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Rheumatic fever-- clinical features, diagnosis, investigation, complications and management.

rheumatic-fever-clinical-features-diagnosis-investigation-complications-and-management

RHEUMATIC FEVER


Definition-

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.


Aetiology--

1. Season:

Commonly seen during autumn and winter months.

2. Climate:

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 .

4.Social history

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 .


Clinical Features--

Onset is usually acute in about 70 % of the cases but may be insidious in the remaining cases .

Symptoms --

  • 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.

Special Investigations--

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.


Differential Diagnosis--

• 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 .

Complications--

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 .


Management--

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.