Rheumatic fever

Rheumatic fever can develop after an untreated infection with Group A streptococcus bacteria, such as ‘strep throat’. It is a delayed complication that causes widespread inflammation in other parts of the body, particularly the joints, heart, skin and brain. It is classed as an autoimmune disease because the inflammation is probably caused by the immune system’s reaction to the bacteria.

Rheumatic fever can develop at any age, but children between five and 14 years are at increased risk. Without treatment, it can lead to serious complications such as rheumatic heart disease.

Only a small percentage of people who have a streptococcal infection go on to develop rheumatic fever. In many higher-income settings the disease has become uncommon, but it remains far more common in some populations and in places with poverty, overcrowding and limited access to medical care, where rates can be among the highest in the world.

Symptoms#

Most symptoms resolve with medical treatment. The symptoms of rheumatic fever can include:

• Sudden onset of illness
• Fever
• Painful and inflamed joints
• Fatigue
• Unexplained weight loss
• Breathlessness
• Skin problems, such as a raised rash (erythema marginatum) or lumps under the skin around the affected joints
• Nervous system problems, such as involuntary movements and twitches (Sydenham’s chorea, also known as Saint Vitus’ dance)
• Heart problems such as inflammation (carditis), an enlarged heart (cardiomegaly), rapid heartbeat (tachycardia) or a heart murmur
• Chest pain

Rheumatic heart disease#

Rheumatic heart disease usually develops after recurring or lengthy bouts of rheumatic fever during childhood, although it can also follow a single bout. It may be a permanent complication, as inflammation can damage various structures of the heart, including the muscle, the lining and the valves.

In some cases, rheumatic heart disease does not cause any symptoms. In other cases, the person may have a range of symptoms, including breathlessness, chest pain and heart palpitations.

Where rheumatic fever often goes undiagnosed or untreated, the rate of rheumatic heart disease is correspondingly high.

Risk factors#

Rheumatic fever is a complication of untreated streptococcal infection.

Certain living conditions make streptococcal infections more likely#

Known risk factors include poverty, overcrowding and limited access to medical care. It is also thought that streptococcal bacteria may enter the body through skin cuts and abrasions, so a high rate of skin infections such as scabies in a community may help to explain why rheumatic fever is more common there.

Diagnosis#

There is no single test that diagnoses rheumatic fever. Assessment may include:

• Medical history, including evidence of a prior streptococcal infection
• Physical examination
• Throat swabs to test for the presence of Group A streptococcus bacteria
• Blood tests to look for ‘markers’ that suggest inflammation is present
• Electrocardiogram (ECG) to monitor the electrical activity of the heart
• Chest x-rays to look at the heart for signs of enlargement and the lungs for congestion

Treatment#

Treatment may include:

• Hospital admission
• Penicillin, usually given as an intramuscular injection
• A course of aspirin
• Corticosteroids (cortisone) if the arthritis is severe or there is carditis (inflammation of the heart)
• Long-term antibiotic treatment, which may include monthly penicillin injections for up to five years to reduce the risk of rheumatic heart disease
• In the case of rheumatic heart disease, cardiac catheter treatment or surgery may be needed to repair damaged heart valves

With prompt and appropriate medical care, the long-term outlook for a person with rheumatic fever is excellent. However, having rheumatic fever once does not protect against getting it again, so it is important to seek prompt medical attention for any future throat infections.

There is currently no vaccine for rheumatic fever, although researchers are working to develop one. A vaccine that prevents streptococcal infections would also be expected to prevent rheumatic fever and rheumatic heart disease.

Key points#

• Rheumatic fever can develop at any age, but children between five and 14 years are at increased risk.
• Without treatment, the disease can lead to serious complications such as rheumatic heart disease.
• Most symptoms resolve with medical treatment.
• In some cases rheumatic heart disease causes no symptoms; in others it can cause breathlessness, chest pain and heart palpitations.

Where to get help#