It is an acute, subacute and chronic systemic disease involving the connective tissue throughout the body characterized by fleeting polyarthritis and a great tendency to carditis which is usually a sequel to Tonsillo-pharyngeal infection by Streptococcus haemolyticus. The streptococci belong to Group A of Lancefield (GAS). Though the incidence of RF has sharply declined in many developed countries it still remains a major problem in many developing countries.
Commonly seen during autumn and winter months.
It chiefly affects people in the temperate climates, comparatively less common in tropics.
3. Family history .
The disease may run in families which is often due to poor hygienic conditions .
It is a disease of poverty and usually affects persons of the lower income group .
5. Sanitary condition
The disease is often seen amongst people living in the bustee areas where there is overcrowding , low sanitary condition and dampness .
6. Upper respiratory infection :
The disease is usually preceded by upper respiratory infection commonly tonsillitis or pharyngitis 1-3 weeks before the attack .
7. Age :
Common in lower age group ( 5 years to 15 years ) ; rare before 4 years and after 50 years .
8. Sex :
It is equal in both sexes but when chorea is present it ny is common in females .
9. Auto - immune theory : Antimyocardial antibodies may react with the sarcolemma and sub - sarcolemmal myofibril particularly at the intercalated discs and may have an at antigen - antibody reaction with the antigen on the streptococci .
Onset is usually acute in about 70 % of the cases but may be insidious in the remaining cases .
- Fever ---Temperature remains usually high upto 39 ° C which is usually of remittent or intermittent in character . Some degree of fever is always present so long as the rheumatic activity persists . The fever is not associated with chill and rigour . Occasionally hyperpyrexia may occur as a complication .
- Arthritis--It is seen in 70 % of the cases and is characteristically fleeting or migratory polyarthritis . Big joints are commonly affected and knees , ankles , elbows , wrists , shoulder and hip joints are affected in this order . Small joints may rarely be affected last of all . Temporomandibular and sternoclavicular joints are usually not involved . The affected joint becomes red , hot , painful , swollen and tender , so that all movements of joints are restricted .
- Sweating-- Sweating is moderate in amount , acrid or offensive in odour .
- Other symptoms --These include sore throat , epistaxis , abdominal pain , skin rashes , constitutional symptoms like anorexia , constipation , weakness , vague aches in different parts of the body . Signs--
- General--Age : 5 15 years . Sex : both . Temperature is raised . Pulse shows tachycardia even during sleep . Patient is reluctant to change the posture for fear of joint pain . Tonsils are enlarged , congested with presence of pus points . Tonsillar lymph nodes are enlarged and tender .
- Heart-- Cardiac involvement occurs even upto 75 % of the cases in the form of carditis particularly seen in children and adolescents .
- Lungs--Lungs may show evidences of pleurisy in 10 % and pneumonia in 2 % of cases .
- Nervous System-- In 3 % of the cases , rheumatic chorea develops which is due to involvement of the basal ganglia and mild encephalitis . In this condition peculiarly arthritis , high ESR or leucocytosis are not seen . It is common in female in the ratio of 3 : 1 and rare in adults . This is a very important diagnostic feature .
- Abdomen-- Diffuse abdominal pain may be complained of in absence of definite tenderness anywhere which may be attributed to rheumatic peritonitis .
skin changes-- a ) Rheumatic nodules are seen in children and they indicate activity of the rheumatic process . These are non - tender , firm small nodules found over the bony prominences or around the affected joints . They are usually seen over the knuckles , suboccipital region , scapular margins , joints and shin bones . They persist for days or weeks and are usually relapsing in nature . Pathologically these are aggregation of Aschoff's nodules . These are indistinguishable from Rheumatoid nodules .
b ) Erythema nodosum : These are rarer than rheumatic nodules.The superlying skin shows some colour changes day - to - day .
C)Erythema annulare is specific for the rheumatic fever will appear on the trunk and on the proximal parts of limbs. These are erythematous or pinkish rashes will circular , crescentic , or zig - zag margin which persist for a short period . Few such patches may conglomerate together forming big irregular rashes . These are either transient or persistent .
d ) Other skin rashes : These include maculopapular rashes , urticarial , purpuric spots , sudaminal rashes or miliaria .
- Joints ---The affected joints are swollen and show all features of inflammation and when they subside no residual deformity is seen . Clinical evidence of fluid in the joint is usually lacking though it is present.Surrounding muscles never show wasting .
- Modified Ducket Jones criteria for the diagnosis of Rheumatic fever--- The diagnosis of Rheumatic fever is almost certain when at east one major and two minor or two major and one minor eriteria are present.
1. Blood:-- Polymorphonuclear leucocytosis is the usual feature and some degree of normocytic normochromic anemia is also seen. ESR is always raised and is an important sign of rheumatic activity.
2. Urine:-- It may show albuminuria.
3. ECG shows evidences of carditis as mentioned before.
• Rheumatoid arthritis--Symmetrical , persistent , progressive , arthropathy involving the small joints of hands and feet , ankylosis , ulnar deviation o the hands , wasting of muscles above and below the involved joints , absence of cardiac findings , less response to Aspirin positive Rose - Waaler test will help in the diagnosis of rheumatoid arthritis .
- Osteomyelitis --History of trauma , non - involvement of the joints , absence o cardiac signs , positive X ray finding in favour of osteomyelitis will help in the diagnosis .
- Acute Suppurative Arthritis--Single joint will be involved , systemic toxaemia is marked Fleeting joint involvement is absent , skin around the joint will of be red , glossy and oedematous . Cardiac signs are absent.
- Still's Disease --Joint involvement is not fleeting and the joints are not acutely tender , cardiac valvular involvement . Rheumatoid serologie test may be positive .
1. Cardiac arrhythmias .
2. Pericarditis usually dry but may be with effusion .
3. Rheumatic Pneumonia .
4. Pulmonary embolism .
5. Congestive cardial failure .
6. Chronic valvular deformity .
1.Rest in bed is essential during the active stage of the disease.The activity of Rheumatic process is assessed by :
a ) Fever .
b ) Subjective symptom of pain in joints .
c ) Epistaxis .
d ) Haematuria .
e ) Tachycardia during sleep .
f ) Rheumatic nodules or erythema nodosum.
g ) Chorea
h ) High ESR with leucocytosis .
i ) ECG changes.
2. Care of the joint :The joint should be kept in their optimum position of comfort .
3.Diet : During febrile stage milk , bread , horlicks , etc. are to be given and then as fever subsides gradually diet is to be increased .
4. During convalescence : Polyvitamins are to be given for sometime and question of removal of tonsils is to be thought of.periodical check-up is also essential for prevention of relapse.
Treatment of Complications--
- Congestive cardiac failure -This is to be treated in the usual line but digitalis is not so much effective . If given one should be very much careful as it irritates the heart producing cardiac arrhythmias . Steroids respond dramatically in CCF and pericarditis . As sodium is to be restricted one should be cautious in using Sodium salicylate .
- Pericarditis. This is to be treated as other forms of non -purulent pericarditis.