RHEUMATIC FEVER……. It is an acute, subacute and chronic systemic disease involving the connective tissue throughout the body characterized by fleeting polyarthritis and great tendency to carditis which is usually a sequel to tonsillo-pharyngeal infection by streptococcus haemolyticus. The streptococci belong to group A of lancefield (GAS). Through the incidence of the RF has sharply declined in many developed countries it still remains a major problem in many developing countries. RHEUMATIC FEVER
The main characteristic lesion consists of perivascular granulomatous lesion associsted with vasculitis. RHEUMATIC FEVER
Through widespread involvement of connective tissue id seen in the disease, cardiovascular system is mainly affected usually in the form of pancarditis, i,e., endocarditis, myocarditis and pericarditis. There are two types of reactions—proliferative and exudative. Proliferative reaction consists of formation of Aschoff;s body which is most characteristically seen in myocardium and is called myocardial Aschoff body. These are fusifrom lesions with central area of fibrinoid degeneration consisting of swelling, fragmentation, hyalinization and acidophilic staining. This is surrounded by histiocytes mainly multinucleated, called Aschoff’s cell, inflammatory cells like lymphocutes, monocytes and polymorphonuclear leucocytes. These rheumatic granulomata are found throughout the body such as heart, blood vessels, trachea, pharynx, oesophagus, joint capsule, bursea, tendon sheath, etc. These Aschoff bodies are converted to spindle shaped or triangular scars in course of time. Rheumatic endocarditis produces lesions along the line of closure of heart valves with the formation of rheumatic verrucous vegetation which leads to fibrosis and different types of valvular defects. The mitral valve in 75%-80% cases, aortic valve in 30% (but rarely alone), tricuspid and pulmonary valves in less than 5% of the cases are affected. Rheumatic pericarditis is usually a serofibrinous inflammation which may lead to calcification but no pericardial constriction. Extracardiac lesions involve the joints, subcutaneous tissue, lungs, pleura and brain. The joint lesion is mainly exudative, that is why there is no scarring. The extracardiac lesions are not definite and characteristic. RHEUMATIC FEVER
Onset is usually acute in about 70% of the cases but may be insidious in the remaining cases.
Temperature remains usually high up to 39’C which is usually of remittent or intermittent in character. Some degree of fever is always present so long as the rheumatic activity persists. The fever is not associated with chill and rigour. Occasionally hyperpyrexia may occur as a complication. RHEUMATIC FEVER
It is seen in 70% of the cases and is characteristically fleeting or migratory polyarthritis. Big joints are commonly affected and kness, ankles, elbows, wrists, shoulder and hip joints are affected in this order. Small joints may rarely be affected last of all. Temporomandibular and sternoclavicular joints are usually not involved. The affected joint becomes red, hot, painful, swollen and tender, so that all movements of joints are restricted. This persists for a day or two when another joint is involved. Very rarely in adults the disease may be limited to a single joint. The affected joint improves after 1-5 weeks without any residual deformity except rarely in Jaccoud’s arthritis, where there may be minor deformities of the hand and feet. The joint swelling is mainly periarticular. Though the joint fluid is very much viscid with high protein content and increased cellularity (mainly polymorphonuclear) it does not suppurate and the culture is sterile. A characteristic feature is promt improvement of arthritis with therapeutic trial of salicylates or non-steroidal agents. RHEUMATIC FEVER
Sweating is moderate in amount, acrid or offensive in odour
These include sore throat, epistaxis, abdominal pain, skin rashes. constitutional symptoms like anorexia, constipation, weakness, vague aches in different parts of the body.
Age: 5-15 years. Sex: both. Temperature is raised. Pulse shows tachycardia even during sleep. Patient is reluctant to change the posture for fear of joint pain. Tonsils are enlarged, congested with presence of pus points. Tonsillar lymph nodes are enlarged and tender. RHEUMATIC FEVER
Cardiac involvement occurs even upto 75% of the cases in the form of carditis particularly seen in children and adolescents. Due to carditis the following features are seen:
. LESS SPECIFIC SINGS OF CARDITIS:
In absence of above findings of carditis the following less specific signs should also be considered valuable.
Lungs may show evidences of pleurisy in 10% and pneumonia in 2% of cases.
. Nervous System
In 3% of the cases, rheumatic chorea develops which is due to involvement of the basal ganglia and mild encephalitis. In this condition peculiarly arthritis, high ESR or leucocytosis are not seen. It is common in female in the ratio of 3: 1 and rare in adults. This is a very important diagnostic feature.
Diffuse abdominal pain may be complained of in absence of definite tenderness anywhere which may be attributed to rheumatic peritonitis.
The affected joints are swollen and show all features of inflammation and when they subside no residual deformity is seen. Clinical evidence of fluid in the joint is usually lacking though it is present. Surrounding muscles never show wasting.
Modified Ducket Jones criteria for the diagnosis o Rheumatic fever:
The diagnosis of Rheumatic fever is almost certain when at least one major and two minor or two major and one minor criteria are present.
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