Understanding Rheumatic Fever

What Is Rheumatic Fever?

A rare but potentially life-threatening disease, rheumatic fever is a complication of untreated
strep throat caused by bacteria called group A streptococcus. The main symptoms -- fever,
muscle aches, swollen and painful joints, and in some cases, a red, lattice-like rash --
typically begin one to six weeks after a bout of strep. In some cases, though, the infection
may have been too mild to have been recognized.
Rheumatic fever can also cause a temporary nervous system disorder once known as St.
Vitus' dance. Today it is called chorea, or Sydenham's chorea. This is a nervous disorder --
characterized by rapid, jerky, involuntary movements of the body -- occurring chiefly in
childhood or during pregnancy and closely associated with rheumatic fever. People with mild
cases of chorea may find it difficult to concentrate or write. More severe cases can cause the
muscles of the arms, legs, or face to twitch uncontrollably.
The knees, ankles, elbows, and wrists are the joints most likely to become swollen from
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, forcing this vital organ to work harder to pump
blood. Over a period of months or even years -- particularly if the disease strikes again -- this
damage to the heart can lead to a serious condition known as rheumatic heart disease, which
can eventually cause the heart to fail.
Because of antibiotics, rheumatic fever is now rare in developed countries. In recent years,
though, it has begun to make a comeback in the U.S., particularly among children living in
poor, inner-city neighborhoods. The disease tends to strike most often in cool, damp weather
during the winter and early spring. In the U.S., it is most common in the northern states.
What Causes Rheumatic Fever?
Rheumatic fever results from an inflammatory reaction to certain group A
streptococcusbacteria. The body produces antibodies to fight the bacteria, but instead the
antibodies attack a different target: the body's own tissues. The antibodies begin with the
joints and often move on to the heart and surrounding tissues. Because only a small fraction
(fewer than 0.3%) of people with strep throat ever contract rheumatic fever, medical experts
say that other factors, such as a weakened immune system, must also be involved in the
development of the disease.
CAUTION! Monitor That Sore Throat
Pay attention to sore throats, especially in children. If your child has a severe sore throat
without other cold symptoms, accompanied by a fever higher than 101 degrees Fahrenheit, or
a milder sore throat that persists for more than two or three days, see a doctor. It may be strep
throat, which should be treated with antibiotics
Endocarditis
Endocarditis is inflammation of the inside lining of the heart chambers and heart valves
(endocardium).
Causes
Endocarditis can involve the heart muscle, heart valves, or lining of the heart. Most people
who develop endocarditis have a:
Birth defect of the heart
Damaged or abnormal heart valve
History of endocarditis
New heart valve after surgery
Endocarditis begins when different germs enter the bloodstream and then travel to the heart.
Bacterial infection is the most common cause of endocarditis.
Endocarditis can also be caused by fungi, such as Candida.
In some cases, no cause can be found.
Germs are most likely to enter the bloodstream during:
Central venous access lines
Injection drug use, from the use of unclean (unsterile) needles
Recent dental surgery
Other surgeries or minor procedures to the breathing tract, urinary tract, infected skin,
or bones and muscles
Symptoms
Symptoms of endocarditis may develop slowly or suddenly.
Fever, chills, and sweating are the classic symptoms. These sometimes can:
Be present for days before any other symptoms appear
Come and go, or be more noticeable at nighttime
Fatigue, weakness, and aches and pains in the muscles or joints may also be present.
Other symptoms can include:
Small areas of bleeding under the nails (splinter hemorrhages)
Red, painless skin spots on the palms and soles (Janeway lesions)
Red, painful nodes in the pads of the fingers and toes (Osler's nodes)
Shortness of breath with activity
Swelling of feet, legs, abdomen

Exams and Tests
The health care provider may detect a new heart murmur, or a change in a past heart murmur.
An eye exam may show bleeding in the retina and a central area of clearing. This is known as
Roth's spots. There may be small, pinpoint areas of bleeding on the surface of the eye or the
eyelids.
Tests that may be done include:
Blood culture -- helps identify the bacteria or fungus that is causing the infection
Complete blood count (CBC), C-reactive protein (CRP), or erythrocyte sedimentation
rate (ESR)
A routine echocardiogram or a transesophageal echocardiogram provides a closer
look at the heart valves
Treatment
You may need to be hospitalized at first to receive antibiotics through a vein (IV or
intravenously). Blood cultures and tests will help your health care provider choose the best
antibiotic.
You will then need long-term antibiotic therapy.
Patients usually need therapy for 4-6 weeks to fully remove all the bacteria from the
heart chambers and valves.
Antibiotic treatments that are started in the hospital will need to be continued at home.
Surgery to replace the heart valve is usually needed when:
The infection is breaking off in little pieces, resulting in strokes
The person develops heart failure as a result of damaged heart valves
There is evidence of more severe organ damage
Outlook (Prognosis)
Getting treatment for endocarditis right away improves the chances of a good outcome.
More serious problems that may develop include:
Brain abscess
Further damage to the heart valves, causing heart failure
Spread of the infection to other parts of the body
Stroke, caused by small clots or pieces of the infection breaking off and traveling to
the brain.


When to Contact a Medical Professional
Call your health care provider if you notice the following symptoms during or after treatment:
Blood in urine
Chest pain
Fatigue
Fever
Numbness
Weakness
Weight loss without change in diet
Prevention
The American Heart Association recommends preventive antibiotics for people at risk for
infectious endocarditis, such as those with:
Certain birth defects of the heart
Heart transplant and valve problems
Man-made (prosthetic) heart valves
Past history of endocarditis
These patients should receive antibiotics when they have:
Dental procedures that are likely to cause bleeding
Procedures involving the breathing tract
Procedures involving the urinary tract system
Procedures involving the digestive tract
Procedures on skin infections and soft tissue infections
Alternative Names
Valve infection; Staphylococcus aureus - endocarditis; Enterococcus - endocarditis;
Streptococcus viridans - endocarditis; Candida - endocarditis
Myocarditis
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Myocarditis is inflammation of the heart muscle.
See also: Pediatric myocarditis
Causes
Myocarditis is an uncommon disorder that is usually caused by viral, bacterial, or fungal
infections that reach the heart.
Viral infections:
Coxsackie
Cytomegalovirus
Hepatitis C
Herpes
HIV
Parvovirus
Bacterial infections:
Chlamydia
Mycoplasma
Streptococcus
Treponema
Fungal infections:
Aspergillus
Candida
Coccidioides
Cryptococcus
Histoplasma
When you have an infection, your immune system produces special cells that release
chemicals to fight off disease. If the infection affects your heart, the disease-fighting cells
enter the heart. However, the chemicals produced by an immune response can damage the
heart muscle. As a result, the heart can become thick, swollen, and weak. This leads to
symptoms of heart failure.
Other causes of myocarditis may include:
Allergic reactions to certain medications or toxins (alcohol, cocaine, certain
chemotherapy drugs, heavy metals, and catecholamines)
Being around certain chemicals
Certain diseases that cause inflammation throughout the body (rheumatoid arthritis,
sarcoidosis)
Symptoms
There may be no symptoms. Symptoms may be similar to the flu. If symptoms occur, they
may include:
Abnormal heartbeat
Chest pain that may resemble a heart attack
Fatigue
Fever and other signs of infection including headache, muscle aches, sore throat,
diarrhea, or rashes
Joint pain or swelling
Leg swelling
Shortness of breath
Other symptoms that may occur with this disease:
Fainting, often related to irregular heart rhythms
Low urine output
Exams and Tests
A physical examination may show no abnormalities, or may reveal the following:
Abnormal heartbeat or heart sounds (murmurs, extra heart sounds)
Fever
Fluid in the lungs
Rapid heartbeat (tachycardia)
Swelling (edema) in the legs
Tests used to diagnosis myocarditis include:
Blood cultures for infection
Blood tests for antibodies against the heart muscle and the body itself
Chest x-ray
Electrocardiogram (ECG)
Heart muscle biopsy (endomyocardial biopsy)
Red blood cell count
Ultrasound of the heart (echocardiogram)
White blood cell count
Treatment
Treatment is aimed at the cause of the problem, and may involve:
Antibiotics
Anti-inflammatory medicines to reduce swelling
Diuretics to remove excess water from the body
Low-salt diet
Reduced activity
If the heart muscle is very weak, your health care provider will prescribe medicines to treat
heart failure. Abnormal heart rhythms may require the use of additional medications, a
pacemaker, or an implantable cardioverter-defibrillator. If a blood clot is in the heart
chamber, you will also receive blood thinning medicine.
Outlook (Prognosis)
How well you do depends on the cause of the problem and your overall health. The outlook
varies. Some people may recover completely. Others may have permanent heart failure.
Possible Complications
Cardiomyopathy
Heart failure
Pericarditis
When to Contact a Medical Professional
Call your health care provider if you have symptoms of myocarditis, especially after a recent
infection.
Seek immediate medical help if you have severe symptoms or have been diagnosed with
myocarditis and have increased:
Chest pain
Difficulty breathing
Swelling
Prevention
Promptly treating conditions that cause myocarditis may reduce the risk.
Alternative Names
Inflammation - heart muscle