Rheumatic Fever

Rheumatic Fever: Symptoms, Causes, Types, Diagnosis, and Treatments

Rheumatic fever is a serious inflammatory condition that can develop as a complication of untreated or poorly treated streptococcal throat infections, particularly in children. Though less common in developed nations due to the widespread use of antibiotics, it remains a significant health concern in developing countries. The disease primarily affects children between the ages of 5 and 15 and can have lasting effects on the heart, joints, skin, and brain.

In this comprehensive guide, we will explore everything you need to know about rheumatic-fever — from its causes and symptoms to diagnosis, treatment, and prevention strategies.

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1. What Is Rheumatic Fever?

Rheumatic fever is an inflammatory disease that may develop after a Group A Streptococcus (GAS) infection, such as strep throat or scarlet fever. It is not an infection itself but a delayed autoimmune response. The body’s immune system, while fighting the streptococcal bacteria, mistakenly attacks its own tissues — particularly the heart, joints, skin, and brain.

Rheumatic-fever can lead to rheumatic heart disease, a condition that causes permanent damage to the heart valves and is one of the most serious complications.

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2. Causes of Rheumatic Fever

The primary cause of rheumatic-ever is an untreated or inadequately treated infection with Group A Streptococcus bacteria, which commonly causes:

• Strep throat
• Scarlet fever

Pathogenesis: How It Happens

1. Initial Infection: A child or adult contracts a strep throat infection.
2. Immune Response: The body mounts an immune defense against the streptococcal bacteria.
3. Molecular Mimicry: Antibodies produced against the bacteria cross-react with the body’s own tissues.
4. Inflammation: Inflammation occurs in organs such as the heart, joints, skin, and central nervous system.

Not everyone who has strep throat will develop rheumatic-fever — genetic predisposition and other factors contribute to susceptibility.

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3. Risk Factors

Certain individuals are more at risk for developing rheumatic fever. These include:

• Age: Children aged 5–15 are most commonly affected.
• Geography: More common in developing countries with limited access to healthcare.
• Socioeconomic Status: Poor housing, overcrowding, and lack of medical care increase risk.
• Family History: A genetic predisposition can increase likelihood.
• Untreated Strep Infection: Delayed or no antibiotic treatment increases risk.

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4. Symptoms of Rheumatic Fever

Symptoms usually begin 2–4 weeks after a streptococcal throat infection. They can vary widely and may affect multiple organ systems.

Major Symptoms

1. Fever – Often moderate to high.
2. Polyarthritis – Migratory joint pain and swelling, often in knees, ankles, elbows, or wrists.
3. Carditis – Inflammation of the heart, leading to murmurs, chest pain, or heart failure symptoms.
4. Chorea (Sydenham’s Chorea) – Involuntary jerky movements, usually affecting the face, hands, and feet.
5. Erythema Marginatum – A rare, ring-shaped rash with pink borders.
6. Subcutaneous Nodules – Painless lumps under the skin, typically near joints.

Minor Symptoms

• Fatigue
• Shortness of breath
• Abdominal pain
• Rapid heartbeat
• Nosebleeds

The diagnosis is based on a combination of major and minor criteria (Jones Criteria), discussed further below.

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5. Types of Rheumatic Fever

Rheumatic fever is generally classified based on its primary manifestations and severity:

1. Acute Rheumatic-Fever

• Occurs shortly after a strep throat infection.
• Symptoms may resolve with treatment but can recur.

2. Recurrent Rheumatic-Fever

• Multiple episodes over time.
• Increases risk of permanent heart valve damage.

3. Rheumatic Heart Disease

• A long-term consequence of rheumatic-fever.
• Involves scarring and deformity of heart valves.
• Can result in chronic heart failure, arrhythmias, or stroke.

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6. Complications

Without proper treatment, rheumatic-fever can cause severe and permanent damage.

Short-Term Complications

• Severe joint pain
• Fever and malaise
• Acute heart inflammation (myocarditis)

Long-Term Complications

• Rheumatic Heart Disease (RHD) – The most serious consequence.
• Valve Stenosis or Regurgitation – May require surgical repair or replacement.
• Congestive Heart Failure
• Atrial Fibrillation
• Stroke – Due to emboli from damaged valves.

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7. Diagnosis

Diagnosis is made based on clinical evaluation, history, physical examination, and specific tests. The Jones Criteria, established by the American Heart Association, are used for diagnosis.

Jones Criteria (Revised)

Major Criteria

• Carditis
• Polyarthritis
• Sydenham’s chorea
• Erythema marginatum
• Subcutaneous nodules

Minor Criteria

• Fever
• Arthralgia
• Elevated ESR or CRP
• Prolonged PR interval on ECG

A diagnosis typically requires:

• 2 major criteria, or
• 1 major + 2 minor criteria, plus evidence of recent streptococcal infection

Laboratory and Diagnostic Tests

• Throat Swab Culture – To detect streptococcus.
• Anti-Streptolysin O (ASO) Titer – Indicates recent strep infection.
• Echocardiogram – To assess heart involvement.
• Electrocardiogram (ECG) – May show PR interval prolongation.
• Blood Tests – To check inflammation markers like ESR, CRP.

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8. Treatment Options

The primary goals of treating rheumatic fever are to eliminate the streptococcal bacteria, reduce inflammation, manage symptoms, and prevent recurrence.

1. Antibiotic Therapy

• Penicillin is the drug of choice.
• If allergic: alternatives like erythromycin or azithromycin.
• A full 10-day course is essential.

2. Anti-inflammatory Treatment

• Aspirin – Reduces joint pain and inflammation.
• Corticosteroids – Used in severe carditis or when aspirin fails.

3. Symptomatic Treatment

• Anticonvulsants or sedatives – For chorea.
• Bed Rest – Essential in acute stages, especially with heart involvement.

4. Long-Term Antibiotic Prophylaxis

To prevent recurrence:

• Monthly penicillin injections or
• Oral antibiotics daily

This may continue for:

• 5–10 years, or
• Until age 21 or longer if heart involvement persists.

5. Surgical Treatment (If Required)

• Valve repair or replacement may be needed in advanced rheumatic heart disease.

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9. Prevention

Primary Prevention

• Early diagnosis and treatment of strep throat.
• Complete the full antibiotic course.

Secondary Prevention

• Regular prophylactic antibiotics in individuals with prior rheumatic-fever.
• Health education about throat infections and hygiene.

Community-Level Prevention

• Improve living conditions to reduce overcrowding.
• Increase access to healthcare in low-resource areas.
• Mass treatment programs in high-incidence regions.

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10. Living with Rheumatic Fever

Lifestyle Tips

• Take all prescribed medications.
• Regular follow-up with a cardiologist.
• Avoid strenuous activity if heart is affected.
• Practice good dental hygiene — dental infections can exacerbate heart disease.
• Maintain a healthy diet and weight.

Psychosocial Support

• Children and teens may struggle emotionally due to illness limitations.
• Family and school support are crucial.
• Psychological counseling may be needed for children with chorea or long-term effects.

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12. Conclusion

Rheumatic fever, though preventable, remains a pressing global health issue in many regions. Prompt treatment of streptococcal infections is key to avoiding this potentially life-altering condition. With proper care, antibiotic prophylaxis, and regular follow-ups, most individuals can lead normal, healthy lives without long-term complications.

Frequently Asked Questions (FAQs) About Rheumatic Fever

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