Acute rheumatic fever( abbreviation - ORL) is a severe inflammatory process of connective tissue with damage to the structures of the heart, joints, skin, nervous system and subcortical nodes of the brain. Can have very negative consequences, if not in time do not start treatment. About the pathogenesis and etiology of acute rheumatic fever in children and adults, the medical history, the diagnosis and diagnostic criteria, read in our today's material.
Features of the disease
The fever arises as a complication after infection of the lymphatic tissue of the tonsils( tonsillitis, tonsillitis), pharynx( scarlet fever), triggered by the aggression of beta-hemolytic streptococcus from group A. It mainly affects children 7 to 16 years of age. Pathogenesis is associated:
- with toxin-releasing streptococcal enzymes that cause cell poisoning in the tissues of the heart.
- with the similarity of antigenic complexes of the pathogen and myocardial tissue, which provokes immunity against aggression against "native" cells, which are perceived as alien.
The video below provides useful information on rheumatism and acute respiratory disease:
ORL classification
Standard classification of acute rheumatic fever in children and adults:
| Classification parameters | Forms |
|---|---|
| Type | Acute( ORL) and repeated( PRL) forms of |
| Symptoms | Baseline: carditis, rheumoarthritis, small chorea, erythema, subcutaneous rheumatic nodules. Additional: febrile condition( fever, chills);articular, abdominal( in the abdomen) pain; |
| Degree of involvement of the cardiac muscle | without myocardial infarction( rare) or development of rheumatic heart disease in chronic form with the formation of a defect( or without it) |
| Degree of cardiac dysfunction( insufficiency) | classesfunctioning 0;I;II;III;IV |
Next, the main cause of acute rheumatic fever will be considered.
Reasons for
Identify the underlying causes and additional factors of fever development.
Aggression of beta-hemolytic streptococcus A-type
Rheumatic fever typically develops 3 to 4 weeks after scarlet fever, sore throat, or pharyngitis, the causative agents of which are certain strains of gram-positive streptococci, which have a high degree of infectiousness. After the introduction of the pathogen into the blood, the normal functioning of the immune complexes of the body is disrupted.
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M-proteins of the streptococcal microorganism cell are similar in structure to proteins of myocardial tissue, joints and synovial membranes( inner layer of the joint cavity).For this reason, immunity, reacting to the penetration into the body of a foreign agent, attacks its own cells, provoking inflammatory processes.
Hereditary factor
The study of the pathogenesis of rheumatic fever confirms that the greatest frequency of the disease, subsequent complications and cardiac defects are observed in individual families. Hereditary predisposition to ORL caused by the presence of a specific antigen in the body was detected in almost all patients and only 6-7 of those who did not have pain.
Acute rheumatic fever has its symptoms, which we'll talk about further.
Symptoms of
General signs of
More than half of children and adolescents started the attack of rheumatic fever manifested:
- by an unexpected and sudden jump in temperature by the type of "flash";
- by the appearance of symmetrical pains in the knee, elbow, hip joints, which usually change the localization;
- swelling and reddening of the tissues around the inflamed joints;
- signs of rheumatic heart disease - inflammation of the heart structures( chest pains, high fatigue, weak pulse with a malfunction of rhythm and frequency, stretching of the heart cavities, lowering of pressure).
In young patients aged 15-19 years, the onset of the disease is usually not as acute as in younger children:
- does not normally reach 38.5 C;
- arthralgia( tenderness) in large joints is not accompanied by marked inflammation and edema;
- manifestations of carditis - moderate.
Specific signs for different forms of the disease
Rheumoarthritis
Rheumoarthritis gives symptoms at the first attack of the ORL in 70-100% of cases. This:
- marked soreness, swelling of the hip, wrist, elbow, ankle, knee joints due to accumulation of effusion in the joint bag( synovitis);
- limited mobility due to pain;
- specificity of arthritis caused by ORL - the "migrating" nature of inflammation( in some joints pain and swelling disappear within 1 to 4 days, followed by a severe defeat of others), as well as rapid reversibility of symptoms when exposed to anti-inflammatory pharmacological agents.
Cardiovascular
Carditis is commonly observed in patients with ARI in 85% to 95% of patients. Sometimes the severity of the symptoms is muffled, but in any case:
- heart rhythm disorder;
- shortness of breath, pain behind the sternum on the left;
- swelling of the feet and ankles, sweating and severe fatigue.
- defeats the heart valves, rapidly losing elasticity and the ability to fully open and tightly close, passing blood( even with erased symptomatology and a moderate and easy course of rheumatic carditis).
Abnormal changes in the valves are often combined with myocarditis, pericarditis( inflammation of the muscles of the heart and the outer shell), which leads to a violation of cardiac electrical conductivity, the appearance of noise, muffled tone, the expansion of cavities.
With active and timely treatment, the normal rhythm of cardiac contractions and myocardial borders, sonority of tones, reduction in the degree of abnormal noise, disappearance of signs of impaired blood supply are observed.
Rheumatic chorea
Rheumatic chorea( synonyms - small chorea, known since the Middle Ages dance of St. Vitus) - a pathology that develops during the spread of inflammation processes to brain tissue. It is manifested by vasculitis( inflammation) of small cerebral vessels and symptoms of damage to the central trunks of the brain and spinal cord and peripheral nerves.
The target of pathology is mainly young children( 15 - 30%), less often adolescents in the puberty, after 35 - 65 days after the child suffered acute infection with streptococcal microorganism. It is more often defined in children of a female.
Symptoms of small chorea combine syndromes:
- motor anxiety, uncontrolled twitching( hyperkinesia) of muscles, hands and feet, grimacing, disappearing during sleep;
- indistinctness of speech, fatigue, change in gait, inability to hold small items;
- muscle hypotension( severe relaxation, similar to paralysis), dysfunction of swallowing, physiological dispensing;
- apathy, tearfulness, aggressiveness, irritability, sleep disturbance.
Usually these symptoms of chorea are combined with carditis and rheumoarthritis, but in rare cases( in 5-7 children from 100 cases) chorea is the only obvious symptom of rheumatic fever. In cases where other signs of RLS are absent, the diagnosis of small chorea is made after excluding other possible causes of neuropsychiatric disorder.
Ring-shaped erythema
Ring-shaped erythema with ORL appears at the peak of the disease in the form of pink ring-shaped spots measuring 50-100 mm, then appearing on the skin of the chest, arms, legs and back, then disappearing. In addition to them, rashes in the form of small nodules - painless dense dark red formations appearing under the skin in the periarticular tissues - spread over the vertebrae, protrusions of the heels, ankles, and the nape. Only occur in children. Disappear within 25 - 30 days.
Erythema and rheumatic nodules are rare but very specific signs of rheumatic fever, therefore are of great importance for accurate diagnosis. Next we will consider differential diagnosis of acute rheumatic fever.
Diagnosis of
Diagnosis of ORL is often difficult, because the baseline manifestations( excluding erythema and nodules) are not unique to this pathology, but arise in other diseases. With mild symptomatic carditis, to determine the diagnosis, do:
- echocardiogram using Doppler mode. This study provides an opportunity to assess changes in the structure of the heart, coronary blood flow, identify the degree and nature of the defeat of the valves, inflammation of the pericardium( the outer shell of the heart);
- electrocardiogram , allowing in time to determine whether there are violations in the rhythm of contractions of the heart muscle.
Laboratory tests
In acute ORL attack,
- in the blood is detected - an increase in ESR( greater than 40 mm / hr) and CRP( the amount of C-reactive protein that is formed in the liver in acute inflammation), sometimes an increase in leukocytes or neutrophils;
- increased concentration of antibodies( AT) against streptococcus( in 82% of cases);
- hemolytic streptococcal agent for bacteriological examination of a smear taken from the oral cavity.
Differential diagnosis
Classical signs of ORLs are not common, therefore, for accurate diagnosis it is necessary to distinguish ORL from other pathological conditions with similar manifestations.
If there is no clear relationship between streptococcal aggression and the occurrence of rheumatic heart disease, other possible pathologies of the heart are identified:
- prolapse( bulging) of the mitral valve;
- endocarditis - infection of valves;
- viral myocarditis( inflammation of the heart tissue);
- myxoma( benign atrial formation).
Important to know:
- Chorea in ORL should be distinguished from encephalitis, neuropsychiatric disorders PANDAS, caused by streptococcal infections.
- Arthritis, carditis and cutaneous erythema are also manifested in lymoborreliosis, when infection occurs from a tick bite( spirochete).
- To distinguish ORL from Lyme disease, it is required to identify the presence of antibodies to the spirochaete in the blood.
For treatment in the clinic and at home, as well as emergency care for acute rheumatic fever, read below.
Treatment of
In the treatment of ARF, a comprehensive scheme is provided that includes:
- etiotropic therapy( elimination of the cause);
- pathogenetic( correction of organ failure, stabilization of metabolic processes, enhancement of immune resistance of the organism), symptomatic( alleviation of symptoms).
Medicated
- To eliminate the cause of the disease - to destroy beta-streptococcus - use antibiotics of the penicillin group( from 14 years of benzylpenicillin at a dosage of 2 to 4 million units, children under 14 years from 400 to 600 thousand units).Course - not less than 10 days. Or more "advanced" amoxicillin is used.
- When penicillin allergy is prescribed drugs from a number of macrolides( Roxithromycin, Clarithromycin) or lincosamides. After completion of the course of injections, antibiotics are prescribed in long-acting tablets.
- Pathogenetic therapy of ORL is the use of hormonal drugs and NSAIDs. In severe carditis and serositis, at least 18 to 22 days, prednisolone is administered at a dose of 20 to 30 mg per day until a pronounced therapeutic effect is obtained. After that, the glucocorticosteroid dosage is slowly reduced( 2.5 mg per week).
- Elimination of symptoms:
- In the treatment of rheumoarthritis, chorea is prescribed diclofenac, which reduces inflammation of the joints, in a daily dosage of 100-150 mg per course lasting 45-60 days.
- If signs of rheumatic heart disease are observed, funds for the stimulation of myocardial activity must be prescribed( Digoxin).
- Hormones specifically affect metabolic processes, therefore, taking into account the degree of dystrophic changes in the heart, medicines are used:
- Nandrolone with a course of 10 injections of 100 mg once a week;
- Asparks 2 tablets 3 times a day with a course of 30 days;
- Inosine three times a day 0,2 - 0,4 g, the course lasting 1 month.
- With diarrhea that indicates fluid retention in tissues, diuretics such as Lasix are used. Use stimulants of the immune system.
Heart defects, formed with rheumatic carditis, are treated with drugs from arrhythmia, nitrates, moderate use of diuretics. The duration and specificity of cardiac therapy depends on the degree of disruption of the structure of the myocardium, the severity of the symptoms and the degree of failure of the function of the heart.
Surgical
If a severe heart disease is diagnosed in the diagnosis of acute respiratory disease, the task is to perform an operation on the valves, the possibility of plastic and valvular prosthetics is evaluated.
Physiotherapy
Physiotherapy
Simultaneously with the use of medicines, treatment of ARF includes a course of physiotherapy:
- UHF heating,
- application of mud and paraffin applications,
- infrared radiation,
- application of oxygen and radon baths,
- therapeutic massage( after recovery).
For national and clinical recommendations on the prevention of acute rheumatic fever in children and adults, read below.
Prevention
- Preventing the development of ARF or primary prevention consists in the early detection and cure of infectious diseases of the pharynx caused by streptococci with antibiotics( Amoxicillin, Cefadoxil, Ofloxacin, Azithromycin).
- When re-infected, Amoxicillin with clavulanic acid is used. If this therapy does not produce results or causes allergic reactions, Lincomycin, Clindomycin is prescribed.
- Secondary prophylaxis is necessary to prevent re-attack of the ORL in patients who have already had the disease. Antibacterial agents of long-term action - bicillin( Extensillin and Retarpen) are prescribed, which reduce the likelihood of recurrence of ORL 5 to 20 times.
- For those patients who have had ORL without carditis, the duration of antibacterial treatment is at least 5 years. If carditis was diagnosed, which was cured without consequences - not less than 10 years.
- For patients who have a defect in the myocardium( including those who have undergone surgery) - for life.
Complications of acute rheumatic fever
Rheumatic fever can have a favorable outcome, and the patient recovers if the diagnosis was carried out quickly, and the treatment was timely and competent. Possible complications that threaten ill ORL:
- transition of the ORL to the chronic form of rheumatic heart disease( CHD), formation of myocardial infarction, mitral valve function deficiency, deformity, valvular valve atrophy with significant disruption of their function or without it;
- prolapse( for every tenth sick child) or stenosis( constriction of the opening of the atrial-ventricular aperture) of the mitral valve, failure of the aortic valve function;
- violation of the rhythm of contractions of the heart with the development of chronic arrhythmia, tachycardia;
- increase in the likelihood of endocarditis( inflammation of the inner shell of the myocardium when harmful microbes enter the general bloodstream, and further - to damaged valves).
Forecast
The risk of a fatal outcome in acute rheumatic fever is absent( except for extremely rare cases of pancarditis - a common inflammation of the heart layers - in children). The incidence of heart defects after a rheumatic pathology experienced in children reaches 25%.
The prognosis of the disease depends on:
- myocardial state - the presence and severity of heart disease formed during carditis;
- degree of failure of myocardial pumping function;
- on how quickly they started to treat, since the risk of malformation is significantly increased with the late onset of therapy.
The disease may result in complete recovery( high probability) without the formation of cardiac and valvular defects with timely and competent therapy.
This video will tell you about the ORL and rheumatic heart disease:
- Elimination of symptoms: