Rheumatic Fever

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or poorly treated streptococcal throat infection (strep throat). It primarily affects children and young adults and can cause long-term damage to the heart and other organs.

Aetiology

Rheumatic fever is caused by an immune response to infection with Group A Streptococcus (GAS) bacteria. The body’s immune system mistakenly attacks its own tissues, leading to inflammation in the heart, joints, skin, and central nervous system.

Pathophysiology

The pathophysiology of rheumatic fever involves:

• Initial infection with Group A Streptococcus, typically causing pharyngitis (strep throat).
• The body mounts an immune response against the bacteria.
• In some individuals, cross-reactivity occurs, where the immune system attacks the body's own tissues that have molecular similarities to the bacterial antigens.
• This leads to inflammation and damage in various organs, particularly the heart (rheumatic heart disease), joints (arthritis), skin (erythema marginatum), and central nervous system (Sydenham's chorea).

Risk Factors

• Age: Most common in children aged 5-15 years
• Previous history of rheumatic fever
• Family history of rheumatic fever or rheumatic heart disease
• Living in crowded or unsanitary conditions
• Untreated or poorly treated streptococcal throat infections

Signs and Symptoms

The signs and symptoms of rheumatic fever include:

• Fever
• Painful and swollen joints (arthritis), particularly in the knees, ankles, elbows, and wrists
• Chest pain or palpitations (carditis)
• Fatigue
• Shortness of breath
• Skin rash (erythema marginatum)
• Small, painless nodules under the skin (subcutaneous nodules)
• Involuntary, jerky movements (Sydenham's chorea)

Investigations

Specific investigations to diagnose rheumatic fever include:

• Throat culture: To identify Group A Streptococcus.
• Rapid antigen detection test: For quick detection of streptococcal antigens.
• Antistreptolysin O (ASO) titre: To measure antibodies against streptococcal bacteria.
• Full blood count (FBC): To check for elevated white blood cell count and markers of inflammation.
• Echocardiography: To assess for carditis and heart valve damage.
• Electrocardiogram (ECG): To detect heart rhythm abnormalities.

Management

Primary Care Management

• Antibiotics: To eradicate the streptococcal infection. Penicillin is commonly used, or erythromycin if the patient is allergic to penicillin.
• Anti-inflammatory treatment: Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and relieve pain.
• Bed rest: To reduce the strain on the heart and prevent complications.

Specialist Management

• Hospitalisation: For severe cases, particularly if there is carditis or other complications.
• Corticosteroids: May be used in severe cases of carditis to reduce inflammation.
• Management of heart failure: If heart failure develops, appropriate treatments including diuretics, ACE inhibitors, or beta-blockers may be necessary.
• Long-term prophylaxis: Long-term antibiotic prophylaxis (e.g., penicillin) to prevent recurrent streptococcal infections and subsequent rheumatic fever episodes.
• Regular follow-up: Monitoring for potential complications such as rheumatic heart disease.

References

1. NHS (2024) Rheumatic fever. Available at: https://www.nhs.uk/conditions/rheumatic-fever/ (Accessed: 24 June 2024).
2. Centers for Disease Control and Prevention (2024) Rheumatic Fever. Available at: https://www.cdc.gov/groupastrep/diseases-hcp/rheumatic-fever.html (Accessed: 24 June 2024).
3. World Health Organization (2024) Rheumatic Fever and Rheumatic Heart Disease. Available at: https://www.who.int/cardiovascular_diseases/en/cvd_rheumatic_fever_rheumatic_heart_disease.pdf (Accessed: 24 June 2024).
4. British Medical Journal (2024) Rheumatic fever: clinical features, diagnosis, and management. Available at: https://www.bmj.com/content/350/bmj.h2825 (Accessed: 24 June 2024).

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