HWN Suggests

Rheumatic Fever – Still A Threat, Believe It Or Not

The hospital wards once set up to care for children with this dangerous disease (it can cripple the heart) had closed. To most young people, the image of the sad-eyed rheumatic fever victim watching from a window while friends romped and played outside was just a scene from some old melodrama, an artistic idea from the past. A dramatic 90 percent drop in the annual rate of new cases since the 1960s seemed to show rheumatic fever was going out with bell bottoms and love beads. Then–like Jason and Freddie and those other indestructible horror movie villains–it was back.

Unwelcome and unexplainable outbreaks of rheumatic fever in places as far apart as Salt Lake City, Pittsburgh, and…

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Featured

 Acute Rheumatic Fever – Don’t Forget about it!

It is certainly safe to say that we’ve done a great job of reducing the incidence of this dreaded complication in the United States (although perhaps overdoing it now with the antibiotics); however, Acute Rheumatic Fever (ARF) still occurs in isolated outbreaks and can easily be encountered in those traveling from abroad. Additionally, ~1/3 of ARF cases result from undetected strep infections. Therefore, it is still important that we know how to recognize and diagnose it.

 Decoding Rheumatic Fever

The bacteria behind the disease picked up their wicked ways from viruses. Doctors can't predict who will contract the disease, in part because strep tests don't distinguish between M18 and other strains.

 From Crisis to Challenge: The Evolving Landscape of Rheumatic Fever in the 20th Century

Imagine a time when childhood strep throat wasn’t just an inconvenience but a potential gateway to heart disease. That was the reality for many children in the 20th century when rheumatic fever reigned as a leading cause of heart problems. But thanks to a remarkable story of public health intervention and scientific advancement, this silent threat has been largely vanquished.

 From the throat to the heart: Charting the long history of rheumatic fever

What eventually clarified the situation was what Brown called the “heroic” antistreptolysin O titer. “The ASO titer showed that the vast majority of patients with rheumatic fever had previous exposure to streptococcus,” he said.

Articles of Interest

Case Presentation: Acute Rheumatic Fever

Acute rheumatic fever (ARF) is a delayed, non-suppurative sequela of infection with group A beta-hemolytic streptococci or Streptococcus pyogenes. The acute phase of ARF is caused by a proliferative inflammatory reaction that involves the connective and/or collagen tissues and commonly affects the heart, joints, brain and subcutaneous tissues, although any organ may be involved.1

Meet Lavenita, Our Rheumatic Fever Fighter

Rheumatic fever is an autoimmune disease which often starts with a sore throat. Also known as 'strep throat', it is caused by bacteria called 'group A Streptococcus' (GAS). While most strep throats get better, if left untreated, it can lead to rheumatic fever. Rheumatic fever causes an autoimmune reaction where the immune system mistakenly attacks other parts of the body as it tries to fight the GAS bacteria. This causes the heart, joints, brain and skin to become inflamed and swollen.

A Child with Fever and Chest Pain

ARF is a sequela of an untreated Group A Streptococcus (GAS) pharyngitis, which typically occurs two to four weeks after infection.[1] Various clinical findings can be present, including carditis, arthritis, chorea, rash (erythema marginatum), and subcutaneous nodules. If left untreated, the disease can cause gradual damage to heart valves, resulting to heart failure. RHD and ARF remain prevalent in the developing world, where people live in crowded conditions with poor sanitation.

Acute Rheumatic Fever and Rheumatic Heart Disease

It is RHD that remains a significant worldwide cause of morbidity and mortality, particularly in resource-poor settings. While ARF and RHD were once common across all populations, improved living conditions and widespread treatment of superficial S. pyogenes infections have caused these diseases to become comparatively rare in wealthy areas. The development of ARF occurs approximately two weeks after S. pyogenes infection. The clinical manifestations and symptoms of ARF can be severe and are described in the Revised Jones Criteria

Acute Rheumatic Fever: An Evidence-Based Approach to Diagnosis and Initial Management

Acute rheumatic fever is an inflammatory reaction involving the joints, heart, and nervous system that occurs after a group A streptococcal infection. It typically presents as a febrile illness with clinical manifestations that could include arthritis, carditis, skin lesions, or abnormal movements. Of these, the cardiac manifestations of acute rheumatic fever are most concerning, as children may present in acute heart failure and may go on to develop valvular insufficiency or stenosis. Because this is a rare presentation to emergency departments in developed countries, it is crucial for clinicians to keep a broad differential when presented with clinical presentations suspicious for acute rheumatic fever.

An Understated Myth? Strep Throat & Rheumatic Fever

The majority of sore throat is viral. Although the historical incidence of ARF and its correlation to strep pharyngitis has led many to believe an antibiotic regimen is necessary to prevent consequential sequelae, no definitive community-based data has ever supported this claim. Unfortunately due to the rarity of ARF in the United States it seems unlikely that such a study will ever be formally conducted. However, correlative data leaves us with an NNT that many would argue does not justify the added risks associated with an antibiotic regimen. For patients in whom symptoms remain the major concern, consider a cocktail of dexamethasone, acetaminophen/ibuprofen, and buckwheat honey instead.

Fresh Concerns About a ‘Forgotten’ Killer

In the 1920s, rheumatic fever was the leading cause of death among young people aged 5 to 20 years in the United States. But since the late 1970s, the condition has become so rare that it ceased to be a reportable disease and most US doctors today have never encountered a death caused by a routine group A Streptococcus infection—better known as strep throat. However, in low-income nations, the unwanted outcome of undertreated strep throat remains a serious threat to child health. Worldwide, more than 40.5 million cases occur and more than 350,000 children and adults a year die from heart damage caused by rheumatic fever.

Launch of “Heart on Your Sleeve” Social Media Campaign

The aim of the social media campaign is to raise awareness about acute rheumatic fever (ARF) and rheumatic heart disease (RHD) within the community at a ground level. Within Australia, Aboriginal and Torres Strait Islander people are almost twenty times more likely to die of RHD.

Medical Mnemonics: Major and Minor Criteria for Rheumatic Fever

Rheumatic fever occurs after a streptococcal infection (usually caused by Group A Beta-Hemolytic Strep (GABHS)). It is an inflammatory condition that affects the joints, skin, heart and brain. Major criteria are referred to as Jones criteria and can be remembered by the mnemonic of the same name.

Predictors of rheumatic fever in sore throat patients: a systematic review and meta-analysis

Rheumatic fever (RF) is an autoimmune disease triggered by group A streptococcal (GAS) pharyngitis that can affect multiple systems including the joints and cardiac tissue. It is thought that both genetic and environmental factors play a role in RF susceptibility, although these factors remain virtually unknown.

Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum

Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts.

Rheumatic fever & rheumatic heart disease: The last 50 years

Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies.

Rheumatic fever in a developed country – is it still relevant?

The findings emphasize that ARF and RHD remain an important cause of morbidity and mortality, with relapses continuing after 9 years, highlighting the need for prolonged prophylaxis.

Rheumatic Fever Licks at the Joints, but Bites at the Heart

Rheumatic fever is the result of an abnormal autoimmune response to group A streptococcal pharyngeal infection in a susceptible host. However, in approximately one-third of cases a history of pharyngeal infection is not elucidated prior to the development of rheumatic fever. In certain individuals, which is not uncommon, streptococcal pharyngeal infection does not result in rheumatic fever.

Rheumatic Fever Week: Bringing long overdue recognition to this preventable condition

Rheumatic Fever itself is an abnormal immune reaction against a common bacterium called Group A Streptococcus. Patients typically experience a range of symptoms that can include joint pain, fever above 38°C, feeling generally unwell and tired with shortness of breath, sometimes a skin rash, and uncontrolled body movements. Rheumatic Fever (RF) is preceded two or three weeks earlier by a bacterial throat infection, commonly called strep throat.

The Full Moon Dance’ – Guest Blog from Christian James

In 2006 I was fortunate to be working in the Gibson Desert and I vividly remember my first experiences with Rheumatic Fever. It was the full moon dance as I used to call it. When I first arrived in the desert I was given a lengthy list, the list read ‘Full Moon monthly penicillin injections’. I knew from looking at a few of charts that these children had notes stating they had rheumatic fever; coming from a major tertiary hospital in the eastern states. I had to refer to the CARPA to actually see what Rheumatic Fever was, as I had never even seen or heard of the disease.

Resources

CDC

Inadequate or lack of antibiotic treatment of streptococcal pharyngitis increases the risk of someone developing acute rheumatic fever. In approximately one-third of patients, acute rheumatic fever follows subclinical streptococcal infections or infections for which medical attention was not sought.

DermNet

Erythema marginatum rheumaticum – This is a characteristic type of annular erythema that occurs in about 10% of first attacks of ARF in children; it is very rare in adults. The rash can be difficult to detect in dark-skinned people. When present, it is found on the trunk and upper arms and legs, but almost never on the face, palms or soles. The rash appears as pink or red macules (flat spots) or papules (small lumps), which spread outwards in a circular shape.

Emergency Care BC

When to suspect ARF: Children with polyarthritis or new onset cardiac murmurs. Less commonly, ARF may present with chorea or skin manifestations, Most common among children aged 10-14, followed by ages 5-9.

MedlinePlus

Rheumatic fever is still common in countries that have a lot of poverty and poor health systems. It does not often occur in the United States and other developed countries. When rheumatic fever does occur in the United States, it is most often in small outbreaks. The latest outbreak in the United States was in the 1980s.