RHEUMATIC FEVER

Rheumatic fever is an autoimmune inflammatory condition that can affect children, typically occurring
after a streptococcal throat infection, such as strep throat or scarlet fever. This condition primarily
affects the connective tissues in the body, including the heart, joints, skin, and brain. Rheumatic fever is
more common in children and adolescents, especially between the ages of 5 and 15.

CAUSES AND RISK FACTORS

1. Streptococcal Infection: Rheumatic fever typically begins with an initial streptococcal infection,
often involving the throat (pharyngitis) or skin (such as in the case of scarlet fever). The
streptococcal infection is caused by Group A Streptococcus bacteria, which are highly contagious
and can be easily transmitted from person to person through respiratory droplets or direct
contact with infected surfaces.

2. Lack of Timely Treatment: In some cases, individuals, including children, may not receive timely
or adequate treatment for their streptococcal infection. This can occur due to factors such as
delayed diagnosis, lack of access to medical care, non-compliance with prescribed antibiotics, or
asymptomatic carriers of the bacteria.

3. Susceptibility: Not everyone who contracts a streptococcal infection develops rheumatic fever.
The development of rheumatic fever is influenced by genetic predisposition and individual
immune responses. Some individuals are more susceptible to the autoimmune reaction
triggered by streptococcal infection, while others may not develop rheumatic fever despite
being infected.

4. Autoimmune Response: In susceptible individuals, the streptococcal infection can trigger an

abnormal autoimmune response. During this response, the immune system produces
antibodies, particularly antistreptolysin O (ASO) antibodies, directed against specific
components of the streptococcal cell wall.

5. Molecular Mimicry: A crucial aspect of rheumatic fever's pathogenesis is molecular mimicry.

The streptococcal antigens, especially the M protein on the bacterial surface, have a molecular
structure that resembles certain proteins found in human tissues, including the heart, joints,
skin, and brain.

6. Autoimmune Attack: Due to molecular mimicry, the immune system may mistakenly identify
these self-antigens (found in human tissues) as foreign invaders and mount an autoimmune
attack. This means that the immune system starts attacking and damaging the body's own
tissues, particularly in the heart and joints.

7. Multiple Organ Involvement: Rheumatic fever can affect various organs and tissues, including
the heart (leading to rheumatic heart disease), joints (causing arthritis), skin (resulting in skin
rashes), and the central nervous system (causing neurological symptoms).
PATHOPHYSIOLOGY

The pathophysiology of rheumatic fever in children is a complex and multifaceted process that primarily
involves the immune system's response to a preceding streptococcal infection, typically a Group A
Streptococcus bacterial infection (such as strep throat). Rheumatic fever is an autoimmune
inflammatory condition that can affect various organs and tissues in the body. Here is an overview of the
pathophysiology of rheumatic fever in children:

1. Streptococcal Infection: The pathophysiological process begins with an initial streptococcal

infection, often localized in the throat (strep throat) or skin (scarlet fever). In some individuals,
particularly children, the body's immune system recognizes and mounts a response against the
invading streptococcal bacteria.

2. Immune Response: In susceptible individuals, the immune response becomes dysregulated.

Instead of solely targeting the streptococcal bacteria, the immune system produces antibodies,
notably antistreptolysin O (ASO) antibodies, directed against specific components of the
streptococcal cell wall.

3. Molecular Mimicry: A crucial aspect of rheumatic fever's pathophysiology is molecular mimicry.

The streptococcal antigens, specifically the M protein on the bacterial surface, have a molecular
structure that resembles certain proteins found in human tissues, including the heart, joints,
skin, and brain.

4. Autoimmune Reaction: Due to molecular mimicry, the immune system mistakenly identifies
these self-antigens (found in human tissues) as foreign invaders and mounts an autoimmune
response. This means that the immune system starts attacking and damaging the body's own
tissues, particularly in the heart and joints.

5. Inflammatory Response: The autoimmune response triggers a widespread inflammatory

reaction in various tissues, including the heart. Immune cells and inflammatory mediators, such
as cytokines, accumulate in the affected tissues, leading to localized inflammation.

6. Cardiac Involvement: The most concerning consequence of rheumatic fever in children is

cardiac involvement. The inflammation affects the heart muscle (myocarditis) and can lead to
inflammation of the heart's inner lining (endocarditis). In particular, the heart valves are
commonly affected. This inflammation can cause swelling, thickening, and damage to the heart
valves, especially the mitral valve. Over time, this damage can lead to valvular insufficiency
(leakage) or stenosis (narrowing).

7. Joint Involvement: Rheumatic fever often causes migratory polyarthritis, which involves painful
inflammation and swelling of multiple joints. This can move from one joint to another over a
period of time.
 8. Other Manifestations: Rheumatic fever can also affect other organs and tissues, leading to
symptoms such as skin rashes (erythema marginatum), subcutaneous nodules, neurological
symptoms (Sydenham's chorea), and fever.

9. Resolution and Recurrence: The acute phase of rheumatic fever eventually resolves with or
without treatment, but it can lead to long-term consequences, including chronic rheumatic
heart disease. Additionally, children who have had one episode of rheumatic fever are at a
higher risk of experiencing recurrent episodes if they are exposed to streptococcal infections.

SIGNS AND SYMPTOMS

1. Fever: Rheumatic fever often begins with a sudden high fever.

2. Joint Pain and Swelling: Joint pain and swelling, known as polyarthritis, are common symptoms.
This typically involves large joints like the knees, ankles, elbows, and wrists. The pain and
swelling can migrate from one joint to another and may be accompanied by redness and
warmth.

3. Cardiac Symptoms: Rheumatic fever can affect the heart and lead to various cardiac symptoms,
including:

 Chest Pain: Children may experience chest pain, which can be mild to severe.

 Heart Murmurs: Abnormal heart sounds, or heart murmurs, may be detected during a
physical examination.

 Shortness of Breath: Difficulty breathing and shortness of breath can occur if the heart's
valves are damaged.

4. Skin Rash: Some children with rheumatic fever develop a rash. This rash is usually red or pink,
raised, and may have a "lacy" or "net-like" appearance. It often appears on the trunk and
extremities.

5. Chorea (Sydenham's chorea): Chorea is a neurological symptom characterized by involuntary,

purposeless movements of the limbs and facial muscles. It may also include muscle weakness
and emotional disturbances.

6. Subcutaneous Nodules: Small, painless nodules can form under the skin, typically over bony
prominences. These nodules are not common but are a characteristic sign of rheumatic fever.

7. Fever and Fatigue: Children with rheumatic fever may experience persistent fever and
generalized fatigue.

8. Joint Stiffness: Joint stiffness may occur, making it difficult for children to move their affected
joints.
 9. Abdominal Pain: In some cases, children may experience abdominal pain and tenderness due to
inflammation of the abdominal organs.

10. Irritability and Behavioral Changes: Children with rheumatic fever may exhibit mood swings,
irritability, and behavioral changes, which can sometimes be attributed to the neurological
symptoms.

DIAGNOSIS

1. Clinical Evaluation:

 Medical History: The healthcare provider will start by taking a detailed medical history,
including any recent illnesses, symptoms, and family medical history.

 Symptoms Assessment: They will assess the child's symptoms, which can vary but often
include fever, joint pain and swelling, skin rash, and a history of a recent sore throat or
strep infection.

2. Physical Examination:

 The healthcare provider will perform a thorough physical examination to look for signs
of rheumatic fever, such as joint inflammation (arthritis), skin rash (erythema
marginatum), heart murmurs, and other associated findings.

3. Laboratory Tests:

 Throat Culture: To confirm the presence of streptococcal bacteria, a throat swab or

culture may be done. This helps determine if the child had a recent strep infection that
could have triggered rheumatic fever.

 Blood Tests: Specific blood tests can be ordered to check for markers of inflammation,
such as an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP).

 Anti-Streptolysin O (ASO) Titer: This blood test measures the level of ASO antibodies,
which can indicate a recent streptococcal infection.

 Complete Blood Count (CBC): A CBC can reveal abnormalities such as an elevated white
blood cell count, which may be associated with inflammation.

4. Electrocardiogram (ECG) and Echocardiogram:

 ECG: An ECG measures the electrical activity of the heart and can detect any
abnormalities in heart rhythm, which may occur in severe cases of rheumatic fever.

 Echocardiogram: This ultrasound of the heart can help assess the structure and function
of the heart valves, looking for signs of damage or inflammation.
 5. Jones Criteria:

 The Jones Criteria are clinical guidelines used to diagnose rheumatic fever. These criteria
involve evaluating the child's clinical presentation, including symptoms, physical exam
findings, and laboratory results. The criteria consider major and minor criteria, and a
child must meet specific combinations of these criteria for a definitive diagnosis.

NURSING MANAGEMENT

1. Monitoring Vital Signs:

 Regularly monitor the child's vital signs, including temperature, heart rate, respiratory
rate, and blood pressure. Elevated vital signs can indicate worsening inflammation or
heart involvement.

2. Pain Management:

 Rheumatic fever can cause joint pain and discomfort. Administer prescribed pain relief
medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), to alleviate joint
pain and reduce inflammation.

3. Antibiotic Therapy:

 Ensure that the child receives the appropriate antibiotic therapy, typically penicillin or
another suitable antibiotic, to eradicate the streptococcal infection and prevent its
recurrence. Administer antibiotics as prescribed, and educate the child and their family
about the importance of completing the full course of antibiotics.

4. Bed Rest:

 Encourage the child to rest and limit physical activity during the acute phase of
rheumatic fever. Bed rest helps reduce strain on the heart and allows the body to
recover.

5. Supportive Care:

 Provide emotional support to the child and their family. A diagnosis of rheumatic fever
can be distressing, and the child may experience anxiety or fear. Offer reassurance and
explain the treatment plan to alleviate concerns.

6. Skin Care:

 If the child has a skin rash associated with rheumatic fever (erythema marginatum),
keep the skin clean and dry. Apply soothing lotions or creams as prescribed to relieve
itching and discomfort.

7. Cardiac Monitoring:
  If the child has cardiac involvement, closely monitor their heart function. This may
include continuous or periodic cardiac monitoring (ECG) to detect any abnormalities in
heart rhythm or heart valve function.

8. Education:

 Educate the child and their family about the importance of completing the full course of
antibiotics, adhering to follow-up appointments, and recognizing signs of worsening
symptoms or complications. Emphasize the need for ongoing heart health monitoring,
even after the acute phase.

9. Nutritional Support:

 Ensure the child receives a balanced diet to support their recovery and growth.
Encourage the consumption of foods rich in vitamins and minerals, especially those that
promote heart health.

10. Prevention Education:

 Teach the child and their family about the importance of preventing future
streptococcal infections. Stress the need to practice good hand hygiene and avoid close
contact with individuals who have strep throat.

11. Medication Administration:

 Administer medications as prescribed, and monitor for any potential side effects or
adverse reactions. Ensure that the child takes medication consistently and at the correct
dosage.

12. Collaboration with Healthcare Team:

 Collaborate closely with the healthcare team, including physicians, cardiologists, and
other specialists, to ensure a comprehensive and coordinated approach to care.

Medical Management:

1. Antibiotic Therapy: The cornerstone of medical management is the use of antibiotics to treat
the underlying streptococcal infection and prevent its recurrence. The child is typically
prescribed a full course of antibiotics, most commonly penicillin or amoxicillin. This treatment
aims to eradicate the bacteria responsible for triggering rheumatic fever.

2. Anti-Inflammatory Medications:

 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These medications, such as ibuprofen

or naproxen, are often prescribed to relieve joint pain and reduce inflammation.
  Corticosteroids: In cases of severe inflammation or involvement of the heart,
corticosteroids like prednisone may be prescribed to control inflammation and manage
symptoms.

3. Pain Management: Pain relief measures, including over-the-counter or prescription pain

medications, are used to alleviate joint pain and discomfort.

4. Cardiac Medications: If the child has cardiac involvement, medications like diuretics, beta-
blockers, or ACE inhibitors may be prescribed to manage heart-related symptoms and reduce
strain on the heart.

5. Bed Rest: During the acute phase of rheumatic fever, bed rest is often recommended to reduce
the risk of cardiac complications and aid in recovery.

6. Long-Term Antibiotics (Prophylaxis): After the acute phase, children with a history of rheumatic
fever may need long-term prophylactic antibiotic therapy to prevent recurrent streptococcal
infections. This secondary prophylaxis is essential to prevent further episodes of rheumatic fever
and cardiac damage.

Surgical Management:

Surgical intervention in the management of rheumatic fever is relatively rare but may be necessary in
cases of severe cardiac involvement or complications. Surgical options include:

1. Valve Repair or Replacement: In cases where rheumatic fever has caused significant damage to
the heart valves, surgical repair or replacement of the affected valves may be required. This
procedure can help restore proper cardiac function.

2. Pericardial Interventions: Inflammation of the pericardium (the sac around the heart) can occur
in some cases. Surgical drainage of pericardial fluid or other pericardial interventions may be
necessary if this condition is present.

3. Cardiac Catheterization: In certain situations, cardiac catheterization may be used to assess the
severity of heart valve damage or to guide further treatment decisi

COMPLICATIONS

1. Rheumatic Heart Disease (RHD): This is one of the most serious and common complications of
rheumatic fever. RHD occurs when the inflammation associated with rheumatic fever affects the
heart, particularly the heart valves. Over time, the heart valves can become damaged, leading to
conditions such as:

 Valvular Stenosis: Narrowing of the heart valve openings, which restricts blood flow and
can lead to increased pressure in the heart chambers.
  Valvular Regurgitation: Incomplete closure of the heart valves, causing blood to leak
backward into the chambers it just left. This can result in heart murmurs and increased
workload on the heart.

2. Cardiac Arrhythmias: Rheumatic fever can disrupt the normal electrical signals in the heart,
leading to irregular heart rhythms (arrhythmias). These irregular rhythms can potentially cause
palpitations, dizziness, and fainting.

3. Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can occur as a
complication of rheumatic fever. This can lead to chest pain, discomfort, and difficulty breathing.

4. Joint Complications: Rheumatic fever often causes migratory arthritis, where joints become
swollen, painful, and inflamed. These joint symptoms typically resolve with treatment but can
be temporarily debilitating.

5. Sydenham's Chorea (St. Vitus' Dance): This is a neurological complication that can occur in
some cases. It involves involuntary, rapid, and jerky movements of the face, limbs, and trunk,
along with muscle weakness. Emotional instability and difficulty with fine motor skills may also
occur.

6. Skin Manifestations: Skin symptoms like erythema marginatum (a rash with raised borders) and
subcutaneous nodules (painful lumps under the skin) can occur in some cases of rheumatic
fever.

7. Fever and General Illness: During the acute phase of rheumatic fever, the child may experience
high fever, weakness, fatigue, and general discomfort.

8. Complications in Other Organs: In rare cases, rheumatic fever can affect other organs, such as
the brain, leading to neurological complications like seizures or altered mental status.

9. Recurrent Rheumatic Fever: If a child has had one episode of rheumatic fever, they are at an
increased risk of having recurrent episodes if they experience new streptococcal infections that
go untreated.

10. Heart Failure: In severe cases of rheumatic heart disease, where the heart valves are
significantly damaged and unable to function properly, heart failure can develop. This condition
occurs when the heart cannot pump blood ef