A bout of streptococcal pharyngitis (strep throat) may, in rare instances, lead to rheumatic fever. This illness, which generally does not occur before age five, results from the immune system's attempt to rid the body of harmful substances (toxins) produced by the strep bacterium. In the process, however, the antibodies also attack normal tissues in the joints, heart, skin or nervous system.
Antibiotic treatment of strep infections in the United States and Europe has led to a steady decline in rheumatic fever in recent decades. Although it is rare, rheumatic fever still appears sporadically. Since the disease can damage the heart, every effort should be made to prevent it.
WHEN SHOULD I SUSPECT THAT MY CHILD HAS RHEUMATIC FEVER?
Muscle or joint aches, as well as joint swelling and tenderness, are usually the first signs, developing three to eight weeks after a strep infection. This pain usually affects the hips, knees, shoulders, elbows and wrists, and migrates from one area to another. Permanent joint damage does not occur. Occasionally, heart abnormalities develop without joint pain. In other cases, stomach pain, nosebleed or weight loss are the initial signs.
WHAT HAPPENS DURING RHEUMATIC FEVER?
The bacterium responsible for strep throat—group A beta-hemolytic Streptoccus— produces a number of substances that can damage normal body tissues. This organism also contains a substance that resembles proteins found in the heart. As a result, antibodies produced to fend off strep also can target and injure the heart. A similar sort of immune-system cross reaction is probably also to blame for the other manifestations of rheumatic fever.
The syndrome can affect the central nervous system. Within two to six months after the initial strep throat, muscle weakness and poor coordination may develop, causing poor grasp, sloppy handwriting and jerky movements. Odd facial expressions and rapid mood swings may also occur. This neurologic disorder is termed Sydenham's chorea or St. Vitus dance. Although distressing, this phase of the illness is almost always short lived, resolving without long-term consequences.
Rheumatic fever also may cause a rash composed of small red lesions with clear centers and wavy, well-defined borders. These lesions appear first on the trunk, followed by the arms and the legs. Over bony regions, such as the feet, hands, elbows, shoulder blades and spine, the skin may be marked by small, hard swellings (nodules) measuring about one-quarter or one-half inch wide.
HOW IS THE HEART AFFECTED?
In some but not all cases of acute rheumatic fever, the heart valves may be inflamed and deformed. The mitral valve between the left collecting chamber (left atrium) and pumping chamber (left ventricle) is most commonly affected. The aortic valve may also be involved. Rarely the muscle (myocardium) of the heart and outside covering of the heart (pericardium) are also inflamed. In the most severe cases, heart failure may occur. It is important to know that the greatest incidence of severe heart disease occurs in children who have multiple attacks of rheumatic fever over months or years. That is why prevention of future repeated attacks by antibiotic prophylaxis is so vital.
IS MEDICAL ATTENTION NECESSARY?
Yes, absolutely. Even though rheumatic fever tends to run its course within two or three months after the initial strep infection, residual heart disease may remain. It may, in addition, evolve into permanent rheumatic heart disease. These difficulties are preventable if antibiotic therapy for strep infection is instituted promptly.
HOW CAN THE PEDIATRICIAN TELL THAT MY CHILD HAS RHEUMATIC FEVER?
The pediatrician looks for evidence of a recent strep infection by reviewing results of recent throat cultures and ordering laboratory tests for antibodies against strep toxins. Elevations in two or more of these antibodies point strongly to rheumatic fever. The pediatrician also evaluates the number and type of rheumatic fever symptoms.
LONG-TERM CARE FOR A CHILD WHO HAS HAD RHEUMATIC FEVER
It is extremely important to take prescribed medicines and follow the physician's recommendations about exercise and diet, even after the acute episode of rheumatic fever has passed. Measures to take include:
• Encourage the child to be as physically active as possible, within the doctor's guidelines. Sometimes the most competitive team sports and track are off limits.
• To help prevent recurrence, make sure your child takes all recommended doses of antibiotics.
• Ask your pediatrician about special precautions to take prior to dental work or other surgical procedures, which incur a risk of infection of damaged heart valves.
• Be aware that chorea can come on as long as several months after the initial illness. If it develops, the child is likely to feel angry and self-conscious. Emphasize that chorea is a short-lived illness over which the child has not control.
WHAT TREATMENTS ARE AVAILABLE?
Penicillin, administered either orally or by injection, is highly effective in clearing the body of strep. Children allergic to penicillin can take erythromycin.
Antibiotic therapy orally on a daily basis or injection monthly will be maintained for many years to prevent occurrences, which are most likely in the first three years. Penicillin or erythromycin usually is continued until the age of 18, or longer if the heart valves have sustained damage. This is referred to as antibiotic prophylaxis.
Bed rest, proper nutrition and mild pain relievers are the mainstay of treatment in the acute stage of rheumatic fever. In some cases, corticosteroids are given to combat more severe inflammations of the joints or heart. Depending on the severity of heart disease, cardiac medicines may be prescribed.
GETTING HELP
Call your doctor if:
• Your child develops joint pain, a rash, fever or other symptoms of rheumatic fever after a bout of strep throat or scarlet fever.
