Rheumatic Fever ( Acute Rheumatic Fever )

                   Acute rheumatic fever (ARF) is a complication of a strep throat caused by particular strains of group A beta-haemolytic streptococci.

Facts
1. Rheumatic fever is an autoimmune disease which may develop after strep throat infection.
2. The Jones criteria are used to help physicians make the clinical diagnosis of rheumatic fever.
3. Rheumatic fever does not affect all individuals who have had a strep throat infection.
4. Antibiotics are used to treat the strep throat infection and may prevent development of rheumatic fever.
5. Rheumatic fever affects the joints, heart, skin, and nervous system.
6. Rheumatic fever may cause long-term damage to the heart and its valves.

Jones Criteria
The major criteria for diagnosis include :
1. Arthritis in several joints (polyarthritis),
2. Heart inflammation (carditis),
3. Nodules under the skin (subcutaneous nodules or Aschoff bodies),
4. Rapid, jerky movements (Sydenham's chorea), and
5. Skin rash (erythema marginatum).
The minor criteria include :
1. fever,
2. High ESR (erythrocyte sedimentation rate, an laboratory sign of inflammation),
3. Joint pain (arthralgia),
4. EKG changes (electrocardiogram), and
5. ther laboratory findings (elevated c-reactive protein, elevated or rising streptococcal antigen test).

Clinical Picture
Although common in developing countries, ARF is rare in the United States, with small isolated outbreaks reported only occasionally. It is most common among children between 5-15 years of age. A family history of ARF may predispose an individual to the disease.

Symptoms typically occur 18 days after an untreated strep throat. An acute attack lasts approximately 3 months. The most common clinical finding is a migratory arthritis involving multiple joints.

The most serious complication is carditis, or heart inflammation (rheumatic heart disease), as this may lead to chronic heart disease and disability or death years after an attack. Less common findings include bumps or nodules under the skin (usually over the spine or other bony areas) and a red expanding rash on the trunk and extremities that recurs over weeks to months. Because of the different ways ARF presents itself, the disease may be difficult to diagnose. A neurological disorder, chorea, can occur months after an initial attack, causing jerky involuntary movements, muscle weakness, slurred speech, and personality changes.

Treatment 
1. The first step in treating rheumatic fever is to eradicate the bacteria which initially caused the immunologic response. This is usually accomplished with the use of penicillin. For penicillin-allergic patients, there are other options such as Erythromycin or Azithromycin.
2. The joint pains are treated with aspirin or aspirin-related medications. It may be necessary to use very high doses to decrease the symptoms.
3. Carditis is treated by high-dose steroids but other cardiac medications may be needed to control the inflammation of the heart. This is a serious condition and is most often initially managed in an acute-care setting such as a hospital.
4. The most difficult and unpredictable symptom to treat is the chorea (involuntary movements). It often responds to antipsychotic medications such as haloperidol (Haldol) but may continue for a protracted period.

Complications
1. May develop long-lasting heart dysfunction
2. Atrial Fibrillation (irregular fast heart rate)
3. Heart Failure
4. Sydenham's chorea

Related articles :

- Myocarditis (Inflammatory Cardiomyopathy)

- Rheumatic Heart Disease (RHD)

- Myocardial Infarction (Heart Attack)