Acute rheumatic fever

The diagnosis of acute rheumatic fever has become difficult. A growing number of diseases that were not recognized in the past could fulfill its diagnostic criteria. We emphasize its changing incidence, current knowledge of its pathogenesis, and lesser known clinical features such as pneumonitis, encephalitis and glomerulonephritis.

Rheumatic fever and chronic rheumatic heart disease in Yarrabah aboriginal community, north Queensland. Establishment of a prophylactic program

OBJECTIVE

To establish a program for the prevention of rheumatic fever and rheumatic heart disease in a semi-isolated Aboriginal community in far north Queensland and to test its efficacy.

DESIGN

A prevalence study of acute rheumatic fever and chronic rheumatic heart disease was conducted in the community in 1985 and subjects with possible acute rheumatic fever were assessed. A prophylactic antibiotic program was instituted. Records were kept of the prevalence of acute rheumatic fever for six years after the 1985 survey. A second survey of the community was held in 1991 to detect chronic rheumatic carditis resulting from undetected acute rheumatic fever.

SETTING

The Yarrabah Aboriginal community in north Queensland (latitude 17 degrees S). The program was conducted by the Yarrabah Health Team, a part of the North Queensland Aboriginal Health Division.

PARTICIPANTS

The whole Yarrabah community (population 1250) was invited to participate. In 1985, after the completion of an educational program, 89% of the community cooperated in the survey. There was no educational program before the 1991 survey and the compliance rate was much lower. Importantly, however, 87% of the vulnerable group (4-16 year olds) were examined.

INTERVENTIONS

After the 1985 survey, all community members aged 4-16 years had throat swabs taken three times each year. Those with swabs showing Group A streptococci were treated; their contacts were also swabbed and treated if Group A streptococci were found.

RESULTS

Before the institution of the swabbing program there were four new cases of acute rheumatic fever each year in the Yarrabah community. In the six years after the program was introduced only one case of acute rheumatic fever occurred. This was at a time when swabbing had temporarily lapsed for a three-month period.

CONCLUSIONS

These results support the use of a prophylactic antibiotic program in Aboriginal communities as a cost effective and efficient method for the prevention of rheumatic fever. The cooperation of the community is an integral part of its success and this can be obtained by community education.

The interplay of nature versus nurture in predisposition to the rheumatic diseases

The revolution in microbiology and genetics that has transpired in the past few years has brought fresh debate in the question of the relative contributions of nature and nurture in susceptibility to the rheumatic diseases. For nature, a variety of immunologically relevant genes have been identified whose presence has been shown to be associated either with an increased risk for certain diseases or for complications or subsets thereof. For nurture, the role of infectious agents in disease triggering and modification has been found.

[Rheumatic fever: atypical joint manifestations]

The diagnosis of rheumatic fever (RF) continues to be a difficult one in Pediatrics, mainly because of the polymorphism of its clinical presentation and the lack of specific laboratory test. Among the Jones' major criteria, arthritis is the most frequent and the least specific. Ninety three children with RF who presented 117 flares of the disease were studied in the Department of Pediatrics, Escola Paulista de Medicina, between Dec. 1989 and Dec. 1991. The presence of arthritis was defined as an inclusion criterion. The diagnosis was based on history, physical and laboratory examinations (Modified Jones' Criteria). The mean age was 10 years and the sex ratio was 1 male: 1.4 female. In 45% of the flares, arthritis was the only major criterion. In 44% there were arthritis and carditis, in 7% arthritis and chorea and in 4% arthritis, carditis and chorea. In 64% of the flares the pattern of articular involvement was migratory and in 36% addictive. Polyarthritis and oligoarthritis were observed respectively in 64% and 36%. Monoarthritis was reported in 3%. The definitive diagnosis of RF with atypical articular involvement only was possible in the presence of carditis or chorea. The authors conclude that physicians should be aware of the atypical involvement observed in some cases of RF, specially when arthritis is the only major criterion.

A one-year study of streptococcal infections and their complications among Ethiopian children

Post-streptococcal complications are known to be common among Ethiopian children. Little is known, however, about the epidemiology of beta-haemolytic streptococci in Ethiopia. A total of 816 children were studied during a one-year period: 24 cases of acute rheumatic fever (ARF), 44 chronic rheumatic heart disease (CRHD), 44 acute post streptococcal glomerulonephritis (APSGN), 143 tonsillitis, 55 impetigo, and 506 were apparently healthy children. Both ARF and APSGN occurred throughout the year with two peaks during the rainy and cold seasons. The female:male ratio among ARF patients was 1.4:1 and 1:1.9 among APSGN. The monthly carrier rate of beta-haemolytic streptococci group A varied from 7.5-39%, average being 17%. T type 2 was the most frequent serotype. Marked seasonal fluctuations were noted in the distribution of serogroups among apparently healthy children. Beta-haemolytic streptococci group A dominated during the hot and humid months of February-May. Strains were susceptible to commonly used antibiotics, except for tetracycline.

Rheumatic fever and disorders of the musculoskeletal system

New information provided on the pathogenesis and management of rheumatic fever is of current interest. Invasive disease by group A streptococci has been shown to be due to production of toxin A. The natural history and immunopathologic basis for chronic Lyme arthritis are reported. Attention is drawn to pyomyositis and clinical presentation of chronic fatigue syndrome in children. Patients with Sweet's syndrome often have antineutrophil cytoplasmic autoantibodies. Biopsy specimens of panniculitis should be taken to aid treatment. Long-term outcome in chronic osteomyelitis is favorable; recommendations on the rational use of imaging have been reported.

Infection as a cause of reactive arthritis, ankylosing spondylitis, and rheumatic fever

Recent advances in understanding the role of infectious agents in the etiology of reactive arthritis (Reiter's syndrome), ankylosing spondylitis, and rheumatic fever are reviewed. The reader is referred to other reviews in this section for discussions of septic, spirochetal, mycobacterial, and fungal arthritis, and human immunodeficiency virus-related connective tissue diseases.

[Acute articular rheumatism: physiopathology, clinical aspects]

Acute rheumatic fever is characterized by non suppurative inflammatory lesions involving the heart, joints, subcutaneous tissues and central nervous system. It is a complication of group A streptococcal upper respiratory tract infection. The pathogenic mechanisms remain unknown although there is a general agreement as to an immunological hypothesis. Pharyngitis must be treated, even if streptococcal origin is not proved. Penicillin remains the first choice antibiotic. Epidemiological studies of all group A streptococcal serotypes isolated should be performed.

[Current status on the epidemiology of acute pharyngitis and post-streptococcal syndromes]

So far, no ideal study providing an exhaustive knowledge of acute pharyngitis epidemiology has been carried out. What is available now is a number of investigations, all with deficiencies, which concern the duration of the disease (there may be seasonal variations), its limits in space and, above all, the number of pathogens sought for. A well-organized investigation span over at least one year, involve a fairly wide range of age-groups and be repeated in several countries. Bacterial epidemiology is dominated by beta-haemolytic streptococci group A, but other streptococcal groups, notably group C, have been incriminated. Other responsible bacteria, such as Haemophilus spp., Staphylococcus spp. and Corynebacterium spp., are extremely rare but most probable. Mycoplasma pneumoniae and perhaps Chlamydia pneumoniae are probably found more frequently. Rheumatic fever--which had virtually disappeared in medically advanced countries due to a higher level of life and to the general use of penicillin therapy--has reappeared in recent years, as shown by a few North-American epidemics. Such epidemics have come on time to remind us that we should be vigilant and continue, as in the past, to treat all streptococcal foci systematically, in order to prevent the occurrence of rheumatic fever.

Rheumatogenic streptococci and autoimmunity

The uniqueness of the group A streptococcus in initiating a cardiodestructive disease in a limited segment of the human species, regardless of race or ethnic group, makes the quest for a unique host response to a specific streptococcal antigen an intriguing and persisting challenge for clinical investigators, particularly for those investigators interested in autoimmunity. New methodology is making possible more incisive research approaches. The defined streptococcal antigens that turn out to be epitopes identical with host tissues, such as the M protein/cardiac myosin model or the hyaluronate in the capsule of mucoid rheumatogenic strains, offer the opportunity for more incisive clinical investigations. The isolation and cultivation of cardiotoxic T cell clones directed against such epitopes shared by host and parasite may eventually be possible. We may then learn more about whether autoimmunity is indeed a factor in the pathogenesis of rheumatic heart disease.

Host-parasite interaction in the pathogenesis of rheumatic fever

Recent investigation has delineated some of the bacterial and host factors that may play a role in the pathogenesis of rheumatic fever. Continuing studies support the role of antibodies to crossreactive antigens in human tissues and the group A streptococcal cell in inducing tissue damage associated with this disease. Several specific epitopes have now been defined that are common to the crossreactive antigens. Data from recent outbreaks of rheumatic fever in the USA suggest that mucoid group A streptococcal strains, belonging to serotypes M1, M3, M5, M6 and M18 may have accounted for these outbreaks. While these strains are thought to be rheumatogenic, the exact characteristic(s) that renders them so is yet to be determined.

[Relation between foci of chronic oral infection, rheumatic fever and general or local anesthesia]

We make a study about Rheumatic fever diagnostical on boys who need an exeresis of bucals focus, which we make under general or local anaesthesia effects, and we verify the quantity of ASLO descent which depended on type of anaesthesia and the number of sessi that we make.

A new heart-cross-reactive antigen in Streptococcus pyogenes is not M protein

To identify tissue-cross-reactive antigens other than M protein in Streptococcus pyogenes, proteins of M-positive strains and an M-negative strain were probed in Western blots for reactivity with cross-reactive streptococcal monoclonal antibodies (MAbs) 36.2.2 and 54.2.8. A protein(s) near a molecular mass of 60 kDa in extracts of five group A streptococcal serotypes and the M-negative strain reacted with the MAbs. A study of human antibody responses to purified membranes of S. pyogenes indicated a hyperreactivity to a 60-kDa protein in acute rheumatic fever. Since MAbs 36.2.2 and 54.2.8 are known to cross-react with myosin or actin and streptococcal M protein, the data suggest that a homology or conformation is shared between the 60-kDa antigen and M protein. Therefore, the 60-kDa antigen is a new heart- or tissue-cross-reactive antigen of S. pyogenes that shares immunologic epitopes with but is distinct from M protein.

[Rheumatic fever]

While rheumatic fever (RF) remains a major problem in underdeveloped countries, in continental United States and Western Europe the incidence of this disease declined markedly in the sixties and reached a nadir during the seventies. However in the last eighties a resurgence of RF has been documented in some areas of the United States with an eightfold increase of incidence over the prior 15 year average. Although a true outbreak of RF has not been documented in Italy, a trend towards an increased number of new cases per year has been observed at the Centre for Rheumatic Children at the Gaetano Pini Institute in Milan. Most of these children presented a mild disease with clinical features rather different from those described in classical textbooks. Most of them satisfied the revised Jones' criteria, in some cases the objective signs of arthritis could not be noticed, but the joint involvement presented as marked arthralgia while other features supported the diagnosis of RF. Rheumatic carditis was observed in more than 1/3 of cases with a high rate of residual valvular heart disease of a mild degree of severity in most cases. In conclusion RF has not completely disappeared in Italy and remains as a possible cause of permanent valvular heart damage in children. It is possible that the increasing morbidity observed in the last eighties may be related to the reduced primary prophylaxis against streptococcal infections due to the wrong conviction that RF is no more a risk in developed countries.

Facts and fallacies about streptococcal infection and rheumatic fever

Recent outbreaks of acute rheumatic fever (ARF) in the United States are drawing attention to a previously declining disease. Authorities agree that penicillin treatment of group A beta-hemolytic streptococcus (GABHS) pharyngitis contributed to the decline in incidence and severity of ARF. However, because the pathogenic mechanism that links GABHS and ARF is still a debatable issue, the cause of the recent outbreaks is unknown. A review of the current literature generates interesting questions about the current status of ARF and common GABHS testing and treatment practices. Facts about GABHS and ARF and current recommendations for the diagnosis and treatment of GABHS pharyngitis are presented.

Role of oxygen free radicals generated by blood monocytes and neutrophils in the pathogenesis of rheumatic fever and rheumatic heart disease

The generation of oxygen free radicals by peripheral blood monocytes and neutrophils of patients with rheumatic fever and rheumatic heart disease has been studied using luminol enhanced chemiluminescence technique. Five groups of patients; acute rheumatic fever, recurrence of rheumatic activity, chronic rheumatic heart disease, acute pharyngitis and normal controls were studied. In all groups except the controls, measurements were made on 0, 15, 90 and 180 days. The chemiluminescence was measured in response to streptococcal membrane antigen, carbohydrate antigen and latex as triggering agents. Chemiluminescent response of monocytes, as well as, neutrophils was significantly higher (P less than 0.01) in acute rheumatic fever and recurrence of rheumatic heart disease as compared to patients with acute pharyngitis and chronic rheumatic heart disease through the study period and with all the triggering agents. A significant decline (P less than 0.001) in chemiluminescence was observed from day 0 to day 180 in the acute rheumatic fever, recurrence of rheumatic heart disease and pharyngitis patients while no such change, was observed in the chronic rheumatic heart disease group. This study raises the possibility that these phagocytic cells, which infiltrate the myocardium, may have a role in the pathogenesis of cardiac disease seen in patients with rheumatic heart disease, through the generation of oxygen free radicals.

An outbreak of acute rheumatic fever in Tennessee

From January, 1987, until July, 1988, a significant increase in newly diagnosed cases of acute rheumatic fever was noted at our hospital. In sharp contrast to the 3 cases seen in 1986, 14 cases were diagnosed in 1987 (a significant increase from 1985 to 1986, P = 0.001). In the first 6 months of 1988 an additional 12 new cases were diagnosed (a further significant increase from 1987, P = 0.02). No further cases were diagnosed between July, 1988, and September, 1989. The major clinical manifestations were carditis in 73%, polyarthritis in 58% and chorea in 31%. In 15 of 26 patients an antecedent illness which included pharyngitis was noted; the remainder of patients were asymptomatic. Group A beta-hemolytic streptococci were isolated from 13 of 19 children cultured. Isolates from two patients with acute rheumatic fever were submitted for M typing: one isolate was mucoid M18/T18; the other isolate was a mucoid nontypable strain. The demographic characteristics of the 26 patients agree with classic descriptions in that patients were more likely to be urban, to come from large families and to have low incomes; racial breakdown of the group mirrored the Tennessee pediatric population. These characteristics stand in contrast to reports of recent outbreaks which describe suburban high income patients. These data suggest that practitioners should be again aware of acute rheumatic fever and that aggressive identification and treatment of streptococcal pharyngitis should continue to be a relevant public health concern.