Rheumatic fever, Arthritis, Chorea and Heart disease

Rheumatic fever occurs in children and young adults, as a complication of a bacterial infection of the throat by an organism called streptococcus. This disease is more prevalent in poor countries and in communities living in overcrowded damp houses with poor ventilation; in such conditions, throat infections tend to spread easily from person to person. The complication referred to above is an "allergic" (immunological) response to the streptococcal infection. A common manifestation of the disease is pain and swelling of large joints such as the knee joints, ankle joints and elbow joints. This is called Rheumatic Arthritis. The pain and swelling may move from onejoint to another, within a few days. Some children with acute rheumatic fever become jittery and develop abnormal movements. This is called Rheumatic Chorea; in some of them the heart is also affected. Affection of the heart is called Rheumatic Carditis. This condition leads to inflammation (congestion and swelling) of all parts of the heart, especially of the heart valves - mitral and aortic. This results in a disorder of the heart function. At this stage a doctor would hear (with a stethoscope) an abnormal heart sound which is called a murmur. Sometimes the rhythm and regularity of the heartbeats become abnormal; this worsens the pumping action of the heart. The heart muscle may also get involved leading to enlargement of the heart. When the heart is seriously affected, the patient would become breathless on exertion, and this may gradually progress breathlessness at rest. These are the symptoms of acute heart failure.

With adequate treatment most of these patients recover completely. Some however develop permanent damage to the valves, resulting in chronic rheumatic heart disease. In a few years, the mitral valve may develop a stricture, which causes a difficulty in pumping the blood through the mitral valve; this condition is referred to as mitral stenosis. Or it may develop incompetence, resulting in a leak of the blood from the left ventricle to the left atrium; this condition is referred to as mitral incompetence or mitral regurgitation. Similarly if the aortic valve is affected, aortic stenosis or aortic incompetence may result. These disorders of the valves usually get worse with advancing years and may lead to chronic heart failure. In a child with rheumatic heart disease each subsequent episode of acute rheumatic fever carries a greater risk of further heart damage. In a patient with chronic damage to the heart valves, surgery has to be considered. Either the narrowed valve orifice has to be dilated or the valve may have to be replaced. In some countries, facilities for replacement of heart valves are limited. Rheumatic fever “licks the joints, but bites the heart”.

Treatment and Prevention 

It is of vital importance for rheumatic fever to be prevented. How could this be achieved? At the individual level, all throat infections (sore throats) thought to be of bacterial origin should be treated with an appropriate course of antibiotics - usually penicillin or erythromycin. At the community level, measures should be taken to minimize streptococcal throat infection through better housing (good ventilation) and good nutrition. Secondly, any patient who develops painful swelling of a joint or joints should seek medical treatment where tests could be carried out to diagnose or exclude rheumatic fever. Soluble aspirin, in large doses, is the drug of choice at this stage of the disease. Thirdly, in a patient with rheumatic fever, prevention of further attacks of streptococcal infection is important. This is achieved by giving the patient either injections of long-acting penicillin once in 3-4 weeks, penicillin tablets by mouth twice a day morning and night. This course of treatment should be continued up to at least 21 years of age or 5 years after the last episode, whichever is longer. In a patient with established rheumatic heart disease, it is recommended that this preventive treatment with penicillin be continued lifelong. Unfortunately, there is yet no vaccine available for protection against streptococcal infections. Research is being carried out in certain countries to develop such a vaccine. A child with rheumatic heart disease could lead a normal life, except that physical activity may have to be restricted in certain patients. This is an individual matter and specific advice regarding this should be obtained from the doctor treating the patient. In those who have established rheumatic heart disease, dental procedures, such as extractions and fillings, should be carried out under the cover of antibiotics to prevent complications. This prevents organisms from getting into the blood stream and infecting damaged heart valves - a serious complication called endocarditis or subacute bacterial endocarditis. There is an additional burden on the heart during pregnancy in women who have rheumatic heart disease. For this reason a doctor should be consulted preferably before the pregnancy.