Side effects of rheumatic fever: Rash, Symptoms, Treatment, What Is It

24.05.198008.12.2021 by alexxlab

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Rash, Symptoms, Treatment, What Is It

Overview

What is rheumatic fever?

Rheumatic fever is an autoimmune disease that inflames the body’s tissues, such as the joints and heart. Healthcare providers may also call it acute rheumatic fever. It happens when the body’s immune system overreacts to a strep throat or scarlet fever infection that hasn’t been fully treated.

Rheumatic fever causes your body’s immune system to attack its own tissues, causing inflammation (swelling). Rheumatic fever may affect the joints, heart or blood vessels.

Are rheumatic fever and scarlet fever the same thing?

No. Scarlet fever and strep throat are infections caused by group A Streptococcus bacteria. Scarlet fever and strep throat are common group A Streptococcus infections. Healthcare providers treat them with antibiotics.

Rheumatic fever is a very rare complication of scarlet fever and strep throat. It can happen when one of these infections goes untreated.

How common is rheumatic fever

While strep infections are common in the U.S., rheumatic fever is not. Because antibiotics are widely available in the U.S., most people get treatment for strep throat and scarlet fever. Clearing up these conditions prevents rheumatic fever.

Rheumatic fever happens more often in places with limited resources, such as resource-poor countries. But it can occur in the U.S., especially in areas with limited access to medical care.

Symptoms and Causes

What causes rheumatic fever?

Rheumatic fever is an overreaction of your body’s immune system that causes it to fight healthy tissues. An untreated strep throat or scarlet fever infection can trigger this overreaction. It happens when group A streptococcus infections are not adequately treated with antibiotics.

When your body’s defenses (antibodies) begin to fight back, the reaction can damage healthy tissues and organs instead of the bacteria.

Who gets rheumatic fever?

Anyone can get rheumatic fever. But it mostly affects young children and teenagers (ages 5 to 15). When people get rheumatic fever, it usually develops two to three weeks after an untreated strep throat or scarlet fever. Acute rheumatic fever generally does not occur in young children (less than 5y) and those older than 15 years.

How often does strep throat or scarlet fever cause rheumatic fever?

Most people who get strep throat or scarlet fever don’t develop rheumatic fever. It only happens when these conditions don’t get treated as they should. Even then, rheumatic fever is exceedingly rare in the U.S.

Who’s at risk for rheumatic fever?

Certain factors can increase your risk of getting rheumatic fever:

Where you live: Most people with rheumatic fever live in places that have limited medical resources, such as resource-poor countries. Living in an area where it’s difficult to get medication or medical care may also put you at risk.
Age: Rheumatic fever mostly affects children or teenagers between 5 and 15.
Overall health: Having a weakened immune system can increase your risk. Children who frequently get strep infections may be more likely to get rheumatic fever.
Family history: If someone in your family has had rheumatic fever, other family members may be more likely to get it.
Crowded areas: Bacteria spread more easily in places where large groups gather.

Can adults get rheumatic fever?

It’s very rare, but adults can also get rheumatic fever.

Is rheumatic fever contagious?

Rheumatic fever is not contagious. You can’t give it to or get it from someone else. But strep throat and scarlet fever are contagious. These infections spread through respiratory droplets (by coughing or sneezing on someone else).

What are the symptoms of rheumatic fever?

Rheumatic fever (and bacterial infections in general) can affect people in different ways. Sometimes, people experience such mild strep symptoms that they don’t realize they had a strep infection until rheumatic fever develops later on.

Rheumatic fever symptoms look similar to many other health issues. Most of these other problems are routine and not dangerous. Symptoms can vary widely, depending on what part of the body the disease impacts.

Because rheumatic fever can be serious, always call your provider if you suspect you or your child may have this condition. Common rheumatic fever symptoms include:

Swollen, tender and red joints, especially the large joints such as the knees, ankles and elbows
Chest pain or abnormal heartbeat.
Feeling overly tired all the time (fatigue).
Fever, especially one over 100.4 degrees Fahrenheit.
Flat, red rash with a jagged edge.
Unexplained or ongoing headaches, especially if your child has never complained of head pain before.
Jerky movements you can’t control in your hands, feet or other body parts.
Muscle aches or painful, tender joints.
Small bumps under the skin.
Swollen, red tonsils.

Diagnosis and Tests

How is rheumatic fever diagnosed?

If you or your child has a sore throat for more than a couple of days, reach out to your healthcare provider. Treating a group A Streptococcal infection can prevent rheumatic fever.

If your provider suspects rheumatic fever, they will first swab your throat to check for group A streptococcus bacteria. They may use a rapid strep test or order a throat culture.

A rapid strep test can provide results within 10 minutes. A throat culture takes a few days to get results. However, rapid step tests sometimes give false-negative results (saying you don’t have strep when you really do).

Depending on your symptoms, your healthcare provider may also order:

Blood tests: Sometimes, providers order a blood test to confirm a strep infection. Blood tests can detect antibodies (your body’s defenses against the bacteria) when the bacteria no longer show up on tests. Other blood tests check for substances (like proteins) that show inflammation in the body.
Heart tests: Heart tests, such as an electrocardiogram (EKG) or an echocardiogram (Ultrasound of the heart), help providers check your heart function.

Management and Treatment

How is rheumatic fever treated?

Rheumatic fever treatments first focus on getting rid of the bacterial infection. Treatments then address inflammation inside the body.

Rheumatic fever treatments include:

Antibiotics: Healthcare providers prescribe antibiotics to treat the underlying bacterial infection. Some antibiotics are one injection (shot). Others you take by mouth for a week or more.
Anti-inflammatory medications: Your provider will likely recommend a medication, such as aspirin, to reduce inflammation (swelling) throughout the body. This medication may also relieve symptoms, such as joint pain. For severe symptoms, your provider may prescribe a stronger medication (corticosteroids) to fight inflammation.
Other therapies: Rheumatic fever can affect people in different ways. Your provider may recommend other treatments based on how the condition affects you. In severe cases, you may need heart surgery or joint treatments to treat serious complications.

Prevention

How can I prevent rheumatic fever?

Treating strep throat and scarlet fever early is essential. It can prevent rheumatic fever. Strep throat and scarlet fever symptoms aren’t always obvious or easy to spot. Call your healthcare provider for guidance if your child has a sore throat for more than three days or has other symptoms that concern you.

If your child has strep throat or scarlet fever, make sure you follow your provider’s instructions carefully. Your child needs to finish the full course of antibiotics, even if they feel better. Otherwise, the infection may not go away and make you more prone to rheumatic fever.

What else can I do to protect against rheumatic fever?

Practicing good hygiene can reduce your chances of getting a bacterial infection. It can also stop you from spreading an infection to someone else. You should always:

Wash your hands often (and well) with soap and water.
Cough or sneeze into a tissue, your elbow or upper shoulder (not your hand).
Use a tissue once for a sneeze or to blow your nose, then throw it away and wash your hands.

If you have been diagnosed with rheumatic fever, your physician may prescribe a long term antibiotic (monthly injections of penicillin) to prevent future bouts of strep throat and to prevent recurrences of rheumatic fever.

Outlook / Prognosis

What’s the outlook for people with rheumatic fever?

Rheumatic fever doesn’t have a cure, but treatments can manage the condition. Getting a precise diagnosis soon after symptoms show up can prevent the disease from causing permanent damage. Severe complications are rare. When they occur, they may affect the heart, joints, nervous system or skin.

Rheumatic disease can come back or become a serious problem. In some cases, rheumatic fever can lead to serious or even life-threatening complications. Your child may need regular checkups to protect their health long-term.

How does rheumatic fever affect the heart?

Rheumatic fever doesn’t always affect the heart. But when it does, it can damage heart tissues, especially the heart valves. Scarred heart tissue doesn’t work correctly. Over time, rheumatic fever may lead to permanent heart damage. Providers may call this condition rheumatic heart disease or congestive heart failure.

If rheumatic fever injures a heart valve, your provider may recommend surgery to repair or replace the affected valve. Heart damage may show up 10 to 20 years after a rheumatic fever diagnosis. It’s important to stay in regular contact with a healthcare provider you trust for the rest of your life.

Living With

Can rheumatic fever come back?

Yes. You can get rheumatic fever again if you get strep throat or scarlet fever again later. If you’ve had rheumatic fever, your provider may recommend you take antibiotics for years or possibly throughout your life. This treatment is called antibiotic prophylaxis. It can prevent another strep infection and keep rheumatic fever from coming back.

What should I ask my healthcare provider?

If you or your child has rheumatic fever, you may want to ask your provider:

What antibiotic do you recommend?
How long does my child need to take this medication?
Will my child need to take antibiotics long-term?
Will my child need other tests, now or in the future?
How could rheumatic fever affect my child, now or in the future?
Are there any activities that could pose a danger to my child’s health?
What type of medical care will my child need moving forward?
What can I do to best protect my child’s health?

When should I call the doctor?

If you suspect your child may have strep throat or scarlet fever, don’t wait to call your provider. Early treatment can prevent rheumatic fever.

Common signs of these bacterial infections include:

Sore throat that lasts more than three days.
Lack of appetite (especially if due to problems swallowing).
Swollen lymph nodes on the neck.
Red rash.
Fever.
Swollen, red, or spotted tonsils (glands in the back of the mouth).
Headache.

A note from Cleveland Clinic

Rheumatic fever is a rare complication. It can happen when treatments don’t eliminate strep throat or scarlet fever. It most commonly affects young children and teens. In severe cases, it can lead to serious health problems that affect the heart, joints or other organs. You can prevent rheumatic fever by seeing your provider right away if you suspect one of these common bacterial infections. People with rheumatic fever often need lifelong medical care to protect their health.

Rash, Symptoms, Treatment, What Is It

Overview

What is rheumatic fever?

Rheumatic fever causes your body’s immune system to attack its own tissues, causing inflammation (swelling). Rheumatic fever may affect the joints, heart or blood vessels.

Are rheumatic fever and scarlet fever the same thing?

Rheumatic fever is a very rare complication of scarlet fever and strep throat. It can happen when one of these infections goes untreated.

How common is rheumatic fever

While strep infections are common in the U.S., rheumatic fever is not. Because antibiotics are widely available in the U. S., most people get treatment for strep throat and scarlet fever. Clearing up these conditions prevents rheumatic fever.

Rheumatic fever happens more often in places with limited resources, such as resource-poor countries. But it can occur in the U.S., especially in areas with limited access to medical care.

Symptoms and Causes

What causes rheumatic fever?

When your body’s defenses (antibodies) begin to fight back, the reaction can damage healthy tissues and organs instead of the bacteria.

Who gets rheumatic fever?

How often does strep throat or scarlet fever cause rheumatic fever?

Who’s at risk for rheumatic fever?

Certain factors can increase your risk of getting rheumatic fever:

Where you live: Most people with rheumatic fever live in places that have limited medical resources, such as resource-poor countries. Living in an area where it’s difficult to get medication or medical care may also put you at risk.
Age: Rheumatic fever mostly affects children or teenagers between 5 and 15.
Overall health: Having a weakened immune system can increase your risk. Children who frequently get strep infections may be more likely to get rheumatic fever.
Family history: If someone in your family has had rheumatic fever, other family members may be more likely to get it.
Crowded areas: Bacteria spread more easily in places where large groups gather.

Can adults get rheumatic fever?

It’s very rare, but adults can also get rheumatic fever.

Is rheumatic fever contagious?

What are the symptoms of rheumatic fever?

Because rheumatic fever can be serious, always call your provider if you suspect you or your child may have this condition. Common rheumatic fever symptoms include:

Swollen, tender and red joints, especially the large joints such as the knees, ankles and elbows
Chest pain or abnormal heartbeat.
Feeling overly tired all the time (fatigue).
Fever, especially one over 100.4 degrees Fahrenheit.
Flat, red rash with a jagged edge.
Unexplained or ongoing headaches, especially if your child has never complained of head pain before.
Jerky movements you can’t control in your hands, feet or other body parts.
Muscle aches or painful, tender joints.
Small bumps under the skin.
Swollen, red tonsils.

Diagnosis and Tests

How is rheumatic fever diagnosed?

If you or your child has a sore throat for more than a couple of days, reach out to your healthcare provider. Treating a group A Streptococcal infection can prevent rheumatic fever.

If your provider suspects rheumatic fever, they will first swab your throat to check for group A streptococcus bacteria. They may use a rapid strep test or order a throat culture.

Depending on your symptoms, your healthcare provider may also order:

Blood tests: Sometimes, providers order a blood test to confirm a strep infection. Blood tests can detect antibodies (your body’s defenses against the bacteria) when the bacteria no longer show up on tests. Other blood tests check for substances (like proteins) that show inflammation in the body.
Heart tests: Heart tests, such as an electrocardiogram (EKG) or an echocardiogram (Ultrasound of the heart), help providers check your heart function.

Management and Treatment

How is rheumatic fever treated?

Rheumatic fever treatments first focus on getting rid of the bacterial infection. Treatments then address inflammation inside the body.

Rheumatic fever treatments include:

Antibiotics: Healthcare providers prescribe antibiotics to treat the underlying bacterial infection. Some antibiotics are one injection (shot). Others you take by mouth for a week or more.
Anti-inflammatory medications: Your provider will likely recommend a medication, such as aspirin, to reduce inflammation (swelling) throughout the body. This medication may also relieve symptoms, such as joint pain. For severe symptoms, your provider may prescribe a stronger medication (corticosteroids) to fight inflammation.
Other therapies: Rheumatic fever can affect people in different ways. Your provider may recommend other treatments based on how the condition affects you. In severe cases, you may need heart surgery or joint treatments to treat serious complications.

Prevention

How can I prevent rheumatic fever?

What else can I do to protect against rheumatic fever?

Practicing good hygiene can reduce your chances of getting a bacterial infection. It can also stop you from spreading an infection to someone else. You should always:

Wash your hands often (and well) with soap and water.
Cough or sneeze into a tissue, your elbow or upper shoulder (not your hand).
Use a tissue once for a sneeze or to blow your nose, then throw it away and wash your hands.

Outlook / Prognosis

What’s the outlook for people with rheumatic fever?

How does rheumatic fever affect the heart?

Living With

Can rheumatic fever come back?

What should I ask my healthcare provider?

If you or your child has rheumatic fever, you may want to ask your provider:

What antibiotic do you recommend?
How long does my child need to take this medication?
Will my child need to take antibiotics long-term?
Will my child need other tests, now or in the future?
How could rheumatic fever affect my child, now or in the future?
Are there any activities that could pose a danger to my child’s health?
What type of medical care will my child need moving forward?
What can I do to best protect my child’s health?

When should I call the doctor?

If you suspect your child may have strep throat or scarlet fever, don’t wait to call your provider. Early treatment can prevent rheumatic fever.

Common signs of these bacterial infections include:

Sore throat that lasts more than three days.
Lack of appetite (especially if due to problems swallowing).
Swollen lymph nodes on the neck.
Red rash.
Fever.
Swollen, red, or spotted tonsils (glands in the back of the mouth).
Headache.

A note from Cleveland Clinic

What is Rheumatic Fever? What Causes This Strep Throat Complication?

What Is Rheumatic Fever?

A rare but potentially life-threatening disease, rheumatic fever is a complication of untreated strep throat caused by bacteria called group A streptococcus. The main symptoms — fever, muscle aches, swollen and painful joints, and in some cases, a red, lattice-like rash — typically begin two to four weeks after a bout of strep. In some cases, though, the infection may have been too mild to have been recognized.

The knees, ankles, elbows, and wrists are the joints most likely to become swollen from rheumatic fever. The pain often migrates from one joint to another. However, the greatest danger from the disease is the damage it can do to the heart. In more than half of all cases, rheumatic fever scars the valves of the heart, forcing this vital organ to work harder to pump blood. Over a period of months or even years — particularly if the disease strikes again — this damage to the heart can lead to a serious condition known as rheumatic heart disease, which can eventually cause the heart to fail.

Rheumatic fever can also cause a temporary nervous system disorder once known as St. Vitus’ dance, now known as Sydenham’s chorea. This is a nervous disorder — characterized by rapid, jerky, involuntary movements of the body, usually occurring more on one side of the body. People with mild cases of chorea may find it difficult to concentrate or write. More severe cases can cause the muscles of the arms, legs, or face to twitch uncontrollably. It can also be associated with muscle weakness and emotional outbursts.

Because of antibiotics, rheumatic fever is now rare in developed countries. In recent years, though, it has begun to make a comeback in the U.S., particularly among children living in poor, inner-city neighborhoods. The disease tends to strike most often in cool, damp weather during the winter and early spring. In the U.S., it is most common in the northern states.

What Causes Rheumatic Fever?

Rheumatic fever results from an inflammatory reaction to certain group A streptococcus bacteria. The body produces antibodies to fight the bacteria, but instead the antibodies attack a different target: the body’s own tissues. The antibodies begin with the joints and often move on to the heart and surrounding tissues. Because only a small fraction (fewer than 0. 3%) of people with strep throat ever contract rheumatic fever, medical experts say that other factors, such as a weakened immune system, must also be involved in the development of the disease.

CAUTION! Monitor That Sore Throat

Pay attention to sore throats, especially in children. If your child has a severe sore throat without other cold symptoms, accompanied by a fever higher than 100.4 degrees Fahrenheit, or a milder sore throat that persists for more than two or three days, see a doctor. It may be strep throat, which should be treated with antibiotics.

Rheumatic Fever – Children’s Health Issues

Sometimes corticosteroids

Treatment of rheumatic fever has three goals:

Eliminating any remaining streptococcal infection
Reducing inflammation, particularly in the joints and heart, and thus relieving symptoms
Preventing future infections

Doctors give children with rheumatic fever antibiotics to eliminate any remaining infection. A long-acting penicillin is given as a single injection or penicillin or amoxicillin is given by mouth for 10 days.

Aspirin is given in high doses for several weeks to reduce inflammation and pain, particularly if inflammation has reached the joints and heart.

Some other nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, may be as effective as aspirin, but, in most children, aspirin is preferred for the treatment of rheumatic fever.

If heart inflammation is severe, corticosteroids such as prednisone are recommended in addition to aspirin and may be given by vein (intravenously) or by mouth to further reduce inflammation.

Children should limit their activities if they have joint pain, chorea, or heart failure. Children who do not have inflammation of the heart do not need to limit their activities after the illness subsides. Prolonged bed rest is not helpful.

The best way to prevent rheumatic fever is with prompt and complete antibiotic treatment of any streptococcal throat infection.

In addition, children who have had rheumatic fever should be given drugs (typically penicillin) by mouth every day or by monthly injections into the muscle to help prevent another streptococcal infection. When antibiotics are given to people who do not yet have an infection, this preventive treatment is called prophylaxis. How long this preventive treatment should be continued is unclear. It depends on the severity of the disease and is usually continued for at least 5 years or until age 21 (whichever is longer). Some doctors recommend that it should be continued for life in certain people, such as those who have lasting heart valve damage and have close contact with young children (because the children may carry streptococcal bacteria, which could reinfect such people).

Rheumatic Heart Disease

What is rheumatic heart disease?

Rheumatic heart disease starts as a sore throat from a bacterium called Streptococcus pyogenes (group A streptococcus) which can pass easily from person to person in the same way as other upper respiratory tract infections. Strep infections are most common in childhood.

In some people, repeated strep infections cause the immune system to react against the tissues of the body including inflaming and scarring the heart valves. This is what is referred to as rheumatic fever. Rheumatic heart disease results then from the inflammation and scarring of heart valves caused by rheumatic fever.

Who is at risk?

Rheumatic fever mostly affects children and adolescents in low- and middle-income countries, especially where poverty is widespread and access to health services is limited. People who live in overcrowded and poor conditions are at greatest risk of developing the disease.

Where rheumatic fever and rheumatic heart disease are endemic, rheumatic heart disease is the principal heart disease seen in pregnant women, causing significant maternal and perinatal morbidity and mortality. Pregnant women with rheumatic heart disease are at risk of adverse outcomes, including heart arrythmias and heart failure due to increased blood volume putting more pressure on the heart valves. It is not uncommon for women to be unaware that they have rheumatic heart disease until pregnancy.

Despite it being eradicated in many parts of the world, the disease remains prevalent in sub-Saharan Africa, the Middle East, Central and South Asia, the South Pacific, and among immigrants and older adults in high-income countries, especially in indigenous peoples.

What are the signs and symptoms?

Rheumatic fever symptoms can include:

fever

painful joints especially knees ankles, elbows and wrists

pain that moves between different joints

fatigue

jerky uncontrollable body movements called ‘chorea’

painless nodules under the skin near joints and/or a rash consisting of pink rings with a clear centre (both rare)

heart murmur

Symptoms of heart valve damage that is associated with rheumatic heart disease may include:

chest pain or discomfort

shortness of breath

swelling of the stomach, hands or feet

fatigue

rapid or irregular heart beat

How is rheumatic heart disease treated?

There is no cure for rheumatic heart disease and the damage to the heart valves are permanent. Patients with severe rheumatic heart disease will often require surgery to replace or repair the damages valve or valves. Depending on the severity of disease, medication may also be needed to treat symptoms of heart failure or heart rhythm abnormalities. Medications which thin the blood to reduce the risk of blood clots may also be needed. In the case of serious disease surgery may be required to repair or replace the heart valves. This is often not available in low-income settings, or when it is available the costs may be too high if not covered as part of national health plans, putting families under increased financial strain.

Rheumatic heart disease is preventable.

Since rheumatic heart disease results from rheumatic fever, an important strategy is to prevent rheumatic fever from occurring. Treatment of strep throat with appropriate antibiotics will prevent rheumatic fever.

Once a patient has been identified as having had rheumatic fever, it is important to prevent additional streptococcal infections as this could cause a further episode of rheumatic fever and additional damage to the heart valves. The strategy to prevent additional streptococcal infection is to treat the patient with antibiotics over a long period of time. The antibiotic treatment that is most effective in preventing further infection is benzathine penicillin G, which is given by intramuscular injection every 3-4 weeks over many years.

For countries where rheumatic heart disease is endemic, the main strategies for prevention, control and elimination include: improving standards of living; expanding access to appropriate care; ensuring a consistent supply of quality-assured antibiotics for primary and secondary prevention; and planning, developing and implementing feasible programmes for prevention and control of rheumatic heart disease, supported by adequate monitoring and surveillance, as an integrated component of national health systems responses.

Challenges

Rheumatic heart disease can be prevented by effective management of streptococcal sore throat, however treatment at this early stage is often not achieved. Families may not have the time or money to access a healthcare facility, or may not seek care due to low awareness of the potential risk of untreated ‘strep throat’. Healthcare workers may also not have the necessary knowledge to appropriately diagnose and manage a ‘strep throat’. If left untreated, rheumatic fever may then ensue.

Currently a large proportion of those suffering rheumatic heart disease are not diagnosed, or are diagnosed at a late stage when damage to the heart is very severe. Rheumatic heart disease remains the leading cause of maternal cardiac complications in pregnancy. In many rheumatic heart disease-endemic countries there is little or no access to life-saving heart valve surgery. Measures to halt the progression to severe rheumatic heart disease require long-term treatments and a well-functioning health system to deliver this service. Additionally, because treatment is long-term, it can be costly and challenging for patients to regularly visit a healthcare facility, and some patients may avoid the injections due to discomfort or fear of adverse events.

A steady supply of benzathine penicillin G is an essential prerequisite for treatment of sore throat and to prevent recurrent infection. However, the antibiotic is prone to global shortages. High manufacturing costs and low purchase prices have pushed some manufacturers out of the market while demand for the drug is rising. When the medication is not available on the shelf, necessary long-term treatment regimens are disrupted.

Investing in the secure supply of quality assured benzathine penicillin G will prevent the recurrence of global shortages and contribute to global efforts to increase access to quality-assured, safe, effective, and affordable essential medicines, as part of universal health coverage.

WHO Response

In 2018, the World Health Assembly adopted resolution WHA 71.14 calling for WHO to launch a coordinated global response to rheumatic heart disease and rheumatic fever. The Organization is working to develop clinical guidelines for rheumatic heart disease and with the help of WHO regional offices, a workplan is being developed to put interventions in place to prevent rheumatic heart disease and care for people already living with it.

Ensuring a steady, quality supply of benzathine penicillin is also a key priority in the 13^th WHO General Programme of Work, specifically the strategic priority on universal health coverage; access to medicines, vaccines and health products. Additionally, the WHO Road map for access to medicines, vaccines and other health products 2019-2023 and the WHO Benzathine Penicillin Technical Working Group are working to address global supply and demand issues for benzathine penicillin and ensure a quality-assured, safe and effective product is available on the shelves when needed.

Rheumatic Fever | Causes, Symptoms and Treatment

What is rheumatic fever?

Rheumatic fever is caused by your immune system overreacting to a germ (a bacterium). It starts with a bad throat infection (what some people call ‘Strep throat’). A few weeks later you get sore joints: it could be your knees, elbows or wrists. The soreness comes and goes.

The initial effects of rheumatic fever aren’t in themselves too harmful. The problem is, the illness can involve your heart. The covering of the heart (the pericardium) can get inflamed, and the valves inside your heart that make the blood flow in the right direction can get damaged.

Occasionally the illness can make you have very weird jerky movements called chorea.

What is the cause of rheumatic fever?

The disease starts with a throat or skin infection with a particular germ (bacterium) called a Lancefield group A beta-haemolytic streptococcus.Usually this bug just causes a really sore throat or a bad skin infection which can be easily treated with the antibiotic penicillin.

For most people that is the end of the problem but in rheumatic fever your immune system overreacts. Your immune system thinks it can recognise bits of the streptococcus bug in your joints, heart and nervous system and so attacks them.

Who gets it?

Until about the mid-1900s rheumatic fever was found in the UK and other western countries. But since antibiotics have become widespread it has practically disappeared from the UK. In Africa, India and rural parts of Australia and New Zealand people still get rheumatic fever: roughly 1 in 300 teenagers will get it each year in those areas.The disease is mainly related to a lack of antibiotics and also to poor social conditions like overcrowding.

The main age range is 8-14 years, with a peak age of 10 years old. Girls are slightly more likely to develop rheumatic fever than boys.

How do doctors diagnose rheumatic fever?

The diagnosis is usually made by the history of a sore throat or a bad skin infection followed, a few weeks later, by the typical features and symptoms. A blood test to show a recent infection with the streptococcus bacterium (called an antistreptolysin titre) can help to confirm that the bacterium has been in your body.

But then there is a scoring system using major criteria and minor criteria. You need two majors, or one major and two minors, to make the diagnosis.

The major criteria are the main symptoms:

Joint pains.
Heart problems.
Jerky movements (called chorea).
Skin problems.

The minor criteria are:

To see the problems on the heart, a specialist will usually use an echocardiogram: a special scan to see the inside of the heart. But in many parts of the developing world there are not echocardiograms available.

Which parts of the body are affected by rheumatic fever?

Rheumatic fever can affect the joints (like your knees, elbows and wrists), the heart, the nervous system (your brain) and sometimes the skin.

How does rheumatic fever affect the joints?

Some joints become hot and red and are sore to move.
The knees, wrists, elbows and ankles are affected.
The pain and redness may come and go: some joints will get better then others will get worse.
Usually only two joints are affected at the same time.
Each joint is usually affected for a few hours to a few days, before improving.

What problems does rheumatic fever cause in the heart?

It causes something called ‘carditis’: this is an inflamed heart.
It can also inflame the covering of the heart and cause something called ‘pericarditis’.
Or the heart muscle itself, causing myocarditis.
Or the little valves inside the heart, causing endocarditis.
This can give you pains in the chest, breathlessness and a fast heart rate.

How does rheumatic fever affect the nervous system?

In about a quarter of people with rheumatic fever they develop strange, jerky movements called ‘chorea’. They usually last a few weeks and then fade away, but in a few cases can go on for months. The movements usually settle down when the person sleeps.

What changes can be seen in the skin with rheumatic fever?

Skin problems only affect about 10% of people with rheumatic fever. They can be tiny bumps under the skin (called subcutaneous nodules). Some people get pale red patches on their arms and tummy (called erythema marginatum).

These skin problems are not serious and they fade away once the rheumatic fever goes away.

What are the treatments for rheumatic fever?

The treatment depends on which part of the body is affected.

For the joint pains, usually aspirin or ibuprofen is sufficient. They settle in a few weeks.
For heart problems, a specialist doctor may need to prescribe medicines that relieve the strain on the heart. These are medicines like ‘water’ tablets (diuretics), angiotensin-converting enzyme (ACE) inhibitors and digoxin. Sometimes the damage to the heart valves is so bad that urgent heart surgery is needed.
The jerky movements (chorea) are sometimes difficult to treat. Generally sedatives are used like diazepam. If the chorea is very severe and lasts several weeks then specialist procedures like plasmapheresis are used: this is a way of ‘cleaning’ your blood by pumping it through a special machine and back into your body.
Usually the antibiotic penicillin is given for ten days to make sure that none of the original bacterium, the streptococcus, is still in the body.
If the heart problems are particularly bad, some people recommend penicillin until the age of 21 years at least.
Rheumatic fever is one of the few conditions where bed rest is recommended, even if the person feels well enough to be up and about. They should rest until the blood tests for inflammation return to normal.

What is the outlook for someone who has had rheumatic fever?

Generally the symptoms of the fever, joint pains, heart problems and chorea fade away by about three months in most people. Very occasionally the chorea goes on for years but this is very rare.

The main long-term problem is with the heart. About a third of people who have had rheumatic fever will get long-term problems with their heart. This is then called rheumatic heart disease. It can damage the heart permanently and require lifelong medication or even surgery to the heart valves many years later.

Rheumatic Fever And Post-streptococcal Reactive Arthritis

1. 1 What is it?
Rheumatic fever is a disease caused by throat infection by a bacterium called streptococcus. There are several groups of streptococci but only group A causes rheumatic fever. Although streptococcal infection is a very common cause of pharyngitis (throat infection) in school-age children, not all children with pharyngitis will develop rheumatic fever. The disease may cause inflammation and damage to the heart; it presents first with short-lived joint pains and swelling, and later with carditis (inflammation of the heart) or an abnormal involuntary movement disorder (chorea) due to brain inflammation. Skin rashes or skin nodules may also occur.
1.2 How common is it?
Before antibiotic treatment became available, the number of cases was high in countries with warm climates. After antibiotic treatment became a common practice for treating pharyngitis, the frequency of this disease decreased, but it still affects many children from 5-15 years of age all over the world, leading to heart disease in a small proportion of cases. Because of its joint manifestations, it is included among the many rheumatic diseases of children and adolescents. The burden of rheumatic fever is unequally distributed around the world.
The occurrence of rheumatic fever varies from country to country: there are countries where no case is registered and countries with medium or high rates (more than 40 cases per 100,000 persons per year). It is estimated that there are over 15 million cases of rheumatic heart disease worldwide, with 282,000 new cases and 233,000 deaths annually.
1.3 What are the causes of the disease?
The disease is the result of an abnormal immune response to throat infection with Streptococcus pyogenes, or Group A β haemolytic Streptococcus. Sore throat precedes the disease onset by an asymptomatic period of variable length.
Antibiotic treatment is needed to treat the throat infection, stop stimulation of the immune system and prevent new infections, because new infections can cause a new disease attack. The risk of a repeated attack is higher in the first 3 years after disease onset.
1.4 Is it inherited?
Rheumatic fever is not a hereditary disease, since it cannot be transmitted directly from parents to their children. However, there are families with several members who developed rheumatic fever. This may be due to genetic factors associated with the possibility of transmission of streptococcus infections from person to person. Streptococcal infection is transmissible through respiratory airways and saliva.
1.5 Why does my child have this disease? Can it be prevented?
The environment and the streptococcus strain are important factors for the development of the disease, but in practice it is difficult to predict who will get it. Arthritis and heart inflammation are caused by abnormal immune response against streptococcus proteins. The chances of getting the disease are higher if certain types of streptococcus infect a susceptible person. Crowding is an important environmental factor, since it favours the transmission of infections. Prevention of rheumatic fever relies on prompt diagnosis and antibiotic treatment (the recommended antibiotic is penicillin) of streptococcal throat infection in healthy children.
1.6 Is it infectious?
Rheumatic fever by itself is not infectious, but streptococcal pharyngitis is. Streptococci are spread from person to person and therefore infection is associated with crowding at home, in schools or at the gym. Careful hand washing and avoidance of close contact with individuals with streptococcal throat infections is important to stop the spread of the disease.
1.7 What are the main symptoms?
Rheumatic fever usually presents a combination of symptoms that may be unique in each patient. It follows streptococcal pharyngitis or tonsillitis not treated with antibiotics.
Pharyngitis or tonsillitis can be recognized by fever, sore throat, headache, red palate and tonsils with purulent secretions and enlarged and painful neck lymph nodes. However, these symptoms can be very mild or completely absent in school-age children and adolescents. After the acute infection has resolved, there is an asymptomatic period of 2-3 weeks. Then the child may present with fever and the signs of the disease described below.

Arthritis

Arthritis most commonly affects several large joints at the same time or may move from one joint to another affecting one or two at a time (knees, elbows, ankles or shoulders). It is called “migratory and transient arthritis”. Arthritis affecting hands and cervical spine is less common. Joint pain may be severe even when swelling is absent. Note that pain usually subsides promptly after administration of anti-inflammatory drugs. Aspirin is the most used anti-inflammatory drug.

Carditis

Carditis (heart inflammation) is the most serious manifestation. Accelerated heartbeat during rest or sleep can elicit the suspicion of rheumatic carditis. Abnormal heart examination, with the presence of heart murmurs, is the main sign of heart involvement. It varies from a subtle to a loud murmur that may indicate inflammation of the heart valves, known as “endocarditis”. If inflammation is located in the heart sac, known as “pericarditis”, some fluid may collect around the heart but this usually causes no symptoms and clears on its own. In the most severe cases of myocarditis, the heart may become inflamed and pumping may be weakened. It can be recognized by cough, chest pain and accelerated pulse and breathing. Referral to a cardiologist and tests may be indicated. Rheumatic valvular heart disease may be a result of the first attack of rheumatic fever, but it is usually a consequence of repeated episodes and might become a problem later in adult life, so prevention is crucial.

Chorea

The term chorea is derived from a Greek word meaning dance. Chorea is a movement disorder resulting from inflammation of parts of the brain controlling the coordination of movements. It affects 10-30% of patients with rheumatic fever. Unlike arthritis and carditis, chorea appears later during disease course, from 1 to 6 months after the throat infection. Early signs are poor handwriting in school age patients, difficulties with dressing and self-care, or even with walking and feeding, due to trembling involuntary movements. Movements may be suppressed voluntarily for short periods, may disappear during sleep or be exacerbated by stress or fatigue. In students, it reflects on academic achievements due to poor concentration, anxiety and mood instability with easy crying. If subtle, it might be overlooked as a behavioural disturbance. It is self-limited, although supporting treatment and follow-up is needed.

Skin rashes

Less common manifestations of rheumatic fever are the skin rashes called “erythema marginatum”, which look like red rings, and “subcutaneous nodules” that are painless mobile grain nodules with normal overlying skin colour, usually seen over the joints. These signs are present in less than 5% of cases and may be overlooked because of their subtle and transient appearance. These signs are not isolated, but they occur together with myocarditis (inflammation of the heart muscle). There are other complaints that may be first noticed by parents such as fever, fatigue, loss of appetite, pallor, abdominal pain and nosebleeds, which may occur in early stages of the disease.

1.8 Is the disease the same in every child?
The most common presentation is the heart murmur in older children or adolescents with arthritis and fever. Younger patients tend to present with carditis and less severe joint complaints.
Chorea may present itself as the only manifestation or may be combined with carditis, but close follow-up and examination by a cardiologist are recommended.
1.9 Is the disease in children different from the disease in adults?
Rheumatic fever is a disease of school children and young people up to 25 years of age. It is rare before the age of 3 and more than 80% of patients are between 5 and 19 years old. However, it may occur later in life if there is non-compliance with permanent antibiotic prevention.

2.1 How is it diagnosed?
Clinical signs and investigations have special importance, because there is no specific test or sign for the diagnosis. Clinical symptoms of arthritis, carditis, chorea, skin changes, fever, abnormal laboratory tests for streptococcal infection and changes in the conduction of the heartbeat, as seen on an electrocardiogram, can help establish the diagnosis (so called Jones criteria). Evidence of a preceding streptococcal infection is generally needed to make the diagnosis.
2.2 Which diseases are like rheumatic fever?
There is a disease called “post-streptococcal reactive arthritis” that also occurs after streptococcal pharyngitis, but which features arthritis of longer duration and which has a lower risk of carditis; antibiotic prophylaxis may be indicated. Juvenile idiopathic arthritis is another disease resembling rheumatic fever, but the duration of arthritis is longer than 6 weeks. Lyme disease, leukaemia, reactive arthritis caused by other bacteria or viruses may also present with arthritis. Innocent murmurs (common heart murmurs with no heart disease), congenital or other acquired heart diseases can be misdiagnosed as rheumatic fever.
2.3 What is the importance of tests?
Some tests are essential for the diagnosis and follow-up. Blood tests are useful during attacks to confirm the diagnosis.
As in many other rheumatic diseases, signs of systemic inflammation are seen in nearly all patients, except those with chorea. In most patients, there is no sign of throat infection and the streptococcus bacteria in the throat are cleared by the immune system by the time of disease onset. There are blood tests to detect streptococcal antibodies, even if the parents and/or the patient are not able to recall the signs of throat infection. Rising titres (levels) of these antibodies, known as anti-streptolysin O (ASO) or DNAse B, can be detected by blood tests carried out 2-4 weeks apart. High titres indicate a recent infection, but there is no proven relationship with disease severity. However, these tests yield normal results in patients with only chorea, making this diagnosis tricky.
Abnormal ASO or DNAse B test results mean prior exposure to the bacteria stimulating the immune system to produce antibodies, and by itself, does not make the diagnosis of rheumatic fever in patients without symptoms. Antibiotic treatment is therefore generally not necessary.
2.4 How to detect carditis?
A new murmur, resulting from heart valve inflammation, is the most common feature of carditis and is usually detected when a physician auscultates (listens to) the heart sounds. An electrocardiogram (an assessment of heart’s electrical activity registered on a paper strip) is useful to ensure the extent of heart involvement. Chest X-rays are also important to check for enlargement of the heart.
Doppler echocardiogram or heart ultrasound is a very sensitive test for carditis. All these procedures are absolutely painless and the only discomfort is that the child must keep still for a while during the test.
2.5 Can it be treated/cured?
Rheumatic fever is an important health problem in certain areas of the world, but it can be prevented by treating streptococcal pharyngitis as soon as it is recognized (i.e. primary prevention). Antibiotic therapy started within 9 days of onset of pharyngitis is effective in preventing acute rheumatic fever. Symptoms of rheumatic fever are treated with non-steroidal anti-inflammatory medications.
Research is currently being carried out to produce a vaccine that can protect against streptococcus: prevention of the initial infection would provide protection against the abnormal immune reaction. This approach might prevent rheumatic fever in the future.
2.6 What are the treatments?
During the past several years, there have been no new treatment recommendations. While aspirin has remained the mainstay of therapy, the exact action of effect is unclear; it appears to be related to the anti-inflammatory properties. Other non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for arthritis for 6-8 weeks or until it disappears.
For severe carditis, bed rest and, in some cases, oral corticosteroids(prednisone) are recommended for 2-3 weeks, tapering the drug off gradually after the inflammation is controlled by observing the symptoms and by blood tests.
In the event of chorea, parental support for personal care and school tasks may be required. Drug treatment for chorea movement control with steroids, haloperidol or valproic acid may be prescribed with close monitoring for side-effects. Common side effects are sleepiness and trembling that can be easily controlled by dose adjustment. In a few cases, chorea may last for several months despite adequate treatment.
After the diagnosis is confirmed, long-term protection with antibiotics is recommended to avoid recurrence of acute rheumatic fever.
2.7 What are the side effects of drug therapy?
In terms of short-term symptomatic treatment, salicylates and other NSAIDs are usually well tolerated. The risk of a penicillin allergy is quite low, but its use must be monitored during the first injections. The main considerations are the painful injections and possible refusal by patients who fear pain; therefore, education about the disease, topical anaesthetics and relaxation before injections are recommended.
2.8 How long should secondary prevention last?
The risk of relapse is higher during the 3-5 years after onset and the risk of developing carditis damage increases with new flares. During this time, regular antibiotics treatment for preventing new streptococcal infections is recommended for all patients who have had rheumatic fever, regardless of the severity, as mild forms may flare as well.
Most physicians agree that antibiotic prevention should continue for at least 5 years after the last attack or until the child is 21 years old. In the event of carditis without heart damage, secondary prophylaxis is recommended for 10 years or until the patient is 21 years old (whichever is longer). If heart damage is present, 10 years of prophylaxis are recommended, or until the age of 40 – or later in life if the disease is complicated by valve replacement.
Prevention of bacterial endocarditis with antibiotics is recommended for all patients with heart valve damage undergoing dental work or surgery. This measure is necessary because bacteria can move from other sites of the body, especially from the mouth, and cause heart valve infection.
2.9 What about unconventional/complementary therapies?
There are many complementary and alternative therapies available and this can be confusing for patients and their families. Think carefully about the risks and benefits of trying these therapies as there is little proven benefit and they can be costly in terms of time, burden to the child and money. If you want to explore complementary and alternative therapies, it is wise to discuss these options with your paediatric rheumatologist. Some therapies can interact with conventional medications. Most doctors will not be opposed to complementary therapies, provided you follow medical advice. It is very important not to stop taking your prescribed medications. When medications, such as corticosteroids, are needed to keep the disease under control, it can be very dangerous to stop taking them if the disease is still active. Please discuss medication concerns with your child’s doctor.
2.10 What kind of periodic check-ups are necessary?
Regular check-ups and periodic tests may be required during long-term disease course. Closer follow-up is recommended in cases where there is carditis and chorea. After remission of the symptoms, a supervised schedule for preventive treatment and long-term follow-up under supervision of a cardiologist looking for late heart damage is recommended.
2.11 How long will the disease last?
Acute symptoms of the disease recede over several days to weeks. However, the risk of recurrent attacks of acute rheumatic fever persists and heart involvement can cause life-long symptoms. Ongoing antibiotic treatment to prevent recurrence of streptococcal pharyngitis is necessary for many years.
2.12 What is the long-term evolution (prognosis) of the disease?
Relapses of symptoms tend to be unpredictable in time and severity. Carditis in the first attack increases damage risk, although complete healing may follow carditis in some cases. Most severe heart damage requires heart surgery for valve replacement.
2.13 Is it possible to recover completely?
Complete recovery is possible, unless carditis resulted in severe heart valve damage.

3.1 How might the disease affect the child and the family’s daily life?
With proper care and regular check-ups, most children with rheumatic fever lead a normal life. However, family support during flare-ups is recommended for patients with carditis and chorea.
The main concern is long-term compliance with antibiotics prevention. Primary care services must be involved and education is needed to improve compliance with treatment, especially for adolescents.
3.2 What about school?
If there is no residual heart damage detected during regular check-ups, there is no special recommendation for daily activities and routine school life; children can proceed with all activities. Parents and teachers should do whatever they can to allow the child to participate in school activities in a normal way, in order not only for the child to be successful academically but also to be accepted and appreciated by both peers and adults. During acute phases of chorea, some limitations during school tasks are expected, and families and teachers may have to cope with this for 1 to 6 months.
3.3 What about sports?
Playing sports is an essential aspect of the everyday life of any child. One of the aims of therapy is to allow children to conduct a normal life as much as possible and to consider themselves not different from their peers. All activities can therefore be performed as tolerated. Nevertheless, restricted physical activity or bed rest may be necessary during the acute phase.
3.4 What about diet?
There is no evidence that diet can influence the disease. In general, the child should enjoy a balanced, normal diet for his/her age. A healthy, well-balanced diet with sufficient protein, calcium and vitamins is recommended for a growing child. Overeating should be avoided in patients taking corticosteroids because these drugs may increase appetite.
3.5 Can climate influence the course of the disease?
There is no evidence that climate can affect the disease manifestations.
3.6 Can the child be vaccinated?
The physician should decide which vaccines the child can receive, considering case by case. Overall, vaccinations do not appear to increase the disease activity and do not cause severe adverse events in patients. However, live-attenuated vaccines are generally avoided because of the hypothetical risk of inducing infection in patients receiving high dose immunosuppressive drugs or biologic agents. Non-live composite vaccines appear to be safe in patients, even those receiving immunosuppressive drugs, although most studies cannot fully assess rare vaccination-induced harm.
A patient on high dose immunosuppressive drugs should be advised by their physician to measure pathogen-specific antibody concentrations after vaccination.
3.7 What about sexual life, pregnancy, birth control?
There are no restrictions on sexual activity or pregnancy due to the disease. Nevertheless, all patients taking medications should be very careful about the possible effects of these drugs on a foetus. Patients are advised to consult their physician about birth control and pregnancy.

4.1 What is it?
Cases of streptococcal-associated arthritis have been described both in children and young adults. It is usually called “reactive arthritis” or “post-streptococcal reactive arthritis” (PSRA).
PSRA commonly affects children between 8 to 14 years of age and young adults between 21 to 27 years. It usually develops within 10 days after a throat infection. If differs from arthritis of acute rheumatic fever (ARF), which mainly involves large joints. In PSRA, large and small joints and the axial skeleton are involved. It usually lasts longer than ARF — about 2 months, sometimes longer.
Low grade fever might be present, with abnormal laboratory tests indicating inflammation (C reactive protein and/or erythrocyte sedimentation rate). The inflammatory markers are lower than in ARF. The diagnosis of PSRA relies on arthritis with evidence of recent streptococcal infection, abnormal streptococcal antibody tests (ASO, DNAse B) and the absence of the signs and symptoms in a diagnosis of ARF according to “Jones criteria”.
PSRA is a different entity to ARF. PSRA patients will probably not develop carditis. Currently, the American Heart Association recommends prophylactic antibiotics for one year after symptoms onset. In addition, these patients should be carefully observed for clinical and echocardiographic evidence of carditis. If heart disease appears, the patient should be treated as in ARF; otherwise prophylaxis can be discontinued. Follow-up with a cardiologist is recommended.
90,000 Acute rheumatic fever – causes, symptoms, complications, treatment

General

Acute rheumatic fever is a serious late complication of angina (acute tonsillitis). It is a systemic inflammation of connective tissue throughout the body. The connective tissue of the heart, joints and under the skin is especially susceptible to the body. Although angina itself is acute, with fever, sore throat, headache, inflammation in rheumatic fever can cause chronic damage to the heart valves, which leads to disability or death many years after the acute illness. Rheumatism usually occurs in children between the ages of 5 and 15, although adults can also get it. The first symptoms of rheumatism usually appear 1-5 weeks after a sore throat. Rheumatic attacks usually last about three months, very rarely they last more than six months.

Causes of acute rheumatism

Complications of acute respiratory disease caused by certain strains of group A hemolytic streptococcus. Poor living conditions and unsanitary conditions lead to greater susceptibility to infections.Malnutrition, inadequate nutrition is a predisposing factor for infection.

Symptoms of rheumatic fever

Fever, joint pain, painful, enlarged joints (most often knee, ankle, but elbow and wrist joints can also be affected). Soreness and swelling may disappear in some joints and appear in others. Subcutaneous nodules in places of bony protrusions. Rash on the torso, arms and legs. Rapid involuntary contractions of the muscles of the face, arms and legs.

Complications of rheumatic fever

Brain damage. Rheumatic heart diseases such as myocarditis (inflammation of the heart muscle), endocarditis (inflammation of the inner lining of the heart), and pericarditis (inflammation of the outer lining of the heart). Death.

What You Can Do

Consult your doctor to avoid possible complications. If a streptococcal etiology is confirmed, you will be prescribed antibiotics.It is imperative to carry out a course of antibiotic therapy in its entirety.

What a doctor can do

The doctor can conduct an examination, prescribe laboratory tests, prescribe an antibiotic to destroy the causative agent of the disease and thereby prevent heart damage. Prescribe symptomatic treatment to alleviate the general condition of the patient. Your doctor may recommend bed rest and a proper diet to increase immunity and strengthen the body’s defenses.Identify complications and prescribe timely treatment.

Preventive measures

See a doctor if you have a sore throat for more than a week. It is advisable to avoid crowded places and provide good sanitary conditions in your place of residence. Maintain the body’s natural defenses. Wash your hands before preparing food, especially if you are sneezing or coughing. This will prevent the bacteria that cause sore throat from spreading.

Rational antibiotic therapy of GABHS infection as a factor in the prevention of primary and secondary acute rheumatic fever

The article was published on p. 62-66

The term “acute rheumatic fever” (ARF) is currently considered to be preferred over the term “rheumatism”, as it emphasizes the relationship of disease with infection and the need for antibiotic therapy. A recurrent episode of rheumatic fever is regarded as a recurrent disease associated with group A b-hemolytic streptococcus (GABHS), and is not considered a relapse of the first rheumatic attack. In recent years, the American and Australian guidelines for the management of patients with ARF and the treatment of GABHS infections of the pharynx have been updated: American Academy of Pediatrics, 2009 [1], American Heart Association, 2010 [2], Infection Disease Society of America, 2012 [3], National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand, 2012 [4]. Antibiotic therapy (ABT) issues deserve special attention in these recommendations.

According to modern concepts, only the transferred GABHS infection in the form of tonsillitis, pharyngitis, tonsillopharyngitis, nasopharyngitis provokes the development of ARF.Streptococcal infection of the skin or other organs cannot cause ARF. Potentially rheumatogenic strains of GABHS are tropic to nasopharyngeal tissue and are highly contagious. The most virulent are groups of streptococci with specific large M-protein molecules on the surface (M 1, 3, 5, 6, 14, 18, 19, 24). The presence of M-proteins interferes with effective phagocytosis, promotes rapid penetration of the pathogen into the tissues of the host organism and the rapid reproduction of streptococci [1, 3]. M-protein molecules have epitopes that cross-react with various tissues of the host macroorganism (myosin, synovia, brain, sarcolemma), which provides them with the properties of a superantigen that induces an autoimmune effect.The acquired autoimmune response can be enhanced by repeated GABHS infection.

Timely and accurate diagnosis of pharyngitis or tonsillitis associated with GABHS and adequate ABT are the main measures for the primary prevention of ARF. Such tactics are necessary not only to prevent ARF and concomitant bacterial complications, but also to reduce the infectiousness of the infection, reduce the likelihood of GABHS transmission to family and children’s contacts, and reduce asymptomatic infection carriers.It is recommended [3] to take a throat swab and test for possible GABHS pharyngitis using a rapid test for the determination of GABHS antigens. In children and adolescents, if the test results are negative, a throat swab should be cultured. Determination of antistreptococcal antibody titers is not recommended for routine diagnosis of strep throat, as they reflect past rather than current events.

In everyday practice, it is enough to simply use the modified W.J. McIsaac (McIsaac) in 1998 with the R.M. Centor to determine the tactics of managing a patient of any age with a complaint of a sore throat (Table 1).

The choice of the therapeutic tactics algorithm using the McIsack scale (Table 2) reduces the risk of unreasonable prescription of antibiotics for viral tonsillitis, pharyngitis.

GABHS remain highly sensitive to penicillin drugs, which remain the first choice in the treatment of acute tonsillitis, tonsillopharyngitis associated with GABHS (tab.3). According to the Cochrane Review (2013), the low cost and lack of resistance make penicillin a first choice drug in both adults and children [5].

Semisynthetic aminopenicillin – amoxicillin synthesized in 1972 for its anti-streptococcal activity is close to phenoxymethylpenicillin, but differs in maximum bioavailability (70% – capsules and 93% – dispersible tablets (Flemoxin Solutab ^®), which is comparable to the injection of an antibiotic). The minimal effect on the intestinal microflora when using amoxicillin in the solutab dosage form reduces the risk of intestinal dyspeptic disorders and increases patient adherence to the completion of the 10-day course of treatment.

The appointment of oral ampicillin for the treatment of GABHS tonsillitis is currently considered inappropriate due to the relatively low bioavailability of the drug (50%). The use of phenoxymethylpenicillin seemed justified only in young children, taking into account the presence of a dosage form in the form of a suspension, however, this advantage was leveled by the possibility of dissolving a solute tablet of amoxicillin with a pleasant tangerine-lemon taste in water (in 20 ml – to obtain syrup, in 100 ml – to obtain suspension).

The appointment of a single injection of benzathine penicillin may be advisable in the following cases: poor performance of patients, a history of ARF and / or chronic rheumatic heart disease (CRHD) in the immediate family, unfavorable social conditions (crowding factor), an outbreak of GABHS infection in organized collectives and when it is impossible to take oral antibiotics [3].

In patients with a burdened allergic history (allergy to penicillin or other b-lactam antibiotics), it is possible to use macrolides with comparable anti-streptococcal activity and the ability to create a high tissue concentration at the site of infection (Table 1).4).

The first antibiotic of this class, erythromycin, is used infrequently, since it is less tolerated than new macrolides (azithromycin, spiramycin, roxithromycin, josamycin, clarithromycin, midecamycin). GABHS resistance to erythromycin was acquired, in some European regions it exceeds 40% [6]. The most significant side effect of macrolides, and primarily erythromycin, is considered a prokinetic effect on the gastrointestinal tract (GIT), which is regarded by many patients and even doctors as a manifestation of dysbiosis and becomes a reason for a faster (less than 10 days) discontinuation of the course of anti-streptococcal therapy.Josamycin (Vilprafen Solutab) from the group of 16-membered macrolides has less effect on gastrointestinal motility, has the advantages of a dispersible dosage form of solutab. Active elimination (efflux) of macrolides from streptococcus cells occurs using a proton pump encoded by the mefA gene. This is the main mechanism of acquired resistance of a microorganism to macrolides. 16-membered macrolide antibiotics (josamycin – Vilprafen Solutab) are not excreted from the microbial cell by efflux, which retains the high sensitivity of streptococcus and the activity of the drug against some erythromycin-resistant strains.Nevertheless, it should be remembered that in the context of the widespread increasing resistance of GABHS to macrolides, these antibiotics should be considered only as alternative agents for the treatment of streptococcal tonsillitis [7].

Oral cephalosporins of the first generation (cefadroxil, cephalexin) are also highly effective in the treatment of GABHS tonsillitis and are well tolerated by patients. However, among patients with penicillin intolerance, cross-allergic reactions to cephalosporins occur in 10-15% of cases.

Lincosamides (clindamycin, lincomycin) have a high anti-streptococcal efficacy, but are prescribed for GABHS tonsillitis only in case of intolerance to both b-lactams and macrolides. It is considered necessary to keep this group of drugs active for the prevention of infective endocarditis when performing dental procedures accompanied by bacteremia in patients with rheumatic heart disease (including those operated on with prosthetic valves) [8]. Such patients most often have a long history of taking oral and durant forms of penicillins, and the sensitivity of green streptococci of the oral cavity to them is quite low.

Patients with chronically recurrent GABHS tonsillitis have a high likelihood of a significant infection producing b-lactamase. In these cases, it is advisable to carry out a course of treatment with inhibitor-protected penicillins (amoxicillin / clavulanate) or oral cephalosporins of the II-III generation: cefuroxime axetil, cefixime (Ceforal Solutab), cefpodoxime, and in case of intolerance to b-lactamami antibiotics – lincoside antibiotics. These antibiotics are also considered as second-line drugs for cases of unsuccessful penicillin therapy of acute GABHS tonsillitis (which is more common with phenoxymethylpenicillin). An important advantage of the dispersible dosage form of amoxicillin / clavulanate (Flemoklav Solutab) in the form of a significant reduction in the frequency of diarrhea, which reaches 24% when using conventional forms of amoxicillin with clavulanic acid, has been shown [9].

Differential diagnosis of carriage and chronic recurrent GABHS-tonsillitis / pharyngitis requires an assessment of the existing symptom complex and the clinical efficacy of ABT. It is necessary to determine GABHS in a throat swab taken during the intersymptomatic period.Antimicrobial therapy is not indicated for most chronic carriers of GABHS. However, there are special clinical situations in which eradication of the pathogen is desirable (Table 5): during local outbreaks of ARF, with acute post-streptococcal glomerulonephritis or invasive GABHS infection, during an outbreak of GABHS pharyngitis in a crowded group, in the presence of ARF in a family or personal anamnesis, with high family anxiety regarding the possible consequences of GABHS infection, with possible tonsillectomy due to frequent relapses of GABHS tonsillitis [2, 3].

Complex treatment of a patient with ARF is carried out in a hospital [4] and includes etiotropic therapy for the eradication of GABHS. Antibiotics of the penicillin series are naturally considered the drugs of choice, macrolides for allergy to penicillin (Table 6).

All patients who have undergone ARF, patients with CRHD, to prevent colonization or infection of the upper respiratory tract with GABHS and the development of recurrent ARF, require secondary antibiotic prophylaxis. The first injection of long-acting benzathine penicillin is injected deeply intramuscularly while still in the hospital and then repeated every 3-4 weeks all year round.Such therapy has the highest level of evidence – IA – and, according to a Cochrane review [10], can reduce the risk of recurrent ARF by 87–96%. Doses of benzathine penicillin: 600 thousand units – for children weighing less than 27 kg; 1.2 million units – for children weighing more than 27 kg; 2.4 million units – for adults. Secondary prophylaxis is carried out for at least 5 years (Table 7).

The alternative daily oral administration of penicillin V, or sulfadiazine, or erythromycin is less effective due to more frequent recurrent ARF attacks [4].

Thus, antibiotic therapy is mandatory in the treatment of patients with acute GABHS tonsillitis, pharyngitis for the primary prevention of ARF, in the treatment of a patient with rheumatic attack, and for a long time – for secondary prevention. Complex therapy of rheumatic heart disease with the inclusion of antibiotics gives a chance for a complete cure, therefore, the current course of ARF may not have a primary chronic nature. The issues of prescribing a specific antibiotic, its dosage and routes of administration are decided by the attending physician, taking into account modern recommendations and the characteristics of the clinical situation.

Bibliography

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4. RHDAustralia (ARF / RHD writing group), National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd ed.). – 2012.

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8. Habib G., Hoen B., Tornos P. et al. ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC) // Eur.Heart J. – 2009. – Vol. 30 (19). – R. 2369-2413.

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Antistreptolysin O

Antistreptolysin O is an indicator of the transferred streptococcal infection.Used to diagnose rheumatic fever and glomerulonephritis.

Synonyms Russian

Antistreptolysin O, ASLO, ASL O.

Synonyms English

ASO, ASLO, AntiStrep, Antistreptolysin O Titer.

Research method

Immunoturbidimetry.

Units

IU / ml (international unit per milliliter).

Which biomaterial can be used for research?

Venous blood.

How to properly prepare for the study?

Eliminate physical and emotional stress 30 minutes before the study.
Do not smoke within 30 minutes prior to examination.

General information about the study

Antistreptolysin O (ASL O) are antibodies produced by the body against streptolysin O, a toxic enzyme secreted by some groups of hemolytic streptococcus.

Betahemolytic streptococcus group A (Streptococcus pyogenes) – a bacterium that causes streptococcal sore throat, scarlet fever, streptococcal pharyngitis, skin infection. In most cases, streptococcal infection has a characteristic clinical picture, is recognized and treated with antibiotics, as a result of which the microbe is destroyed. If the infection is atypical, is not treated or is treated ineffectively, then the risk of post-streptococcal complications – rheumatic fever and glomerulonephritis – increases.This usually occurs in children after a sore throat or scarlet fever. These complications of streptococcal infection are not common, but should be kept in mind.

Rheumatic fever can be manifested by fever, redness of the skin around the joints and their swelling, pain in the region of the heart, shortness of breath, fatigue, and glomerulonephritis – fever, back pain, decreased urine output and redness. Rheumatic fever leads to the development of heart defects, glomerulonephritis – to renal failure and high blood pressure.

Since the symptoms of this disease can accompany other conditions, the analysis for antistreptolysin O allows you to find out if they are caused by a streptococcal infection. The ASL O level increases a week after infection, reaches a maximum after 3-6 weeks and decreases after six months or a year.

What is the research used for?

To determine that a person has recently been infected with group A streptococcus. Most often, this infection has a characteristic clinical picture, so that it is easy to recognize.Streptococcus is treated with antibiotics, and as a result, the microbe is destroyed. When the infection is atypical, untreated (or ineffectively treated), the risk of post-streptococcal complications – rheumatic fever and glomerulonephritis – increases. Thus, the analysis for ASL O is necessary to confirm the connection of the symptoms of these diseases with streptococcal infection.
To assess the effectiveness of treatment, since the concentration of ASL O in the patient’s blood decreases with recovery.

When is the study scheduled?

When there is reason to believe that symptoms are due to a prior streptococcal infection.The study is carried out when complaints appear, as a rule, 2-3 weeks after sore throat or streptococcal skin lesions. The importance of the analysis increases if it is prescribed several times with an interval of 10-14 days – in this case, it is possible to assess the change in the antibody titer (increase or decrease).
1-2 weeks after starting treatment for rheumatic fever or glomerulonephritis (to assess the effectiveness of treatment).

What do the results mean?

Reference values

Age	Reference values
Up to 14 years old	0 – 150 IU / ml
Over 14 years old	0 – 200 IU / ml

Antibodies to streptolysin O begin to be produced by the body 1-2 weeks after infection with streptococcal infection.Their maximum concentration in the blood becomes after 4-6 weeks. They can persist in the blood for several months.

A negative test result for antistreptolysin O or its very low concentration in the blood is highly likely to rule out recent streptococcal infection. Especially if 10-14 days after that, the analysis is again negative. Only in a small number of individuals post-streptococcal complications are not accompanied by an increase in ASL O.

Elevated ASL O (up to four norms and above) or an increase in its titer indicates a recent streptococcal infection.A decrease in the level of ASL O indicates the patient’s recovery after infection.

Nevertheless, by the degree of increase in ASL O one cannot judge whether rheumatic fever and glomerulonephritis will occur and what the degree of their severity will be. However, in the presence of symptoms of these diseases, an increase in ASL O allows confirming the diagnosis.

In addition, antistreptolysin O levels may be elevated in reactive arthritis.

What can influence the result?

False negative results may occur with nephrotic syndrome and treatment with corticosteroids and certain antibiotics.
Hypercholesterolemia and liver disease lead to overestimated rates.

Penicillin slowed down acute rheumatic fever in children – Science

TASS, November 13. Doctors have found that penicillin slows down the development of acute rheumatic fever in children and prevents the associated damage to the heart muscle and valves. The results of the study were published by the New England Journal of Medicine.

“Acute rheumatic fever can be treated in the early stages, but in most patients it is diagnosed after complications develop.Clinical trials have shown that the cheap antibiotic penicillin can slow the progression of the disease and prevent permanent damage to the valves, ”said Emmy Okello, one of the study’s authors, a researcher at the Uganda Heart Institute.

Acute rheumatic fever is a systemic disease of the connective tissue, as a rule, it affects the heart and blood vessels of children aged 7 to 15 years. As a rule, it develops as a result of an overreaction of the immunity of children to the penetration of certain strains of streptococcus into their body.

Sometimes fighting an infection causes the baby’s body to produce antibodies that can attack the heart muscle, valves, and other critical components of the circulatory system. In most cases, this reaction can be suppressed, but sometimes it leads to the development of heart disease and other incurable complications.

Okello and his colleagues have found that these complications can be prevented or significantly slowed down if sick children regularly take penicillin.Scientists came to this conclusion during clinical trials, which were conducted in Uganda with the participation of 800 children aged five to 17 years, suffering from chronic forms of acute rheumatic fever.

In the framework of these experiments, the scientists divided the children into two groups, representatives of one of which received monthly injections of penicillin, and the rest received injections of saline solution. Two years later, doctors summed up the results of the experiment and compared how often complications associated with acute rheumatic fever of the heart developed in children.

As it turned out, regular use of the antibiotic dramatically reduced the incidence of severe forms of acute rheumatic fever. Complications occurred in only three children receiving penicillin (0.8%), while problems with valves and heart muscle appeared in 33 participants in the control group (8.3%).

Such clinical trial outcomes, Okello and colleagues hope, will prompt authorities in Uganda and many developing countries that lack the resources and adequate facilities for valve transplant surgery to use penicillin to combat acute rheumatic fever.

90,000 Treatment of rheumatic heart disease in the Shakhtar sanatorium in Essentuki

Treatment of rheumatic heart disease in the Shakhtar sanatorium in Essentuki

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Unique treatment programs

Modern spa treatment of rheumatic heart disease includes: prevention of repeated attacks of ARF and infective endocarditis, treatment of CHF, cardiac arrhythmias, prevention and treatment of thromboembolic complications, referral to surgical treatment.

Treatment is prescribed individually, taking into account the nature of the valve damage and the prognosis of the disease.

Contraindications

Not earlier than 6-8 months after the end of acute events.

Treatment results

The goal of treatment is to eliminate heart rhythm disturbances, prevent blood thinning and blood clots. Very often, conservative treatment does not give the desired results, then doctors recommend surgery, with valve replacement or its dissection.

Consequences of not receiving treatment

In the absence of treatment for rheumatic heart disease, the patient may develop complications in the form of chronic heart failure, thrombosis of the blood arteries (which will certainly lead to blocking the flow of oxygen to the heart and other vital organs). As a rule, thrombosis of the blood arteries after a while provokes the occurrence of a stroke or heart attack in the patient.

Chronic rheumatic heart disease (CRHD) is a disease characterized by damage to the heart valves in the form of post-inflammatory marginal fibrosis of the valve leaflets or heart disease, which has developed after suffering from acute rheumatic fever.

Treatment for this disease is prescribed by consulting doctors of the Shakhtar sanatorium as a concomitant pathology to the main diseases that are profile for the sanatorium – diseases of the digestive system and the endocrine system.

More detailed advice can be obtained from the resort sales department: +7 (863) 310-01-43

Spa programs

Program “Gastroenterological program”

Tours from 12 days

Prevention of relapses and exacerbations in chronic gastrointestinal diseases.

90,000 Doctors have found that penicillin slows down the development of acute rheumatic fever in children

Doctors have found that penicillin slows down the development of acute rheumatic fever in children and prevents the occurrence of associated damage to the heart muscle and valves.The results of the study were published by the New England Journal of Medicine, reports TASS.

“Acute rheumatic fever can be treated in the early stages, but most patients are diagnosed with it after complications develop. Clinical trials have shown that the cheap antibiotic penicillin can slow the progression of the disease and prevent permanent valve damage from occurring, ”said Emmy Okello, one of the study’s authors and research fellow at the Uganda Heart Institute.

Acute rheumatic fever is a systemic disease of the connective tissue, usually affecting the heart and blood vessels of children aged 7 to 15 years. As a rule, it develops as a result of an overreaction of the immunity of children to the penetration of certain strains of streptococcus into their body.

Sometimes fighting an infection causes the baby’s body to produce antibodies that can attack the heart muscle, valves, and other critical components of the circulatory system.In most cases, this reaction can be suppressed, but sometimes it leads to the development of heart disease and other incurable complications.

Okello and colleagues have found that these complications can be prevented or significantly slowed down by taking penicillin on a regular basis with sick children. Scientists came to this conclusion during clinical trials, which were conducted in Uganda with the participation of 800 children aged five to 17 years, suffering from chronic forms of acute rheumatic fever.

As part of these experiments, the scientists divided the children into two groups, representatives of one of which received monthly injections of penicillin, and the rest received injections of saline solution. Two years later, doctors summed up the results of the experiment and compared how often complications associated with acute rheumatic fever of the heart developed in children.

As it turned out, regular use of the antibiotic has dramatically reduced the incidence of severe forms of acute rheumatic fever. Complications occurred in only three children receiving penicillin (0.8%), while problems with valves and heart muscle appeared in 33 participants in the control group (8.3%).

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Acute rheumatism – symptoms, treatment, signs, causes, acute rheumatic fever

General information

It is a systemic inflammation of the connective tissue throughout the body.The connective tissue of the heart, joints and under the skin is especially susceptible to the body. Although angina itself is acute, with fever, sore throat, headache, inflammation in rheumatic fever can cause chronic damage to the heart valves, which leads to disability or death many years after the acute illness.

Rheumatism usually affects children between the ages of 5 and 15, although adults can also get sick. The first symptoms of rheumatism usually appear 1-5 weeks after a sore throat.Rheumatic attacks usually last about three months, very rarely they last more than six months.

Causes of acute rheumatism

Complications of acute respiratory disease caused by certain strains of group A hemolytic streptococcus. Poor living conditions and unsanitary conditions lead to greater susceptibility to infections. Malnutrition, inadequate nutrition is a predisposing factor for infection.

Symptoms of rheumatic fever

Fever, joint pain, painful, enlarged joints (most often knee, ankle, but elbow and wrist joints can also be affected).Soreness and swelling may disappear in some joints and appear in others. Subcutaneous nodules in places of bony protrusions. Rash on the torso, arms and legs. Rapid involuntary contractions of the muscles of the face, arms and legs.

Complications of rheumatic fever

Brain damage.
Rheumatic heart diseases such as myocarditis (inflammation of the heart muscle), endocarditis (inflammation of the inner lining of the heart) and pericarditis (inflammation of the outer lining of the heart).
Lethal outcome.

What you can do

Consult your doctor to avoid possible complications. If a streptococcal etiology is confirmed, you will be prescribed antibiotics. It is imperative to carry out a course of antibiotic therapy in its entirety.

What a doctor can do

A doctor can do an examination, prescribe laboratory tests, prescribe an antibiotic to destroy the causative agent of the disease and thereby prevent heart damage.Prescribe symptomatic treatment to alleviate the general condition of the patient.

Your doctor can recommend bed rest and a proper diet in order to increase immunity and strengthen the body’s defenses. Identify complications and prescribe timely treatment.

Preventive measures

See your doctor if you have a sore throat for more than a week.

It is advisable to avoid crowded places and provide good sanitary conditions in your place of residence.

Maintain the body’s natural defenses. Wash your hands before preparing food, especially if you are sneezing or coughing. This will prevent the bacteria that cause sore throat from spreading.