Rheumatic Fever (Pediatric Rheumatic Fever)

Rheumatic Fever
Body Parts: Whole Body
Medical Subjects: Children's Health Rheumatism

What Is Rheumatic Fever?

Rheumatic fever is an autoimmune disease caused by the immune system of the body attacking its normal tissues after the throat is infected with Group A hemolytic streptococcus.

Rheumatic fever has five typical manifestations: migratory polyarthritis, carditis, subcutaneous nodules, annular erythema, and chorea.

Treatment of rheumatic fever includes removal of streptococcal infection, reduction of joint and heart damage, and management of various complications.

Is rheumatic fever a common disease?

Rheumatic fever was common before the middle of the 20th century, after which the incidence of rheumatic fever decreased significantly in all countries of the world, especially in developed countries.


What Is The Cause Of Rheumatic Fever?

What causes rheumatic fever?

  • Group A hemolytic streptococcal infection and autoimmune system disorders: Group A type B hemolytic streptococcus infection can cause confusion in the human immune system, causing the immune system to attack its normal tissues and organs while attacking streptococci. Such as joint synovium, synovial fluid, cartilage, myocardium, heart valves, etc., resulting in organ damage.
  • Genetic factors: may also be associated with the onset of rheumatic fever.
  • Bacterial exotoxin: Group A B hemolytic streptococcus can produce harmful substances such as exotoxin and have a toxic effect on human organs directly.

Is rheumatic fever related to the environment?

  • Rheumatic fever has a certain relationship with the environment, but the damp itself does not lead to rheumatic fever.

  • Crowded room, lack of nutrition, lack of medicine and other factors, is conducive to the reproduction and spread of streptococcus, will lead to an increased incidence of rheumatic fever. Rheumatic fever and rheumatic heart disease remain common and serious in developing countries. The incidence is also high in rural and remote areas of the country.

  • However, in recent years, the incidence rate of children from relatively wealthy families is also increasing, and the atypical symptoms of rheumatic fever and vague symptoms (occult disease) of rheumatic fever are increasing.

  • The damp environment itself will not lead to rheumatic fever. In fact, the germs in the damp environment and the health care and medical level in this living condition are the reasons why rheumatic fever cannot be controlled in time.

Is the onset of rheumatic fever related to season?

The disease often occurs in rainy seasons in winter and spring.

What age group does rheumatic fever happen to?

Rheumatic fever can occur at any age, most commonly in children and adolescents aged 5 to 15 years.


What Is The Symptoms Of Rheumatic Fever?

What are the manifestations of rheumatic fever before its onset?

One to six weeks before the typical symptoms of rheumatic fever appear, there are often pharyngolaryngitis or tonsillitis (the manifestation of pharyngeal streptococcus infection), such as fever, sore throat, cough and submandibular lymph node enlargement. Some patients have such uncomfortable symptoms as fatigue, fatigue, nosebleed, and abdominal pain.

What are the typical manifestations of rheumatic fever?

Rheumatic fever has five typical manifestations: migratory polyarthritis, carditis, subcutaneous nodules, annular erythema, and chorea. These manifestation may occur alone or together.

Do rheumatic fever patients have fever?

Not necessarily. 50%–70% of patients have fever, most of which is mild or moderate (rarely over 39℃).

What are the manifestations of arthritis caused by rheumatic fever?

Arthritis caused by rheumatic fever is mainly manifested as migratory polyarthritis. It mainly involves large joints such as knee, ankle, elbow and wrist, manifested as red, swollen, hot, painful and limited mobility. The arthritis in each joint spontaneously resolves after a period of several days without leaving any deformity, but it often recurs. Joint pain generally resolves within 2 weeks and rarely lasts for more than a month.

Arthritis caused by rheumatic fever can also occur in other joints, but it is relatively rare, such as hip joints, finger joints, mandibular joints, sternoclavicular joints, etc.

What are the manifestations of carditis caused by rheumatic fever?

Carditis is the most serious manifestation of rheumatic fever, with the main symptoms including palpitations after exercise, shortness of breath, and chest (precordial) discomfort. According to the different sites, it can be divided into heart valve inflammation, myocarditis and pericarditis.

Heart valve inflammation is the most common. Rheumatic fever occurs repeatedly and can gradually develop into chronic valvular heart disease, which is called rheumatic heart disease or rheumatic heart disease for short. It mainly manifests as one or more valve stenosis and/or insufficiency of mitral, tricuspid and aortic valves. Rheumatic heart disease often shows no obvious symptoms at the initial stage, but it may show such symptoms as palpitation, short breath, fatigue, cough, hemoptysis (cough and hemorrhage), and edema of both lower limbs at the later stage.

What is annular erythema of rheumatic fever?

Annular erythema is a rash that presents as pale red annular spots, varying in size and with a pale center, which are distributed on the trunk and four limbs near the trunk and generally appear suddenly and resolve after a few hours or a day or two, which no longer occurs after resolution. In a few patients, however, annular erythema occurs intermittently and repeatedly, which can last for several weeks. Annular erythema usually occurs later after streptococcal infection.

What is the subcutaneous nodule of rheumatic fever?

Subcutaneous nodules may occur in a small number of patients with rheumatic fever. The subcutaneous nodules of rheumatic fever are small, slightly hard and painless nodules that do not adhere to the skin and have a diameter of 0.1~1 cm, and appear on the outwardly protruding surfaces (extensor surfaces) of joints such as elbow, knee and wrist, or at the positions of posterior brain and spinal eminence. There was no inflammatory change such as swelling on the surface skin. Subcutaneous nodules are often accompanied by carditis, which is one of the manifestations of rheumatic activity.

What is chorea?

Chorea is uncommon and occurs mainly in children aged 4 to 7 years. It manifests as aimless and involuntary movements of the whole body or local muscles, such as winking, shrugging and necking, and tongue twirling. There may also be rhythmic alternating movements of flexion and extension of four limbs, which aggravates when excited and disappears after falling asleep. Children are often accompanied by emotional instability.

Chorea can last for about one to three months, and individual cases recur within one to two years. A small number of children will have sequelae to varying degrees.

What diseases can rheumatic fever cause?

The most common complications of rheumatic fever are infective endocarditis and respiratory tract infection. Patients with chronic or recurrent rheumatic fever may develop hypertension, hyperlipidemia, hyperglycemia, and hyperuricemia, which are mostly caused by the long-term use of glucocorticoids. Middle-aged and old rheumatic fever patients may be combined with coronary heart disease, myocardial infarction and other diseases.


How To Check Rheumatic Fever?

What are the abnormal laboratory results suggesting rheumatic fever?

  • Evidence of positive streptococcal infection.

  • Pharyngeal swab culture: It is carried out by wiping the secretion off the mucosa of the pharynx, and streptococcus can be cultured in some patients, thus supporting the diagnosis.

  • Antistreptolysin O (ASO): ASO is positive about 2 weeks after streptococcal infection, and the positive rate is 50%–75%.

  • Anti-DNA enzyme B: the positive rate was the same as that of ASO, and it could be tested jointly with ASO.

  • Others: including anti-streptococcus kinase (ASK), anti-hyaluronidase (AH).

  • Increased inflammatory reactants: erythrocyte sedimentation rate and C-reactive protein could be increased.

  • Immunological examination: IgM, IgG and complement C3 can be increased. Other unusual specific tests such as anti-myocardial antibodies can be positive.

What test can determine whether there is carditis?

  • Electrocardiogram: helps to find arrhythmia.

  • Echocardiography: valvulitis, myocarditis and pericarditis can be seen.

  • Myocardial radionuclide examination: The extent and severity of myocardial involvement can be detected.

These tests are performed by the doctor depending on the condition and hospital conditions and can also be used as a tool for post-treatment follow-up.

What diseases are similar to rheumatic fever and need to be distinguished?

  • Rheumatoid arthritis: Rheumatoid arthritis is persistent and symmetrical. When getting up in the morning, the symptoms of joint stiffness are obvious. The laboratory test of the hospital shows positive rheumatoid factor. The imaging test shows obvious damage to bone and joint.

  • Reactive arthritis: history of intestinal or urinary tract infection, mainly lower extremity arthritis. With tendinitis, lumbago, and human leukocyte antigen (HLA)-B27 positivity.

  • Allergic arthritis due to tuberculosis infection: History of tuberculosis infection, positive tuberculin skin test, unsatisfactory efficacy of non-steroidal anti-inflammatory drugs (aspirin, etc.), and effective anti-tuberculosis treatment.

  • Subacute infective endocarditis: there is worsening anemia (progressive anemia), ecchymosis, splenomegaly, vascular embolism, and blood culture can produce bacteria.

  • Viral carditis: Pre-symptoms of viral infection such as nasal obstruction, nasal discharge and lacrimation occur. The titer of virus antibody detected is increased, and obvious arrhythmia may occur.


How To Prevent Rheumatic Fever?

Can rheumatic fever be prevented?

Rheumatic fever can be prevented, including primary prevention and secondary prevention.

What is the primary prevention of rheumatic fever?

Primary prevention refers to the prevention of rheumatic fever. Including:

  • Improve social and economic conditions, improve the living environment, improve the nutritional status of residents.
  • To carry out physical exercise, enhance physical fitness.
  • Cold, moisture, and actively prevent streptococcus infection.
  • Completely treat streptococcus infection.

What is the secondary prevention of rheumatic fever?

The secondary prevention refers to prevent the recurrence of rheumatic fever, prevent the occurrence of rheumatic heart disease.

  • Benzathine penicillin was the first choice for secondary prevention. The general dose was 1.2 million units, and intramuscular injection was conducted once every 3–4 weeks. Duration and dose of prevention should be determined according to the age of the patient, susceptibility to streptococcus infection, the number of relapses, and whether the heart is damaged.
  • In patients with pure arthritis, the duration of prevention is maintained until the age of 21 years and a minimum of 5 years in pediatric patients and 5 years in adult patients.
  • In patients with cardiac involvement without valve damage, the period of prevention is at least 10 years, and in children it is up to 21 years of age and at least 10 years.
  • For young patients, susceptible tendency, repeated rheumatic fever attack, had carditis or valvular disease patients, prevention period should be extended as far as possible, to 40 years old and at least 10 years, or even a lifetime prevention.

How To Treat Rheumatic Fever?

How to treat rheumatic fever?

  • General treatment: including attention to rest, keep warm, especially in patients with carditis, should be more bed rest, after the condition is controlled and stable gradually restore activity.

  • Elimination of streptococcal infection: Benzathine penicillin is preferred, and preventive medication for recurrent rheumatic fever or rheumatic heart disease depends on the condition. People who are allergic to penicillin can use other antibiotics instead.

  • Anti-rheumatism treatment: Non-steroidal anti-inflammatory drugs are the first choice for arthritis patients, and aspirin is often used. Small dose maintenance treatment can be conducted after the condition is relieved. The course of treatment for simple arthritis is 4–8 weeks. Glucocorticoid therapy should be used for carditis. A sedative and antirheumatic treatment for chorea.

  • Complication treatment: Patients with rheumatic fever are prone to suffer from pulmonary infection during the disease activity, and may suffer from complications such as cardiac insufficiency and metabolic disorder. It is necessary to timely find and handle the complications during the treatment.

How should rheumatic carditis be treated?

Treatment needs to be conducted under the guidance of a professional physician throughout the course. Cardiac inflammation should be treated with glucocorticoids for a minimum of 12 weeks.

If the condition does not improve, glucocorticoid treatment should be extended for 9 months or even more than one year according to the situation, and aspirin can be used together until the disease is completely recovered. Follow-up visits should be made regularly thereafter for cardiac examinations.

What is subclinical rheumatic carditis? How to treat?

Subclinical rheumatic carditis is rheumatic carditis without obvious symptoms. If you have no previous history of carditis and a recent history of rheumatic fever, you only need to follow up regularly and insist on benzathine benzylpenicillin for injection prevention without special treatment. At ordinary times should avoid heavy manual labor, on the other hand should also be moderate activity and exercise.

For patients who have suffered from carditis or rheumatic heart disease, specific treatment measures can be formulated according to the changes of laboratory tests, echocardiography, ECG and signs, and 1 course of anti-rheumatic treatment can be applied if necessary.

How to treat rheumatic chorea?

Treatment should be performed under the guidance of a skilled physician. Patients with chorea should try to avoid strong light, noise stimulation, the use of sedatives (such as valproic acid), at the same time anti-rheumatic treatment. Glucocorticoids and immunosuppressive agents may also be effective for chorea. Gamma globulin or hormone shock therapy can be given to critically ill patients.

How to treat chronic rheumatic heart disease?

  • The combination of work and rest, the appropriate exercise and physical labor.

  • Active prevention of streptococcus infection and treatment of rheumatic activity.

  • Preventing and treating complications such as infection, arrhythmia, and heart failure.

  • Anticoagulation may be applied as appropriate.

  • Interventional and surgical treatment is performed as necessary.

Is rheumatic fever easy to recur?

Some studies have shown that the recurrence rate of rheumatic fever is about 30%, mostly within 2 to 5 years.

What is the prognosis of rheumatic fever?

  • In general, the earlier diagnosis and treatment is made, the better the result will be. Approximately 70% of patients with acute rheumatic fever recover within two to three months.

  • The younger the patient is, the more serious the illness will become and the worse the prognosis will become. Hence, death is likely to occur. Conversely, the older the patients are, the milder the condition will be and the prognosis will be good.

  • Patients with combined heart diseases such as heart failure, infective endocarditis, coronary heart disease and myocardial infarction have poor prognosis.


What Should Patients With Rheumatic Fever Pay Attention To In Life?

What should patients with rheumatic fever pay attention to in daily life?

  • Improve living conditions, avoid living environment crowded (such as college students, military dormitory, etc.)

  • Eat well and avoid malnutrition.

  • To carry out physical exercise, enhance physical fitness.

  • Prevent cold and streptococcus infection; Visit doctor in time when pharyngitis and tonsillitis occur.

  • Wash hands frequently and use detergents such as soap.

  • Food should be thoroughly cooked, leftovers should be fully heated, and clean disposable gloves should be used when food is handled by hand.

Will rheumatic fever affect fertility?

Rheumatic fever in general does not affect fertility. If accompanied by other symptoms of rheumatic fever (such as carditis), especially rheumatic heart disease caused by repeated rheumatic fever, it will affect fertility, mainly threatening the safety of mother and child during pregnancy and childbirth.

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