Rheumatic fever: Effective prevention is through proper hygiene

Dr. Uyi Ima-Edomwonyi is a Consultant Rheumatologist at the Lagos University Teaching Hospital (LUTH). He spoke with GERALDINE AKUTU about rheumatic fever and how to handle it.

What is rheumatic fever?
Rheumatic fever (RF) is an autoimmune inflammatory disease (a disease in which the body fights against itself) that involves the heart, joints, skin and brain. Rheumatic fever typically develops two to four weeks after a strep throat infection. Rheumatic fever is most common in five to 15- year-old children, though it can develop in children younger than five years and adults as old as 35 years. Rheumatic fever remains common in many developing nations.

What causes rheumatic fever?
Rheumatic fever is caused by a reaction of the body to the bacteria that cause strep throat, group A streptococcus, though not all cases of strep throat result in rheumatic fever. Rheumatic fever happens as an inflammatory reaction to certain group A streptococcus bacteria. The body normally fights against bacteria and the “ammunitions” it uses are called “antibodies”. In this process, the patient’s immune responses (the body’s ammunition) are unable to distinguish between the invading microbe and certain host tissues. But instead, these antibodies attack a different target: the body’s own tissues – “friendly fire”, “innocent by-stander” or “stray bullets” phenomena. These antibodies begin with the joints and often move on to the heart and surrounding tissues.

“Strep,” in this case stands for Streptococcus pyogenes, also known as Group A Strep. This is a common strain of bacteria that can live in your throat and nose for months without causing any harm. Tests show that during the cold weather, about 20 percent of healthy people have the strep “germ” living in them without causing harm in their mouths or throats, without causing any symptoms. These carriers, who have no symptoms, do not spread strep germs and do not need to be tested or treated for strep.

Once in a while, though, these germs can turn on them because of much stress, or their immune system has been overburdened from fighting a virus, such as a common cold or the flu. Or perhaps they’ve picked up the germ from an infected person. Whatever the reason, the normally quiet strep organisms can suddenly become harmful and start attacking the body with inflammatory substances that bring on a sore throat and other symptoms.

What are the signs and symptoms of rheumatic fever?
Rheumatic fever symptoms and signs, which result from this response against the joints, heart, skin or the nervous system may include:
– Fever
– Pain in the knees, ankles, elbows, and wrists, which are most likely to become swollen from the rheumatic fever. The pain often migrates from one joint to another. However, the greatest danger from the disease is the damage it can do to the heart. In more than half of all cases, rheumatic fever scars the valves of the heart, making it work harder to pump blood.
– Small, painless nodules can be felt beneath the skin
– Flat or slightly raised, painless rash with a ragged edge (erythema marginatum)
– Rheumatic fever can also cause a temporary nervous system disorder once known as “St. Vitus’ dance”, now known as Sydenham’s chorea. This is a nervous disorder, characterised by rapid, jerky, involuntary movements of the body, usually occurring more on one side of the body.

How many people have rheumatic fever in Nigeria?
There are no concrete data in Nigeria, but some studies show that about 40 percent of heart diseases in adults in Nigeria are due to previous untreated rheumatic fever episodes. This shows that rheumatic fever largely goes undiagnosed. 

How is rheumatic fever diagnosed?
Your doctor will first want to get a list of your child’s symptoms. They’ll also want to know if your child has had a recent bout of strep throat.
Next, the doctor will:
– look for rash or skin nodules, which are hard bumps under the skin.
– listen to their heart to check for abnormalities.
– perform movement tests to determine their nervous system dysfunction.
– examine their joints for inflammation

He will ask for some tests such as:
– an electrocardiogram, which measures the electric waves of their heart.
– an echocardiogram, which uses sound waves to look at their heart.
– check for elevated or rising antistreptolysin O titre or DNAase
– test throat swab cultures.

How is rheumatic fever treated?
Treatment will involve getting rid of all residual group A strep bacteria and treating and controlling the symptoms. This can include any of the following:
– Antibiotics
– Anti-Inflammatory treatment
– Anticonvulsant medications
– Bed rest

How can rheumatic fever be prevented?
Effective ways to make sure that a child doesn’t develop rheumatic fever is to practise proper hygiene methods that can help prevent strep throat. These include:
– covering the mouth, when coughing or sneezing.
– washing hands.
– avoiding sharing personal items (e.g. eating utensils) with sick people.
Proper treatment of strep can prevent rheumatic fever. See a doctor, if your child has any of the following signs or symptoms:
• A sore throat without cold symptoms, such as a runny nose.
• A sore throat accompanied by tender, swollen glands (nodes).
• A red rash that starts at the head and neck then expands to the trunk and extremities
• Difficulty swallowing anything, including saliva.
• Thick or bloody discharge from the nose, which is more likely in children under three years of age.
• A bright red tongue with bumps all over it, known as strawberry tongue.