Definition of Rheumatic fever :

Rheumatic fever (RF) rheumatic heart disease (RHD) : Rheumatic fever is a febrile disease affecting connective tissues particularly in the heart and joints initiated by infection of the throat by group – A beta haemolytic streptococci.

Consequences of rheumatic heart disease (RHD) :

1. Continuing damage to the heart.
2. Increasing disabilities.
3. Repeated hospitalization.
4. Premature death usually by the age of 35 years or even earlier.

Diagnosis or symptoms of acute rheumatic fever :

A) Major criteria :

1. Carditis
2. Migratory polyarthritis.
3. Sydenham’s chorea.
4. Subcutaneous nodule.
5. Erythema marginatum.

B) Minor criteria : 

Clinical :

• Fever.
• Arthralgia.
• Previous rheumatic fever.

Laboratory findings :

• Raised ESR or C-reactive protein.
• Leucocytosis.
• Prolonged PR interval in ECG.
• ASO titre raised.
• Positive throat culture
• Recent scarlet fever.

Rheumatic fever is higher in slum dwellers:

Rheumatic fever is higher in slum dwellers : Rheumatic fever is a social disease. Its incidence slum dwellers due to —

1. Poor socio-economic condition having high humidity and overcrowding.
2. Poverty.
3. Malnutrition.
4. Lack of health education.
5. Poor housing conditions.
6. Inadequate health services.
7. Inadequate expertise of health care-care providers.
8. A low level of awareness of the disease.

Prevention of rheumatic heart disease (RHD) / Rheumatic fever :

Primary prevention :

1. Improvement of environment, housing & nutritional status.
2. Prophylactic antibiotic in sore throat : Phenoxymethyl penicillin 250mg 6 hourly (10 days).

Secondary prevention :

Prophylactic antibiotic to prevent further attack :

Benzathine penicillin 1.2 million units (6 lakh in < 30 kg) IM once monthly or Oral phenoxymethyl penicillin 250 mg 12 hourly.

• It should be continued for at least 5 years after last attack or upto the age of 18 years which one is longer.
• If carditis (mild mitral regurgitation or healed carditis) is present prophylaxis is continued at least 10 years after the last attack or upto 25 years of age, whichever is longer.
• More severe valvular disease or post-valve surgery cases need lifelong treatment.

Non-medical measures :

1. Improving living condition
2. Breaking the poverty-disease-poverty cycle.
3. Improving socio-economic conditions.

Evaluation :  In the evaluation of the programme, the prevalence of RHD in school children from periodic surveys of random samples is probably the best indicator.

Epidemiological features of rheumatic fever :

Prevalence : World-wide.

Agent factors :

• Agent : Streptococcus
• Carriers : Convalescent transient and chronic carriers.

Host and environmental factors of rheumatic fever :

Age : RF is typically a disease of childhood and adolescence (5-15 years).

Sex : The disease affects both sexes equally.

Immunity : Group A streptococcal products have certain toxic products and components of the streptococcus and of host tissues have an antigenic cross-relationship, leading to immunological processes result in an attack of RF.

Socioeconomic status : Linked to poverty, overcrowding poor housing & inadequate health services.

High risk groups : The school age children between 5 and 15 years, slum dwellers and those living in a closed community (eg, barracks).

Essential to know : 

Concept of prophylaxis of rheumatic fever varies between Park & text hooks of medicine  :

According to different text books of medicine, prophylaxis of rheumatic fever should be –

• It should be continued for at least 5 years after last attack or up to the age of 21 years, which one is longer.
• If carditis is present, prophylaxis should be given for at least 10 years from the last attack to 40 years of age whichever is longer. (an opinion).
• If carditis is present, prophylaxis should be continued for lifelong (another opinion).