Newest treatment for rheumatic fever

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Rheumatic fever is an inflammatory disease which can occur after an infection with streptococcus bacteria (group A) such as strep throat , strep skin infection, or scarlet fever and can involve the heart, joints, skin, and brain.

Rheumatic fever usually affects children between ages five and fifteen and occurs approximately 20 days after strep throat or scarlet fever. In up to a third of cases, the underlying strep infection may not have caused any symptoms.

The rate of development of rheumatic fever in individuals with untreated strep infection is estimated to be 3 percent. Persons who have suffered a case of rheumatic fever have a tendency to develop flare-ups with repeated strep infections.

Symptoms include:

• Fever which may be low grade or spike.
• Joint pain and migratory arthritis involving lower extremity joints such as the knees and ankles as well as the elbows and wrists. Joint pain may be out of proportion to physical findings. Post streptococcal reactive arthritis may be a form of rheumatic fever.
• Joint swelling, redness or warmth
• Abdominal pain which may look like appendicitis
• Skin eruption (erythema marginatum) that is fleeting, red, ring-shaped or snake-like in appearance with a central area of clearing. It is generally located on the torso.
• Skin rash on the trunk and upper part of arms or legs.
• Skin nodules which are subcutaneous (bumps under the skin). These are rare in adults.
• Sydenham's chorea -- rapid, uncoordinated jerky movements affecting primarily the face, feet and hands.
• Epistaxis (nosebleeds).
• Cardiac (heart) involvement which may be asymptomatic or may result in shortness of breath, chest pain.

Given the different manifestations of this disease, there is no specific test which can definitively establish a diagnosis. In addition to a careful physical examination, blood samples may be taken as part of the evaluation. These include tests for recurrent strep infection, complete blood counts, CRP, and sedimentation rate. Elevated levels of antistreptolysin O (ASO), anti-DNase B, anti-NADase, antistreptokinase, and antihyaluronidase all provide presumptive evidence of recent streptococcal infection. Throat cultures are usually negative at the time of the acute attack. An electrocardiogram may also be done to see if there is evidence of heart block. An echocardiogram and chest x-ray may be obtained to diagnose carditis.

In order to standardize the diagnosis of rheumatic fever, several minor and major criteria have been developed. These criteria, in conjunction with evidence of recent streptococcal infection, establish a diagnosis of rheumatic fever. These are termed the Jones criteria.

The major diagnostic criteria:

• Carditis (heart inflammation)
• Polyarthritis
• Subcutaneous skin nodules
• Chorea (Sydenham's chorea)
• Erythema marginatum

The minor criteria:

• Previous rheumatic fever or rheumatic heart disease
• Fever
• Arthralgia (joint pain.)
• Elevated erythrocyte sedimentation rate
• Prolonged PR interval on ECG

Two major criteria, or one major and two minor criteria, when there is also evidence of a previous strep infection support the diagnosis of rheumatic fever.

The management of acute rheumatic fever consists of reduction of inflammation with anti-inflammatory medications. Individuals with positive cultures for strep throat should also be treated with antibiotics.

Despite the many newer antibiotics, the antibiotic of choice remains penicillin. Another important part of treating rheumatic fever includes the continuous use of low dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence.

The recurrence of rheumatic fever is relatively common in patients not taking low dose antibiotics, especially during the first three to five years after the first episode of rheumatic fever. Cardiac complications may be long-term and severe.

Among the complications are:

• Damage to heart valves (in particular, mitral stenosis and aortic stenosis)
• Endocarditis
• Heart failure
• Arrhythmias
• Pericarditis
• Sydenham's chorea
• Persistent arthralgias and arthritis

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