Acute Rheumatic fever is still an enigma

S. Aravinda Kumar¹, Priyanka Kamaraj²

¹Chief Consultant Interventional Cardiologist, Kauvery Heart City, Trichy, India

²Duty Medical Officer, Department of Cardiology, Kauvery Heart City, Trichy, India

Abstract

Acute Rheumatic fever (ARF) is a serious inflammatory condition that can affect various parts of the body particularly the heart, joints, skin and brain. It occurs as an autoimmune response following a streptococcal throat infection caused by Group A Streptococcal bacteria. This article aims to shed the light on the causes, symptoms and management of ARF, with a focus on 10 -years- aged female child who recently developed this condition.

Case Presentation

A 10-year-old female child was brought with complaints of fever and migratory polyarthritis of 10 days duration associated with worsening breathlessness of 2 days duration.

ECG taken showed sinus rhythm, with first degree AV block (PR interval 202 ms).

Fig 1. ECG, showing first-degree heart block.

ECHO indicated rheumatic heart disease,

Mitral valve: Anterior Mitral Leaflet (AML) flail tip, non-co-apting, with moderate to severe Mitral Regurgitation (MR), good biventricular function.

Mild Tricuspid Regurgitation (TR) and severe Pulmonary Artery Hypertension 65 mmHg (PAH).

Blood investigations showed an elevation of total count (11390 cells/cumm) and ESR (40 mm/1 h). CRP was also elevated (103 mg/dl). ASO titre was elevated (502.2). Serial titre of ASO is awaited during revisit after the course of antibiotics.

Acute rheumatic fever was diagnosed based on modified Jones criteria, she satisfied:

Major: Carditis

Migratory Polyarthritis

Minor: Fever

ESR

CRP

Elevated total count

ECG: 1ST Degree AV block

Plus supporting evidence of ASO titre elavation.

Throat swab was not taken as she had no current symptoms.

She was treated with, Primary prophylaxis. Penicillin group of drugs, weight adjusted for 10 days along with Aspirin for joint pain. Even though she had feature of carditis, she was not started on steriods as she did not have severe congestive heart failure.

Secondary prophylaxis

She is planned for Benzathine penicillin, weight adjusted after the course of primary prophylaxis.

Bedrest was advised during the acute phase to mitigate further strain on the heart. She is advised follow up by regular monitoring to assess the progression of valvular dysfunction and determine the need for further interventions.

Discussion

Rheumatic fever is a serious inflammatory condition that affects various parts of body, but mostly joints and the heart, and is most common between ages of 5 and 15. Acute rheumatic fever can evolve into chronic rheumatic heart disease; this article focusses on acute rheumatic fever.

Acute rheumatic fever occurs as a result of untreated streptococcal (especially group A) infection. It is primarily an autoimmune response of the immune system that attacks own body, particularly connective tissue in the joints, heart and blood vessels.

Symptoms include joint pains and swelling, that may affect knees, ankles, wrists and elbows in the form of a migratory polyarthritis where joint pains move from one joint to another. An important characteristic feature is Carditis that may cause chest pain, shortness of breath, palpitations etc. If left untreated it leads to rheumatic heart disease. Oher symptoms include fever, fatigue, skin rash (erythema marginatum), appearance of subcutaneous nodules, involuntary muscle movements (Rheumatic Chorea) and emotional changes.

Considering the presence of carditis, polyarthritis (2 major) fever, elevated total count, ESR, CRP, and First-degree heart block in ECG (4 minor) plus supporting evidence of raised ASO we determined that the patient met Jones criteria for the diagnosis of Rheumatic Fever.

Treatment involves addressing infection with antibiotics usually penicillin or erythromycin. Anti-inflammatory medications like aspirin or corticosteroids are used to reduce the inflammation and to alleviate the symptoms. Bed rest is often recommended during acute phase of illness to prevent further strain in heart.

Prevention of acute rheumatic fever involves prompt and adequate treatment of streptococcal throat infections with antibiotics. It is important to complete the full course of antibiotics as prescribed to reduce the risk of rheumatic fever. Additionally good personal hygiene practices such as regular hand washing can help reduce of transmission of streptococcal bacteria.

Conclusion

This report on a 10-year-old female child highlights the complexity of diagnosing and managing rheumatic fever. Acute rheumatic fever is a serious inflammatory condition that primarily affects children and adolescents following a streptococcal infection. This report emphasizes the importance its early recognition and management to prevent long term complications such as rheumatic heart disease. By raising awareness about ARF, by promoting preventing measures and ensuring timely medical intervention, we can work towards minimizing the burden of this condition on affected individuals, families and communities.

Dr. S. Aravindakumar

Chief Consultant Interventional Cardiologist

Dr. Priyanka Kamaraj

Duty Medical Officer

Acute Rheumatic fever is still an enigma