Archive for the ‘Rheumatic Fever’ Category

Heart Disease In Rheumatic

Rheumatic Heart Disease:

Rheumatic (roo-MAT-ik) heart disease was formerly one of the most serious forms of heart disease of childhood and adolescence.  Rheumatic heart disease involves damage to the entire heart and its membranes.

Rheumatic heart disease is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. The incidence of rheumatic heart disease has been greatly reduced by widespread use of antibiotics effective against the streptococcal bacterium that causes rheumatic fever.

Rheumatic Heart Disease:

Rheumatic heart disease is a complication of rheumatic fever in which the heart valves are damaged. Rheumatic fever is an inflammatory disease that begins with strep throat. It can affect connective tissue throughout the body, especially in the heart, joints, brain and skin. Although rheumatic fever can strike people of all ages, it is most common in children between 5 and 15 years old. The best way to prevent rheumatic fever is to treat strep throat with antibiotics.

Who is at risk for rheumatic fever?

Rheumatic fever is uncommon in the US, except in children who have had strep infections that were untreated or inadequately treated. Children ages 5 to 15, particularly if they experience frequent strep throat infections, are most at risk for developing rheumatic fever.

Why is rheumatic fever a concern?

Rheumatic fever, an inflammatory disease, can affect many connective tissues, especially in the heart, joints, skin, or brain. The infection often causes heart damage, particularly scarring of the heart valves, forcing the heart to work harder to pump blood. The damage may resolve on its own, or it may be permanent, eventually causing congestive heart failure (a condition in which the heart cannot pump out all of the blood that enters it, which leads to an accumulation of blood in the vessels leading to the heart and fluid in the body tissues).

What are the symptoms of rheumatic fever? 

The symptoms of rheumatic fever usually start about one to five weeks after your child has been infected with Streptococcus bacteria. The following are the most common symptoms of rheumatic fever. However, each child may experience symptoms differently.

Symptoms may include:

•     Joint inflammation – including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation “moves” from one joint to another over several days.
•     Small nodules or hard, round bumps under the skin.
•     A change in your child’s neuromuscular movements (this is usually noted by a change in your child’s handwriting and may also include jerky movements).
•     Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
•     Fever.
•     Weight loss.
•     Fatigue.
•     Stomach pains.

The symptoms of rheumatic fever may resemble other conditions or medical problems. Always consult your child’s physician for a diagnosis.

Treatment for rheumatic heart disease:

Specific treatment for rheumatic heart disease will be determined by your child’s physician based on:

•     Your child’s overall health and medical history.
•     Extent of the disease.
•     Your child’s tolerance for specific medications, procedures, or therapies.
•     Expectations for the course of the disease.
•     Your opinion or preference.

The best treatment for rheumatic heart disease is prevention. Antibiotics can usually treat strep throat (a Streptococcus bacterial infection) and stop acute rheumatic fever from dev

eloping. Antibiotic therapy has sharply reduced the incidence and mortality rate of rheumatic fever and rheumatic heart disease.

Children who have previously contracted rheumatic fever are often given continuous (daily or monthly) antibiotic treatments to prevent future attacks of rheumatic fever and lower the risk of heart damage.

If inflammation of the heart has developed, children may be placed on bed rest. Medications are given to reduce the inflammation, as well as antibiotics to treat the Streptococcus infection. Other medications may be necessary to handle congestive heart failure.

If heart valve damage occurs, surgical repair or replacement of the valve may be considered.

What Cardiac Problems Are Seen With Rheumatic Heart Disease?

Mitral valve disease is the most common cardiac problem seen in rheumatic heart disease. In rheumatic heart disease, the mitral valve becomes laden with heavy deposits of calcium, which disrupt the normal function of the valve. Because of these heavy calcium deposits, the valve often fails to open completely (a condition called mitral stenosis). The same calcium deposits can also prevent the valve from closing completely, leading to mitral regurgitation (a “leaky” valve). So, people with rheumatic mitral valves often have both mitral stenosis and mitral regurgitation.

Aortic valve disease is also common in rheumatic heart disease. Aortic valve damage is also caused by calcium deposits that disrupt normal valve function. And as with rheumatic mitral valves, rheumatic aortic valves can develop either stenosis or regurgitation, or both.

The mechanical valve problems (both stenosis and regurgitation) caused by rheumatic heart disease can tremendously increase the workload on the heart muscle, and as a result heart failure frequently develops, often after a period of many years.

Atrial fibrillation is very commonly seen in rheumatic heart disease, especially if the mitral valve is involved. Blood clots (which can lead to stroke, and which are always a risk in patients with atrial fibrillation) are a particular risk in people who have both atrial fibrillation and rheumatic mitral disease. So, virtually all patients with rheumatic mitral disease and atrial fibrillation ought to be on chronic blood-thinning (anticoagulation) therapy with Coumadin.

How Is Rheumatic Heart Disease Treated?

The best way to deal with rheumatic heart disease, obviously, is to prevent it. Aggressive treatment of strep throat (with antibiotics) and of rheumatic fever (should it occur) can help to limit rheumatic heart disease. Read here about the treatment of rheumatic fever.

Once a person has had rheumatic fever, especially if it has caused carditis, it is critically important to prevent any more episodes of rheumatic fever. So anyone who has had rheumatic fever should be on preventative, or prophylactic, therapy with antibiotics to prevent a recurrence. Here are the American Heart Association’s recommendations on prophylaxis for rheumatic fever.

Anyone who has had acute rheumatic fever should have a physical examination annually to see if any change has occurred in the heart. A new heart murmur or a change in a previous heart murmur might indicate that heart valve damage has begun. An echocardiogram would confirm the presence or absence of heart valve damage.

Once you have been diagnosed with rheumatic heart disease, it is critically important to have regular monitoring of the condition of your heart valves and your heart muscle, usually with periodic physical exams and echocardigrams. Since rheumatic heart disease is usually progressive, the heart valve problems tend to worsen over time — and at some point, valve replacement surgery is likely to be required.

The proper timing of this surgery is important and tricky. It is critical to replace the valves before permanent heart muscle damage occurs, but on the other hand it is generally not a good idea to replace the valves too early (since artificial valves themselves may deteriorate over a few decades, and additional surgery may become necessary). For this reason, people with rheumatic heart disease should generally be under the watchful eye of an experienced cardiologist.

Epidemiology:

Rheumatic fever is common worldwide and responsible for many cases of damaged heart valves. In Western countries, it became fairly rare since the 1960s, probably due to widespread use of antibiotics to treat streptococcus infections. While it has been far less common in the United States since the beginning of the 20th century, there have been a few outbreaks since the 1980s. Although the disease seldom occurs, it is serious and has a case-fatality rate of 2–5%.

Rheumatic fever primarily affects children between ages 5 and 17 years and occurs approximately 20 days after strep throat. 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%. The incidence of recurrence with a subsequent untreated infection is substantially greater (about 50%). The rate of development is far lower in individuals who have received antibiotic treatment. Persons who have suffered a case of rheumatic fever have a tendency to develop flare-ups with repeated strep infections.

The recurrence of rheumatic fever is relatively common in the absence of maintenance of low dose antibiotics, especially during the first three to five years after the first episode. Heart complications may be long-term and severe, particularly if valves are involved.

Survivors of rheumatic fever often have to take penicillin to prevent streptococcal infection which could possibly lead to another case of rheumatic fever that could prove fatal.

Background:

Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults in the United States.

Acute rheumatic fever and rheumatic heart disease are thought to result from an autoimmune response, but the exact pathogenesis remains unclear. Although rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States, incidence of this disease has decreased in developed countries, and the mortality rate has dropped to just above 0% since the 1960s. Worldwide, rheumatic heart disease remains a major health problem. Chronic rheumatic heart disease is estimated to occur in 5-30 million children and young adults; 90,000 individuals die from this disease each year. The mortality rate from this disease remains 1-10%. A comprehensive resource provided by the World Health Organization (WHO) addresses the diagnosis and treatment.