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Rheumatic Fever
What causes acute rheumatic fever?
Acute Rheumatic fever is initiated by a throat infection with a specific bacterium called Group A Streptococcus. Usually three weeks after this throat infection, the affected person shows signs and symptoms of acute rheumatic fever. Not everybody in the specified age group who get throat infection with these bacteria develop acute rheumatic fever. It is seen only in certain susceptible individuals who are genetically predisposed to this disease. The disease does not spread from one person to another. What are the signs and symptoms of acute rheumatic fever? Rheumatic fever is a multi-system disease, affecting primarily, the joints, the heart, the brain and the skin and the tissue beneath the skin. Fever with joint pains usually following a history of sore throat three weeks earlier alerts the paediatrician to the possibility of rheumatic fever in the patient. Large joints, most commonly, the knees, ankles, wrists and elbows are affected. Small joints like the finger joints or rib cage joints are never involved. The joints are swollen, warm, painful even at rest, and this pain gets worse with movement of the joints. What is most characteristic is that all joints are not affected at the same time and the arthritis is called migratory. First, one of the joints is affected and then the swelling and pain moves to another joint, while the joint affected earlier gets better and so on. The fever is seen only during the early course of the disease. The arthritis lasts for two to three weeks. As regards the heart, acute rheumatic fever tends to affect the valves, specifically the two valves on the left side of the heart – the Mitral and the Aortic valve. The disease process attacks the tissue of the valves destroying them so that the valves no longer function properly. This may result in either severe leaking of the valves or severe obstruction to blood flow across the valves leading to heart failure and lung congestion. The child has breathing difficulties and may develop swelling of the face, hands and feet. The brain is not affected as frequently as the joints and the heart. When it is affected, it results in a condition called chorea. Such patients have involuntary, purposeless movements of the body, hands and legs. Such movements are also seen in the muscles of the face and tongue. Speech is halting and explosive. Usually these symptoms resolve within one or two weeks even without treatment. A typical rash with a red border is the effect of the fever on the skin. This is seen very rarely and is difficult to appreciate in dark skinned patients and hence may be missed most of the time. A nodule under the skin, particularly over the joints is another less commonly seen effect of rheumatic fever. Are there any tests, which would confirm rheumatic fever?
Why should rheumatic fever be diagnosed early and treated early? As mentioned above, rheumatic fever can affect the joints, the heart, the brain and the skin. Of these, all the effects except those on the heart resolve spontaneously. Once the heart valves are damaged, they are damaged for the rest of the patient's life. What is even worse is the fact that the damaged valves continue to have a bad effect on the heart and the lung circulation, and so the patient becomes progressively more and more sick with time. If rheumatic fever is diagnosed early and the treatment started immediately, the degree of heart damage can be prevented or controlled. What are the precautions that the patient needs to take once a diagnosis of rheumatic fever is made? As the patients are genetically prone, rheumatic fever can attack the same patient repeatedly. When this happens, the risk of the heart getting affected or if already damaged, the risk of worsening of the damage is high. So once a patient has been convincingly diagnosed to have rheumatic fever, he or she needs to take preventive treatment with Penicillin until he or she is 25 years of age. Penicillin is highly effective in killing the streptococcus, the bacteria that causes throat infection, and later on leads to rheumatic fever. Therefore, regular treatment with penicillin prevents repeated throat infection. It is also very important that a correct diagnosis of rheumatic fever is made in patients as they become subjected to unnecessary penicillin treatment for a long time. Can patients who have had their heart damaged by rheumatic fever lead a normal life?
Dr.R.Prem Sekar
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Rheumatic fever is the most common cause of acquired heart disease in children and young adults throughout the world. While the number of patients getting rheumatic fever has reduced dramatically in the western countries, it is seen to be highly prevalent in developing countries including India. It commonly affects children in the age group between 5 years and 15 years. It is very rare in children under the age of five. However it is increasingly seen in young adults and parents of school going children. Rheumatic fever is also typically seen in children in the lower socio-economic group.
Unfortunately, there is no test that can make a conclusive diagnosis of rheumatic fever. The diagnosis is made clinically from the above features seen in a patient. However, there are a few blood tests, which can aid in the diagnosis. The test is called ASO titre and if the values are above the normal limit, is indicative of a possible infection in the patient with the specific streptococcal bacteria which leads to rheumatic fever. 
This depends on the extent of damage to the heart. In cases where there is only a mild damage, the patient should be able to lead a normal life with the help of medications. In those with severe valve damage in the heart, open-heart surgery will be required. If the valve is not repairable, then an artificial valve will need to be placed in the heart instead of the affected valve. Such patients would require extra careful monitoring during pregnancy. Even after heart surgery, the patient will need to continue with the preventive penicillin treatment.
