Rheumatic fever

At a rheumatic fever inflammation of the heart, joints, skin or brain occurs. The disease occurs as a result of untreated bacterial infection with group A streptococci.

What is rheumatic fever?

The rheumatic fever, also Streptococcal Rheumatism is a secondary disease of an upper respiratory tract infection that has become rare in our part of the world.

The disease occurs mainly in childhood. The damage often only becomes apparent decades later. The symptoms of rheumatic fever appear a few weeks after a sore throat and are manifested in a high fever and pain and swelling in the knee, ankle or elbow joints.

A reddish skin rash also indicates a rheumatic fever. Conjunctivitis or tendinitis can also occur. If the heart muscle is affected, chest pain and shortness of breath occur.

causes

The rheumatic fever is triggered by a streptococcal infection, which occurs as a long-term consequence of a sore throat. The tissue damage is caused by an exaggerated defense reaction of the body's own immune system.

The antibodies produced by the body react with its own body cells. A few decades ago the disease was relatively widespread. Many elderly people suffer from mitral valve stenosis as a result of childhood infection. The narrowing of the mitral valve reduces blood flow in the heart. Those affected suffer from tiredness, shortness of breath and palpitations.

The disease is still widespread in developing countries today. Inferior nutrition, many people concentrating in a small space and untreated throat and tonsillitis encourage the occurrence of rheumatic fever.

Symptoms, ailments & signs

The symptoms of rheumatic fever can affect several areas. Symptoms of the skin, joints, heart or brain can occur. Often it starts with a flu-like condition. Patients have a fever and general weakness. In children, there is often also stomach pain.

Various symptoms are possible on the skin. Erythema nodosum occurs relatively often on the lower leg. These are inflamed and painful red spots with nodules that form on the shin. In terms of appearance, they are reminiscent of bruises. It is also possible that skin spots appear on the abdomen and back.

In addition, so-called rheumatoid nodules can form on the arms and legs. Arthritis of the large joints is another symptom. It usually begins symmetrically at the knee and ankle joints, then jumps to other joints and causes severe pain. If the heart is affected, inflammation develops either on the heart muscle tissue (myocardium) or on the inner lining of the heart (endocardium).

This can cause heart valve dysfunction, arrhythmias, or tachycardia. The death of microscopic tissue particles or the formation of so-called Aschoff nodes on the heart muscle are also possible. When listening, this is noticeable in changed heart sounds. Finally, encephalitis can develop in the brain, which manifests itself in apathy, fear and untargeted, involuntary movements (Sydenham's chorea).

Diagnosis & course

In adults it is rheumatic fever difficult to diagnose as the clinical picture is rather untypical. A physical exam is necessary. If a rheumatic fever is suspected, a throat swab is taken and examined for streptococci.

An X-ray of the chest shows whether the heart has enlarged as a result of the inflammation. With the help of echocardiography, the heart valves and the interior of the heart can be visualized using ultrasound. The doctor will order a blood sample.The laboratory values ​​show an increased white blood cell count and an increased number of antibodies against streptococci if there is an infection.

The Jones criteria published by the American Heart Association in 1992 are used to diagnose rheumatic fever. The course of the disease begins with an inflammation of the tonsils or throat, which has not been treated. This is followed by one to three symptom-free weeks.

Then rheumatic fever occurs, which lasts up to twelve weeks. The disease is very protracted. If the heart valves are inflamed, scarring can appear years later. About half of all patients develop chronic rheumatic heart disease.

Complications

The rheumatic fever mainly causes malfunction of the heart valves. The disease is the most common cause of permanent heart disease such as heart valve inflammation and, later, heart failure. In the classic form, which usually occurs in childhood, inflammation of the inner lining of the heart is possible.

If the course is severe, cardiac arrest and death of the patient can occur. The joints, which become inflamed, swollen and cause severe pain, are usually also affected. In general, rheumatic endocarditis is associated with severe physical discomfort. The affected person usually suffers from chronic pain, sweating and high fever - each of these symptoms is associated with further complications.

In the long term, the disease affects mental well-being and can lead to ailments such as depression or anxiety disorders. Treatment with the antibiotic agent penicillin can lead to rashes, nausea and vomiting, and loss of appetite. Often there are also inflammation of the mucous membranes, dry mouth and impaired taste sensation.

Occasionally also anemia and transient liver dysfunction. The acetylsalicylic acid used to inhibit inflammation can cause heartburn, dizziness and gastrointestinal bleeding, among other things. The use of cortisone and immunosuppressants can also cause a number of side effects.

When should you go to the doctor?

If you experience a fever, rash, and joint pain, it may be caused by rheumatic fever. A doctor's visit is recommended if symptoms persist after a day or two. If other symptoms occur, such as chest pain or the typical jerky movements, you should consult a doctor. The rheumatic fever usually occurs in connection with a streptococcal infection. Children between the ages of five and fifteen also belong to the risk groups and should be treated by a doctor if the symptoms mentioned occur.

Other favorable factors are unsanitary living conditions and an unbalanced diet. Rheumatic fever is treated by a family doctor or an internist. The dermatologist is the right contact for any skin changes. If the condition is treated during the initial sore throat, the rheumatic fever can often be averted. On the other hand, heart damage that has already occurred cannot be repaired and also increases the risk of further flare-ups. Therefore, in the event of a severe sore throat with fever and joint pain, the general practitioner or pediatrician should be involved immediately. The doctor can carry out a rapid streptococcal test and thereby quickly make the diagnosis.

Treatment & Therapy

The patient is prescribed strict bed rest for about fourteen days. The drug treatment is started immediately. The administration of penicillin serves to kill the streptococci and should take place over a period of ten days.

If there is an allergy to penicillin, macrolides are given. Anti-inflammatory drugs lower the fever and reduce inflammation of the joints. Common active ingredients are ibuprofen, indomethacin or piroxicam. Corticosteroids are prescribed for inflammation of the heart. These active ingredients are similar to the body's own hormones.

The inflammation is relieved by the active ingredient inhibiting the formation of the natural substances that ultimately trigger the inflammation. At this point, cortisone, prednisolone or dexamethasone should be mentioned. The duration of drug treatment depends on the severity of the disease.

As a rule, the drugs are prescribed until the age of 21 or up to five years after the last onset of rheumatic fever. In severe cases of illness, drug treatment is recommended for up to ten years after the rheumatic fever has occurred.

You can find your medication here

prevention

Since sore throats are treated with antibiotics, the occurrence of rheumatic fever has become a rarity in western industrialized countries. As a preventive measure, febrile diseases of the upper respiratory tract should not be taken lightly. The doctor will decide to what extent the administration of antibiotics is necessary. A recurrence of rheumatic fever can be prevented by taking small doses of antibiotics for several years after the last occurrence of the disease.

Aftercare

In general, after the disease has subsided, long-term therapy with monthly intramuscularly administered benzathine penicillin is carried out as follow-up treatment up to the age of 25; alternatively, however, penicillin can also be administered orally. If there are still impairments to the heart or joints, rehabilitation in the form of physiotherapy is recommended.

In any case, regular cardiac exams are prescribed. In general, children and young adults with resolved rheumatic fever are at high risk of relapses (relapses) in the next five years or for life. Any further disease of the upper respiratory tract caused by Streptococcus A could develop carditis; without further follow-up care, the risk is even 20 percent.

Therefore, depending on whether you already had a rheumatic fever with or without carditis, you will be given antibiotic prophylaxis for five (without carditis) to ten years (with carditis) after the therapy has been completed. If the heart valve defect persists, antibiotic follow-up treatment is sometimes prescribed up to the age of 40 or sometimes for life.

In the case of surgical interventions, endocarditis prophylaxis should also be administered. For environmental prophylaxis, it is recommended that all family members of the affected person have a throat swab to detect the streptococcal A group. If this is positive, the affected family members are also prescribed antibiotic treatment.

You can do that yourself

This disease, which has become rare in Germany, belongs in the hands of family doctors, paediatricians or internists. If the skin is affected, patients should also contact a dermatologist.

If a rheumatic fever is diagnosed, it is extremely important for the patient to take the medication prescribed by the doctor, otherwise the heart can be irreversibly damaged or even fatal. The prescribed bed rest must also be observed. Because most of the people affected are children, parents must pay close attention to following the doctor's instructions. This is possibly made more difficult by the fact that the drugs commonly used for treatment can trigger severe side effects that prevent compliance. However, children in particular have to take the medication for a longer period of time, usually until they are 21 years old.

Since the disease is the result of a streptococcal infection, hygienic measures are often required. This includes cleaning the surrounding area because the bacteria are found on surfaces, taps and door handles that have not been cleaned. Food can also contain streptococci. Therefore, in a household where a patient suffers from rheumatic fever, food should be washed thoroughly before use. The same goes for the hands of all family members, by the way. Frequent washing can prevent infections and reinfections.