle on foods like oatmeal, yogurt, or tea for flavor and potential health benefits.

Remember!

Prioritize ample rest, hydration, and a balanced diet with prescribed pain relievers for recovery. 

Complications Of Rheumatic Fever

Rheumatic fever can lead to several complications, particularly if the initial streptococcal infection is not promptly treated. Some of the complications include:

• Rheumatic heart disease (RHD): It is a severe complication that can result in permanent damage to the heart valves, leading to long-term heart problems.

• Heart valve damage: Rheumatic fever often targets heart valves, causing inflammation and scarring that may lead to valve stenosis (narrowing) or regurgitation (leaking).

• Heart failure: Severe damage to heart valves can eventually lead to heart failure, where the heart is unable to pump blood effectively.

• Atrial fibrillation: Irregular heart rhythms, such as atrial fibrillation, can occur due to the impact of rheumatic heart disease on the heart's electrical system.

• Pulmonary hypertension: Elevated blood pressure in the main arteries of the heart, is commonly associated with advanced rheumatic heart disease.

• Embolic stroke: It can be a complication of rheumatic fever, arising from the migration of blood clots or debris formed due to heart valve damage to the brain's blood vessels.

• Jaccoud arthropathy (joint problems): This causes joint deformities due to recurrent bouts of arthritis. It may result in long-term joint damage and deformities due to repeated arthritis episodes. 

• Subcutaneous skin lesions: Erythema marginatum, a rash with characteristic borders, may appear on the trunk or arms.

• Increased susceptibility: Greater vulnerability to recurrent episodes of rheumatic fever if exposed to streptococcal infections.

• Sydenham's chorea: A neurological complication characterized by involuntary movements and muscle weakness.
  
  

• Sudden cardiac death: It is the abrupt, unexpected loss of heart function, typically caused by an electrical disturbance in the heart.

Misconception: Rheumatic fever causes rheumatoid arthritis.

Reality: There's no direct link between rheumatic fever and rheumatoid arthritis. Although they may exhibit similar early symptoms and affect joints in children, rheumatic fever is a short-term condition lasting a few weeks, while rheumatoid arthritis is a lifelong disorder. 

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Alternative Therapies For Rheumatic Fever

Complementary and alternative medicine (CAM) therapies may be considered for supportive care in rheumatic fever, it is important to take medical advice before starting them. Here are some complementary measures that may be considered:

1. Acupuncture

Acupuncture involves the insertion of thin needles into specific points on the body to promote balance and alleviate symptoms. It may help manage pain and inflammation.

2. Biofeedback

Biofeedback is a technique that teaches individuals to control physiological processes such as heart rate and muscle tension. It may contribute to stress management and symptom relief.

3. Mind-body techniques

Practices such as meditation, relaxation exercises, and yoga may help manage stress and promote emotional well-being.

4. Massage therapy

Massage may relieve muscle and joint discomfort, but it should be done with caution and under the guidance of a knowledgeable therapist.

Living With Rheumatic Fever

Managing rheumatic fever is an ongoing challenge, as exposure to streptococcal bacteria can trigger flare-ups. Managing an ongoing condition can induce stress, affecting overall well-being, and affecting the quality of life, especially in children. 

Coping strategies that can help

• Seek professional guidance for tailored treatment and emotional support

• Collaborate with schools to address attendance and academic challenges

• Strictly adhere to prescribed medications for effective management

• Adapt daily activities to accommodate physical limitations

• Foster a resilient and supportive environment to mitigate the impact of rheumatic fever on a child's overall well-being.

Tips to manage rheumatic fever in children

• Identify streptococcal triggers

• Encourage good hygiene practices

• Plan activities to avoid exposure to streptococcal infections

• Monitor for symptoms and seek medical attention promptly

• Consider prophylactic antibiotics as advised by the doctor.

Things to know about dental visits after rheumatic fever

• Always inform any doctor, including dentists, about your child's history of rheumatic fever.

• Ensure your child receives extra antibiotics before dental procedures to protect their heart valves

• Obtain a rheumatic fever wallet card from your doctor and share it with dentists or doctors before treatment

• Be cautious as dental work may introduce mouth bacteria to the bloodstream, potentially causing endocarditis (inflammation of the inner lining of the heart's chambers ) in the heart valves.

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