Rheumatic fever in children

Acute rheumatic fever is an important cause of acquired heart disease in children. Though the incidence of heart disease due to rheumatic fever has come down due to availability of preventive medicines it still continues to affect children all over the world. The incidence of rheumatic heart disease is higher in developing countries.

Cause and clinical features: The exact cause of this condition is not known. In many children a history of cough or sore throat can be obtained. The disease results from as immune response to a bacterium called streptococcus. The antibodies produced against streptococci also affect the tissues of joints and the heart though it is not clear why this happens in some children and not in others.

The disease usually starts with pain in the joints with or without fever. The joints commonly affected are knee, ankle, elbow and wrist joints. A characteristic feature of this disease is the migratory nature of joint involvement.

One joint is affected after another. The first joint affected may even completely recover before the involvement of the other joint. Movements are very painful and the child may experience severe pain even if the joint is slightly pressed.

In some children the heart may be affected in the acute stage. Mild heart involvement may be detected only on examination of the child or by taking an ECG. If the heart is severely affected child suffers from breathlessness and swelling of feet and face.

Some children may develop small swellings over the body called Rheumatic nodules while others may develop a rash (Erythema marginatum).

As there are many causes of joint pain in children a set of criteria has been developed to diagnose rheumatic fever called Jone’s criteria. It consists of major and minor criteria.

Two major or one major and two minor criteria are required for the diagnosis. The major criteria are polyarthritis (pain with limitation of movements involving more than one joint), carditis (inflammation of the heart), rheumatic nodules, chorea (involuntary movements) and erythema marginatum.

Minor criteria include clinical (arthralgia which means pain in the joints without limitation of movement, fever and previous rheumatic fever with or without heart disease) and laboratory (increase in white blood cell count, elevation of erythrocyte sedimentation rate and some proteins in the blood called C reactive protein. Changes in ECG also constitute minor criteria. Supporting evidence of preceding streptococcal infection is necessary for the diagnosis.

Treatment: Aspirin is the drug of choice for RF without cardiac involvement. Some authorities recommend aspirin even in case of mild cardiac involvement without enlargement of the heart. If the heart involvement is accompanied by enlargement of the heart, then Prednisolone is recommended. A course of suitable antibiotic is given to eradicate streptococcal infection.

Prevention: A major complication of rheumatic fever is damage to the heart. If it is mild there may not be permanent damage to the valves of the heart. But if a child gets repeated attacks of rheumatic fever the risk of permanent damage increases substantially. Hence regular preventive treatment is important for rheumatic heart disease prevention.

The most effective preventive measure is the administration of one form of penicillin (benzathine penicillin) by deep intramuscular injection once every three weeks. One serious problem with this is that in some children the injection can cause severe and even life threatening allergic reaction (anaphylaxis).

Some people have died after getting this injection. Hence the injection should only be given in an institution where facilities for critical care are available.

Though a test is performed before giving the full dose the test is not a fool proof one. Occasionally the test dose itself evokes serious allergic reaction. Some people may develop a serious reaction after the full dose is given even though they did not show any reaction to the test dose.

Oral medicines are less effective. They are erythromycin, oral penicillin. If a child has rheumatic heart disease it is advisable to give preventive treatment lifelong. If there is no heart disease the medication should be given for at least three to five years.

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