Rheumatic fever in adults

Rheumatic Fever in Adults: It is a systemic disease characterized by disseminated inflammatory reactions of the connective tissue that affect the osteoarticular, cardiovascular, nervous system and the skin. It presents as a late complication of a pharyngotonsillar infection.

Summary

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  • 1 Prognosis and natural history course
  • 2 Symptoms
  • 3 Causes
  • 4 Incidents
  • 5 Diagnosis
  • 6 Treatment
  • 7 Acute Rheumatic Fever
  • 8 Rheumatic Fever in Penicillin Allergy
  • 9 Risk factors
  • 10 Complications
  • 11 Sources

Prognosis and natural history course

The course of rheumatic fever is variable. In general, there is a characteristic and predictable sequence of presentation of major manifestations: arthritis and marginal erythema are early manifestations, carditis and intermediate subcutaneous nodules, and late chorea.

Most attacks begin with fever and joint symptoms, if carditis occurs it will do so in the first weeks (until the 4th or 5th). The duration of the attack or outbreak is less than three months, if there is severe carditis it can continue up to 6 months.

Rheumatic fever does not occur if the strep infection is prevented or treated. The prognosis of patients without carditis in the first episode is optimal and worsens if it occurred.

Symptoms

ü Abdominal pain ü Heart (cardiac) problems that may be asymptomatic or may cause respiratory distress and chest pain ü Joint pain (mainly in the knees, elbows, ankles, and wrists) ü Joint inflammation, redness, or heat ü Bleeding nasal ü Skin rash (erythema marginalized) ü Fever is high during the first week, then decreases even without treatment, may persist three to four weeks.

Causes

The pathogenesis of the disease is unknown. It is postulated according to epidemiological and immunological data that the streptococcus responsible for pharyngitis would trigger an immune response with the formation of antibodies that would cross-react with epitopes of the heart, the CNS, hyaluronic acid, etc. or its toxins would act as super antigens. The susceptible population has a B cell-related antigen identified with monoclonal antibodies (D8 / 17). The relationship with other HLAs is not yet defined.

Incidents

It occurs more frequently between 5 and 15 years, with a similar incidence in both sexes (except for chorea and mitral stenosis, which are more frequent in women). Overcrowded conditions and lack of hygiene favor the spread of pharyngotonsillitis infections, increasing in these circumstances the frequency of rheumatic fever. Rheumatic infection is the most frequent cause of cardiovascular morbidity and mortality between the ages of 5 and 25 in countries such as India or the African continent. In developed countries, its incidence decreased even before the antibiotic era, as living conditions improved. The incidence in developed countries is 5 cases per c / 100,000 inhabitants and 50 per c / 100,000 in the undeveloped. Patients suffering from the first episode of rheumatic fever are more likely than the general population to have a reactivation or relapse (always after a new streptococcal infection). Its recurrence is 50% per year and gradually decreases to 10% after the fifth year.

Diagnosis

There is no clinical manifestation or laboratory test that alone establishes the diagnosis of rheumatic fever . Each manifestation is variable in its form of presentation and can be isolated or associated with the others. The most characteristic manifestations are grouped in the so-called Jones criteria (1992). When two or more of them are presented combined, they indicate that there is a high probability that the disease is present. The diagnosis is based on the demonstration of a previous streptococcal infection plus the presence of at least two major criteria or one major and two minor criteria.

Treatment

If you are diagnosed with acute rheumatic fever, you will be treated with antibiotics . Anti-inflammatory medications, such as acetylsalicylic acid (aspirin) or corticosteroids, reduce inflammation to help manage acute rheumatic fever. One may have to take low doses of antibiotics, such as penicillin, zulfadiazine, or erythromycin, for a long period of time to prevent the return of strep throat.

Acute Rheumatic Fever

If rheumatic fever symptoms are severe, corticosteroids, such as prednisone, will be included in the treatment. Corticosteroids should be reserved for the treatment of severe rheumatic fever. After about two to three weeks of corticosteroid treatment, the dose may be tapered, it should be reduced by 25% each week. In extreme cases, methylprednisolone may be necessary, it should be administered intravenously.

When the patient begins to experience involuntary movements, such as those in Sydenham’s chorea, the doctor may prescribe an anticonvulsant, such as valproic acid (Depakene, Stavzor) or carbamazepine (Carbatrol, Equetro, or others). Digoxin may be helpful in these cases, but its use should be closely controlled due to the possibility of heart block.

Treatment of acute rheumatic fever is a long and sometimes even life-long treatment. Treatment includes long-term or lifetime follow-up as well. After a few years of experiencing acute rheumatic fever, heart damage may appear.

Rheumatic Fever in Penicillin Allergy

Penicillin is the quintessential drug for treating rheumatic fever. However, in patients allergic or at risk of presenting an allergic reaction to said antibiotic, a single parenteral injection of benzathine benzylpenicillin will be administered. Oral Cephalosporins, instead of erythromycin, is also a recommended and alternative medicine for patients allergic to penicillin.

Risk factors

Factors that can increase the risk of rheumatic fever include: Family history. Some people may carry a gene or genes that make them more likely to develop rheumatic fever. The type of strep bacteria. Certain strains of streptococcal bacteria are more likely to contribute to rheumatic fever than other strains. Environmental factors. An increased risk of rheumatic fever is associated with overcrowding, lack of sanitation, and other conditions that can result in rapid transmission or multiple exposures to strep bacteria.

Complications

The inflammation caused by rheumatic fever can last from a few weeks to several months. In some cases, inflammation can lead to long-term complications.

Rheumatic heart disease is permanent damage to the heart caused by inflammation of rheumatic fever. Problems are more common with the valve between the two left chambers of the heart (the mitral valve), but the other valves may also be affected. Damage can result in one of the following conditions:

Valve stenosis. This condition is a narrowing of the valve, resulting in decreased blood flow. Valve regurgitation. This condition is a leak in the valve, allowing blood to flow in the wrong direction. Damage to the heart muscle. The inflammation associated with rheumatic fever can weaken the heart muscle, resulting in poor pumping function.

Damage to the mitral valve, other heart valves, or other tissues of the heart can cause future problems with the heart. Resulting conditions may include: Atrial fibrillation, an irregular and chaotic heartbeat of the upper chambers of the heart (atria) Heart failure, inability of the heart to pump enough blood to the body

 

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