Rheumatic fever overview: Difference between revisions
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Rheumatic fever was first described by Hippocrates, a Greek physician, between 400-370 B.C.<ref name="pmid1775859">{{cite journal| author=Quinn RW| title=Did scarlet fever and rheumatic fever exist in Hippocrates' time? | journal=Rev Infect Dis | year= 1991 | volume= 13 | issue= 6 | pages= 1243-4 | pmid=1775859 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1775859 }} </ref> The term was first used post-Renaissance by Guillaume de Baillou, a French physician, in the early 1600s. T. Duckett Jones, MD was the first to publish a set of diagnostic criteria in 1944.<ref name=HIS> THE DIAGNOSIS OF RHEUMATIC FEVER. JAMA (2015). http://jama.jamanetwork.com/article.aspx?articleid=271116 Accessed on October 9, 2015</ref> | Rheumatic fever was first described by Hippocrates, a Greek physician, between 400-370 B.C.<ref name="pmid1775859">{{cite journal| author=Quinn RW| title=Did scarlet fever and rheumatic fever exist in Hippocrates' time? | journal=Rev Infect Dis | year= 1991 | volume= 13 | issue= 6 | pages= 1243-4 | pmid=1775859 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1775859 }} </ref> The term was first used post-Renaissance by Guillaume de Baillou, a French physician, in the early 1600s. T. Duckett Jones, MD was the first to publish a set of diagnostic criteria in 1944.<ref name=HIS> THE DIAGNOSIS OF RHEUMATIC FEVER. JAMA (2015). http://jama.jamanetwork.com/article.aspx?articleid=271116 Accessed on October 9, 2015</ref> | ||
==Classification== | |||
Based on the duration of symptoms, rheumatic fever may be classified into either acute or chronic.<ref name="pmid15468729">{{cite journal| author=Nasonova VA, Kuz'mina NN, Belov BS| title=[Present-day classification and nomenclature of rheumatic fever]. | journal=Klin Med (Mosk) | year= 2004 | volume= 82 | issue= 8 | pages= 61-6 | pmid=15468729 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15468729 }} </ref> | |||
==Pathophysiology== | |||
Rheumatic fever is the result of an autoimmunological sequela to a virulent ''[[Streptococcus pyogenes]]'' infection in a patient who was immunologically sensitized from prior infections. During a streptococcal infection, activated antigen presenting cells, such as [[macrophage]]s, present the bacterial antigen to [[helper T cells]]. Helper T cells subsequently activate B cells and induce the production of antibodies against the cell wall of ''[[Streptococcus]]''. However the antibodies also act against the [[myocardium]] and [[joint]]s, producing the symptoms of rheumatic fever.<ref name=WPatho> Rheumatic Fever. Wikipedia (2015). http://www.mayoclinic.org/diseases-conditions/rheumatic-fever/basics/causes/con-20031399 Accessed on October 12, 2015 </ref> | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Anthony Gallo, B.S. [3]
Overview
Rheumatic fever is a systemic immune disease that may develop after an infection with Streptococcus bacteria, such as strep throat and scarlet fever. It usually affects the heart, joints, blood vessels, and brain. Based on the duration of symptoms, rheumatic fever may be classified into either acute or chronic.[1] The most common cause of rheumatic fever is Group A beta-hemolytic streptococci infection.[2][3] If left untreated, rheumatic fever may cause valvular diseases including stenosis, regurgitation of mitral/aortic valves and myocarditis. This may lead to decreased cardiac output, pulmonary edema and ultimately cardiac failure. For cases without carditis, the prognosis is excellent, demonstrating no residual heart disease. In cases with preexisting heart disease, the prognosis is poor, leading to mortality.[4] Common complications of rheumatic fever include arrhythmias, systemic emboli, and stroke.[5][6][7] Common physical examination findings include fever, cardiac murmurs, and erythema marginatum.[8][9] Echocardiogram and radiograph may be diagnostic of rheumatic fever. The Jones criteria is used to establish the diagnosis of rheumatic fever. Rheumatic fever is usually treated using antibiotics to control Streptococcus infection and medications such as aspirin and corticosteroids to decrease inflammation. A long-lasting injection of penicillin is important and effective to prevent further complications and recurrence.
Historical Perspective
Rheumatic fever was first described by Hippocrates, a Greek physician, between 400-370 B.C.[10] The term was first used post-Renaissance by Guillaume de Baillou, a French physician, in the early 1600s. T. Duckett Jones, MD was the first to publish a set of diagnostic criteria in 1944.[11]
Classification
Based on the duration of symptoms, rheumatic fever may be classified into either acute or chronic.[1]
Pathophysiology
Rheumatic fever is the result of an autoimmunological sequela to a virulent Streptococcus pyogenes infection in a patient who was immunologically sensitized from prior infections. During a streptococcal infection, activated antigen presenting cells, such as macrophages, present the bacterial antigen to helper T cells. Helper T cells subsequently activate B cells and induce the production of antibodies against the cell wall of Streptococcus. However the antibodies also act against the myocardium and joints, producing the symptoms of rheumatic fever.[12]
Epidemiology and Demographics
Rheumatic fever, and therefore Streptococus pyogenes infections, are endemic in many developing countries. In countries affected by the industrial revolution, domestic living conditons became less crowded, due to the development of larger homes and families had fewer children. In addition, living conditions became, generally, more hygienic. The introduction of antibiotics, first sulfonamide in the early 1930's and then penicillin in the 1940's, further caused Streptococcus pyogenes infections to become less common and less severe in economically developed countries although they never disappeared. Rheumatic fever is usually seen among children belonging to age group of 5-15 years[13]
Screening
Screening of rheumatic fever and carditis is important as many cases of RHD are subclinical. Echocardiography in inhabitants of high risk regions is recommended. If any abnormality is detected on echocardiography, further cardiac evaluation is done followed by prophylactic treatment[14].
Diagnosis
Physical Examination
- Fever
- Cardiac murmurs may be noted on cardiac auscultation if heart valves are involved. Regurgitant murmurs are common
- Sydenham's chorea
- Migratory polyarthritis may be noted in 70-75% of patients. Often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) are involved progressing below-upwards.
- Subcutaneous nodules over extensor surface of limbs, bony prominences such as elbows, knees, ankles and knuckles[8]
- Erythema marginatum, also known as erythema annulare are pink-red rash frequently located on trunk, limbs and seldom on face[9].
Lab Tests
Patients with rheumatic fever often have elevated inflammatory markers such as ESR and C-reactive protein which help in monitoring the course of the disease. Presence of streptococcal infection can be established by obtaining throat culture or rapid streptococcal antigen test. Elevated or rising antistreptolysin O antibody titer is often noted. Endomyocardial biopsy demonstrate the presence of Aschoff bodies. However, biopsy is not recommended routinely[15].
Electrocardiogram
Some of the electrocardiographic changes that may be noted in rheumatic heart disease include PR prolongation, conduction abnormalities, arryhthmias or P mitrale depending on the structures involved and the extent of cardiac damage.
Chest X Ray
Cardiomegaly or pulmonary edema secondary to heart failure may be noted on chest x-ray among patients with rheumatic heart disease.
Echocardiography
Echocardiography may be helpful in establishing carditis and in monitoring the progress of valve defect.
Treatment
Primary Prevention
Treatment of streptococcal pharyngitis with appropriate antibiotics (penicillin or cephalosporin) most often prevents development of rheumatic fever.
Secondary Prevention
In order to prevent recurrent development of rheumatic fever, an antibiotic prophylaxis should be initiated immediately after the antibiotic course in treatment of rheumatic fever. Duration of prophylactic treatment varies with degree of cardiac damage secondary to rheumatic fever.
References
- ↑ 1.0 1.1 Nasonova VA, Kuz'mina NN, Belov BS (2004). "[Present-day classification and nomenclature of rheumatic fever]". Klin Med (Mosk). 82 (8): 61–6. PMID 15468729.
- ↑ Coburn AF, Pauli RH (1932). "Studies on the relationship of streptococcus hemolyticus to the rheumatic process: III. Observations on the immunological responses of rheumatic subjects to hemolytic streptococcus". J Exp Med. 56 (5): 651–76. PMC 2132197. PMID 19870091.
- ↑ Martin JM, Barbadora KA (2006). "Continued high caseload of rheumatic fever in western Pennsylvania: Possible rheumatogenic emm types of streptococcus pyogenes". J Pediatr. 149 (1): 58–63. doi:10.1016/j.jpeds.2006.03.006. PMID 16860129.
- ↑ The Natural History of Rheumatic Fever and Rheumatic Heart Disease, Rheumatic Fever Working Party of the Medical Research Council of Great Britain and the American Heart Association (1965). http://circ.ahajournals.org/content/32/3/457 Accessed on October 12, 2015
- ↑ Majeed HA, Yousof AM, Khuffash FA, Yusuf AR, Farwana S, Khan N (1986). "The natural history of acute rheumatic fever in Kuwait: a prospective six year follow-up report". J Chronic Dis. 39 (5): 361–9. PMID 3700577.
- ↑ Rheumatic Fever and Rheumatic Heart Disease. World Health Organization (2004). http://www.who.int/cardiovascular_diseases/resources/en/cvd_trs923.pdf Accessed on October 12, 2015.
- ↑ Garg N, Kandpal B, Garg N, Tewari S, Kapoor A, Goel P; et al. (2005). "Characteristics of infective endocarditis in a developing country-clinical profile and outcome in 192 Indian patients, 1992-2001". Int J Cardiol. 98 (2): 253–60. doi:10.1016/j.ijcard.2003.10.043. PMID 15686775.
- ↑ 8.0 8.1 Ayoub EM (1992). "Resurgence of rheumatic fever in the United States. The changing picture of a preventable illness". Postgrad Med. 92 (3): 133–6, 139–42. PMID 1518750.
- ↑ 9.0 9.1 BURKE JB (1955). "Erythema marginatum". Arch Dis Child. 30 (152): 359–65. PMC 2011784. PMID 13249623.
- ↑ Quinn RW (1991). "Did scarlet fever and rheumatic fever exist in Hippocrates' time?". Rev Infect Dis. 13 (6): 1243–4. PMID 1775859.
- ↑ THE DIAGNOSIS OF RHEUMATIC FEVER. JAMA (2015). http://jama.jamanetwork.com/article.aspx?articleid=271116 Accessed on October 9, 2015
- ↑ Rheumatic Fever. Wikipedia (2015). http://www.mayoclinic.org/diseases-conditions/rheumatic-fever/basics/causes/con-20031399 Accessed on October 12, 2015
- ↑ Grover A, Dhawan A, Iyengar SD, Anand IS, Wahi PL, Ganguly NK (1993). "Epidemiology of rheumatic fever and rheumatic heart disease in a rural community in northern India". Bull World Health Organ. 71 (1): 59–66. PMC 2393425. PMID 8440039.
- ↑ Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Sidi D; et al. (2008). "Echocardiographic screening for rheumatic heart disease". Bull World Health Organ. 86 (2): 84. PMC 2647380. PMID 18297157.
- ↑ Narula J, Chopra P, Talwar KK, Reddy KS, Vasan RS, Tandon R; et al. (1993). "Does endomyocardial biopsy aid in the diagnosis of active rheumatic carditis?". Circulation. 88 (5 Pt 1): 2198–205. PMID 8222115.