Rheumatic Fever: An Economic Disease

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Rheumatic fever is an inflammatory disease that is caused by a bacteria named Streptococcus pyogenes. This organism is responsible for a number of infections in our body.

They include

  • Pharyngitis (strep throat)
  • Skin infections like impetigo (superficial skin), erysipelas and cellulitis (deep layers of skin)
  • Necrotizing fasciitis (life-threatening infection of fascia requiring urgent surgery)
  • Scarlet fever
  • Toxic shock syndrome
  • Post infection syndromes: Glomerulonephritis and rheumatic fever following throat and skin infections.


Rheumatic fever is thought to be caused by antibody cross reactivity.


What is antibody cross reactivity?

When a person is infected with a bacteria, there is development of antibody against it which usually tries to kill and destroy the pathogen. In cross reactivity issues, the antibody destroys the pathogen as well as the normal tissues of the body resulting in damage of different organs. In rheumatic fever the antibody produced against Streptococcus pyogenes destroys heart valve, heart muscles, skin, brain and different joints.

Rheumatic fever usually develops two to three weeks following a sore throat. Acute rheumatic fever is usually a disease of children between the ages of five and 15

How to diagnose rheumatic fever?

According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre or DNAase, positive throat culture etc.

The major criteria includes:

Migratory polyarthritis

Carditis: Myocarditis, pericarditis or pancarditis

Subcutaneous nodules

Erythema marginatum

Sydenham's chorea

The minor criteria are:

Fever (100.8 - 102 F)

Arthralgia

Raised ESR or CRP

Leucocytosis

ECG showing features of heart block

Fig: Conducting system of heart

If a patient has chorea or carditis we should not wait for major or minor criteria. Chorea or carditis by itself indicates rheumatic fever.

What is chronic rheumatic heart disease?

Chronic rheumatic heart disease (RHD) results from repeated inflammation with fibrinous repair of heart valves. The most important changes of the valve include leaflet thickening, commissural fusion, and shortening and thickening of the tendinous cords. As a result, valve stenosis or regurgitation ensue. About half of the patients with acute rheumatic fever develop valve disease in the long run. It can damage any valve but most frequently affected valves are mitral and aortic valves. However, symptoms associated with the inflammation may not be seen until 20-40 years later. Fortunately, this infection was much more common before the introduction of antibiotics to treat it in the 1950s.

How to treat acute rheumatic fever?

Anti inflammatory medications like aspirin or corticosteroids are used initially. If throat swab shows growth of the organism then antibiotic like penicillin is used. If the patient is allergic to penicillin, erythromycin is an alternative antibiotic. In some cases, using aspirin in children may result in the development of Reyes's syndrome. We should stop aspirin when we suspect it and use other NSAIDs like ibuprofen and short course steroids.

If one attack of rheumatic fever has already occurred, we should administer monthly injections of long acting penicillin (or oral antibiotics) for a period of five years. If there is evidence of carditis, the length of therapy may be up to 40 years.

About the Author

Dr Rezahaider's picture
Author: Dr Rezahaider

I am a physician by profession. I dream to work on medicine in the near future. I have completed my residency three years back. Now, I am planning to obtain MRCP. This is very hard exam and surely, I am always scared of it. I have also decided to do my specialization on cardiology. Before medical school, I never thought that our heart could be so complex! So pray for me. I usually don't have enough time to write due to my studies. But whenever I get time I love to write. I write on medical related issues. I try to make it simple for you.

Comments

Ph. Bhagavan P S RPh's picture

I am ammused at the title you have given to your blog yet seems interesting.

Can you tell me sir why do you call it an economic fever?

Bhagavan P.S. B Pharm

Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India
Dr Rezahaider's picture

Sir,

This is called an economic disease because I think sometimes death rate can be purchased. Our country has got little expenditure (compared to other developed countries) in the health sector. That's why rheumatic fever, tuberculosis, parasite infections are so rampant here. If you name a country expending at least moderate amount of money in health sector you will find no tuberculosis, no rheumatic fever and so on.

Let me give an example.

Practically what I have seen is more devastating. No one can cure tuberculosis if proper lock up system is not available. If someone has got tuberculosis, he, or she must be isolated. No other option. But I'm not seeing the proper application of this system. That's why the multi drug resistance organism are increasing and creating an ever increasing problem for us day by day.

Even in 1941 tuberculosis was the most common cause of death in Newyork city. But due to proper isolation policy, now this is a rare disease there. This is the beauty of public health. Adequate expenditure and proper application.

Thank you Sir.

rhaider  

Ph. Bhagavan P S RPh's picture

Thank you Dr Haider,

Unfortunately, the culprit is Govt policy. It spends money on visible activity like structures, super structures in the name of hospital but functionally keep them weak that goes unnoticed. The dictum that :

"Medical care begins when the Healthcare ends" has been well proved.

I only wish your simple message reaches our great policy pundits in Government.

Bhagavan P.S. B Pharm

Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India

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