Rheumatic Fever (Acute Rheumatic Fever or ARF)

  • Medical Author:
    David Perlstein, MD, MBA, FAAP

    Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

  • Medical Author: John Mersch, MD, FAAP
    John Mersch, MD, FAAP

    Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

Rheumatic fever (acute rheumatic fever or ARF) facts

  • Rheumatic fever is an autoimmune disease that may develop after a strep throat infection, especially in children ages 5-15, although older teens and adults may develop the disease.
  • The revised Jones criteria help physicians make the clinical diagnosis of rheumatic fever.
  • Rheumatic fever does not affect all individuals who have had a strep throat infection.
  • Rheumatic fever affects the joints, heart, skin, and nervous system.
  • Antibiotics treat a strep throat infection and may prevent development of rheumatic fever. Antibiotics will not help cure acute rheumatic fever.
  • Rheumatic fever may cause long-term damage to the heart and its valves.

What is rheumatic fever?

Rheumatic fever (acute rheumatic fever or ARF) is an autoimmune disease that may occur after a group A streptococcal throat infection. Such a reaction to a strep throat causes inflammatory lesions in connective tissue, the heart, joints and blood vessels of various organs and subcutaneous tissue. The disease has been around since the 1500s, but the association between a throat infection and rheumatic fever symptom development was not described until the 1880s. The sore throat was later associated with fever and rash (caused by streptococcal exotoxins) in the 1900s. Prior to the broad availability of penicillin, rheumatic fever was a leading cause of death in children and one of the leading causes of acquired heart disease in adults. The disease has many symptoms and can affect different parts of the body, including the heart, joints, skin, and brain. There is no single diagnostic test for rheumatic fever, so the American Heart Association's modified Jones criteria (first published in 1944 and modified in 1992) guide the physician in making the proper diagnosis.

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Rheumatic Fever Symptoms & Signs

Rash

The word "rash" means a change in the color and texture of skin that usually causes an outbreak of red patches or bumps on the skin. In common usage of the term, a "rash" can refer to many different skin conditions. A rash can be caused, directly or indirectly, by a bacterial, viral, or fungal infection. Alternatively, a rash may be unrelated to an infectious organism, such as from an underlying medical illness. Medications, chronic medical conditions, and allergic reactions (hives) are among the multiple different causes of rash.

What are the revised Jones criteria for acute rheumatic fever?

The revised Jones criteria are guidelines decided on by the American Heart Association to help doctors diagnose rheumatic fever. Two major criteria or one major and two minor criteria plus laboratory evidence of a preceding group A streptococcal (GAS) infection are required to make the diagnosis of rheumatic fever.

The major criteria for diagnosis include

The minor criteria for diagnosis include

Evidence of preceding streptococcal infection includes the following:

  • Positive throat culture for GAS infection
  • Positive rapid direct GAS throat swab
  • Recent scarlet fever
  • Supporting blood studies for recent GAS infection. These could include rising ASO titers, anti-DNase titers, or antihyaluronidase titers. Measurement of rising ASO titers is the preferred study.

What causes acute rheumatic fever?

There is a direct and well-described connection between certain streptococcal infections and rheumatic fever. Most commonly, rheumatic fever is preceded by a throat infection caused by group A beta-hemolytic Streptococcus bacteria (strep throat, GABHS, or GAS). The bacterium causes an autoimmune (antibodies that attack the host's own cells) inflammatory response in some people which leads to the myriad of signs and symptoms described by the revised Jones criteria. Streptococcal throat infections are contagious, but rheumatic fever is not. The symptoms of rheumatic fever generally develop within two to three weeks following an infection with streptococcal bacteria, and usually the first symptoms are painful joints or arthritis.

What are rheumatic fever symptoms and signs?

As mentioned above, there are quite a few symptoms associated with rheumatic fever. Major Jones criteria include the following:

  1. Carditis (inflammation of the heart), which occurs in 60% of patients, is the most severe symptom of ARF and can result in permanent damage to the heart valves, heart muscle itself, or tissue surrounding the heart (pericardium). These effects can be life threatening.
  2. Polyarthritis or migratory polyarthritis (joint inflammation), which is usually the first presenting symptom of ARF, occurs in 45% of patients. Large joints (knees, ankles, elbows, and wrists) are the most commonly affected. The pain may be moderately painful.
  3. Aschoff bodies (subcutaneous skin nodules) are firm, painless lumps most frequently found around the wrists, elbows, and knees. These are present in only 2% of patients.
  4. Erythema marginatum is a characteristic rash that occurs in 5% of patients. The rash is wavy and has a snakelike appearance (serpiginous) that has distinct erythematous (red) borders or "margins." The rash is not itchy or painful, starts on the trunk, and expands to involve the extremities. It does not affect the face.
  5. Sydenham's chorea occurs in 30% of patients and is a movement disorder comprising of uncontrollable, purposeless, volatile movements of the face and arms. This was also called St. Vitus' dance, which was named after the patron saint of the "mania dancers" of the middle ages. This movement disorder is characteristic of ARF and may be associated with emotional disturbances and inappropriate behaviors. This movement disorder may appear months following the GAS throat infection.

Minor Jones criteria include the following:

  1. Fever is often present during the acute infection with group A strep and is present during the initial phase of rheumatic fever.
  2. Arthralgia -- sore joints without evidence of swelling, warmth, or associated skin changes
  3. Previous rheumatic fever or rheumatic heart disease
  4. Nonspecific laboratory changes of inflammation: elevated white blood cell (WBC) levels, elevated erythrocyte sedimentation rate (ESR), and elevated C-reactive protein (CRP)
  5. Characteristic changes on an electrocardiogram (EKG)

Evidence of a preceding GAS infection include a

  1. positive throat culture for GAS,
  2. positive rapid throat test for GAS,
  3. recent scarlet fever, or an
  4. increase in anti-strep antibodies -- rising ASO, anti-DNase B, or antihyaluronidase titers.

How do health care professionals diagnose rheumatic fever?

The person must have a history of an infection with group A streptococcal bacteria, either by laboratory documentation (for example, a positive rapid strep test) or positive strep culture, and must have two major or one major and two minor revised Jones criteria findings.

What is the treatment for rheumatic fever?

The first step in treating rheumatic fever is to eradicate the bacteria (usually with penicillin) that initially caused the immunologic response. For penicillin-allergic patients, there are other options such as erythromycin azithromycin or a member of the cephalosporin family. It is important to make sure that patients receive treatment for the acute infection, but such treatment won't necessarily change the course of rheumatic fever once the immunologic response has begun. Your doctor will decide on the best treatment option for you. Aspirin or aspirin-related medications treat the joint pains. It may be necessary to use very high doses to decrease the symptoms. (Caution: Do not routinely use aspirin in pediatric patients because of its association with Reye's syndrome.) Consult a pediatric specialist for treatment protocols.

High-dose steroids treat carditis, but it may be necessary to use other cardiac medications to control the inflammation of the heart. Health care professionals initially manage this serious condition in a hospital.

The most challenging and unpredictable symptom to treat is the chorea (involuntary movements). It often responds to antipsychotic medications such as haloperidol (Haldol) but may continue for a protracted period. For patients who develop Sydenham's chorea, it can be the most difficult of the symptoms, since it involves involuntary movements and can interfere with daily activities. These individuals must remain on chronic long-term antibiotics to prevent recurrence of the strep infection, as a recurrent strep infection may cause chorea to recur.

What are the complications of rheumatic fever?

The most concerning of the complications of ARF are cardiac in nature. Patients with rheumatic fever who develop carditis may develop long-lasting heart dysfunction. Often the mitral valve or the aortic valve is affected. For patients not responsive to medications, surgical valve replacement may become necessary. Atrial fibrillation (irregular fast heart rate) and heart failure can occur. Sydenham's chorea can be the most difficult complication to treat, and the individuals with this complication may get recurrence of the movement disorder. A few people remain very susceptible to reinfection with GABHS and may require lifetime antibiotic treatment.

Is it possible to prevent rheumatic fever?

Prevention of rheumatic fever requires the recognition and diagnosis of group A strep throat infections and appropriate antibiotic therapy. In children 5-15 years of age, strep throat infections are very common and appear as a sudden onset of throat pain, fever, headache, and abdominal pain. Generally, patients with strep throat do not have symptoms such as runny nose, nasal congestion, cough, or other symptoms more commonly seen with a routine upper respiratory infection (URI, or the common cold). Most providers either test for a GAS infection with a rapid strep test or throat culture. Most causes of sore throat are not bacterial but are viral, do not carry the risk of rheumatic fever, and cannot be treated with antibiotics. In addition, once an individual develops rheumatic fever after a strep throat infection, that individual remains at risk for subsequent episodes of rheumatic fever during subsequent strep throat infections. These individuals may need to receive chronic long-term prophylaxis (preventive treatment) with antibiotics. Researchers continue to attempt development of a vaccine against group A beta-hemolytic streptococcal infection, but currently no vaccine is available.

Infectious disease specialists emphasize the importance of preventing recurrent episodes of ARF. There are several options varying from a once a month long-acting injection of penicillin to daily oral antibiotics. The guidelines currently recommend a prophylactic (preventative) antibiotic regimen for patients without carditis for five years or to 21 years of age (whichever is longer). For those with carditis but no residual heart disease, prevention should be for 10 years or well into adulthood (whichever is longer). Those who have residual heart disease because of carditis are advised to utilize antibiotic prophylaxis until 40 years of age and some specialists recommend lifelong therapy.

How common is rheumatic fever?

In the United States and other developed nations, rheumatic fever is exceedingly rare today, though there have been sporadic outbreaks. This is due to the availability of antibiotics and preventive services. In other parts of the world, it remains a common disease and is the leading cause of cardiovascular death in individuals under the age of 50.

Medically Reviewed on 7/3/2018
References
REFERENCES:

"Acute rheumatic fever: Clinical manifestations and diagnosis." UpToDate.com.

"Guidelines for the Diagnosis of Rheumatic Fever. Jones Criteria, 1992 Update." JAMA 268.15 Oct. 21, 1992: 2069-73.

Mirkinson, L. "The Diagnosis of Rheumatic Fever." Pediatrics in Review 19.9 Sept. 1998.

United States. Centers for Disease Control and Prevention. "Group A Streptococcal (GAS) Disease." Sept. 16, 2016. <https://www.cdc.gov/groupastrep/index.html>.
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