Rheumatic fever

Classification according to ICD-10
I00	Rheumatic fever with no indication of heart involvement Acute or subacute arthritis in rheumatic fever
I01	Rheumatic fever with heart involvement
I01.0	Acute rheumatic pericarditis
I01.1	Acute rheumatic endocarditis Acute rheumatic valvulitis
I01.2	Acute rheumatic myocarditis
I01.8	Other acute rheumatic heart disease Acute rheumatic pancarditis
I01.9	Acute rheumatic heart disease, unspecified
I02	Rheumatic chorea
I02.0	Rheumatic chorea with heart involvement
I02.9	Rheumatic chorea without heart involvement
ICD-10 online (WHO version 2019)

The rheumatic fever (synonym: acute rheumatic fever , and acute arthritis , polyarthritis rheumatica acuta and acute rheumatism verus , formerly known as acute arthritis called), also Streptokokkenrheumatismus called, is a now rare in industrialized countries diagnosed inflammatory rheumatic systemic disease of skin, heart , Joints and brain.

It occurs as a result of disease after infection with β-hemolytic streptococci of Lancefield group A on. Often times, these upper respiratory infections have only mild symptoms. Mainly children and adolescents get sick after tonsillitis or pharyngitis with streptococci ( esp . Streptococcus pyogenes ).

In older adults, the clinical picture is difficult to diagnose due to the often atypical courses. The number of heart valve diseases , whose connection with rheumatic fever was first taught by David Pitcairn in 1788 at St. Bartholomew's Hospital in London, in adults in Europe is still 3-4%. The majority of these valve diseases are bacterial or arteriosclerotic . A rheumatic reaction is difficult to rule out.

Symptoms

One to three weeks after the previous streptococcal infection, characteristic symptoms appear which, as a Jones standard (according to T. Duckett Jones and Edward Franklin Bland ), are divided into major criteria and minor symptoms .

• Major criteria:
  • Carditis (inflammation of the heart), v. a.
    • Endocarditis (inflammation of the lining of the heart)
    • Pericarditis (inflammation of the pericardium )
    • Myocarditis (inflammation of the heart muscle)
  • Polyarthritis , an acute inflammation of the large joints in particular, with a characteristic wandering of the symptoms, which are often fleeting (the most common major symptoms in children and adolescents).
  • Chorea minor (Sydenham) with involvement of the corpus striatum , part of the basal trunk ganglia of the brain - almost only in children, see also PANDAS . A minor chorea can still occur months after the infection and therefore does not require any further diagnostic criteria if it occurs, but rather the exclusion of other causes.
  • rheumatic erythema ( erythema annulare )
  • rheumatic nodules under the skin on the extensor sides of the extremities (so-called rheumatic nodules )
• Minor symptoms:
  • fever
  • Joint pain ( arthralgia )
  • increased non-specific inflammatory parameters in the blood: erythrocyte sedimentation rate (ESR) ↑, CRP ↑
  • rheumatic fever or rheumatic heart valve defect that you have already experienced
  • Extended PQ time or PR time in the ECG

Judging the Jones criteria

The diagnosis is confirmed if the previous streptococcal infection is detected (throat swab / increased or increasing antistreptolysin titre ) and if two major criteria or one major criterion + two minor symptoms are present.

therapy

The streptococcal infection is treated with penicillin , with penicillin allergy with a macrolide antibiotic . If rheumatic fever with heart involvement is proven, anti-inflammatory treatment with acetylsalicylic acid is indicated. If this is not sufficiently effective, it must be carried out with cortisone . If there is a suspicion of a spread, surgical rehabilitation of this focus can be carried out (e.g. tonsillectomy ). The recurrence prevention after the streptococcal infection has healed is carried out with penicillin; in the case of penicillin allergy, a macrolide antibiotic is used here as well. After carditis with permanent heart valve defect, prophylaxis is carried out for at least ten years and at least until the age of 40; after carditis without valve defects, it is necessary until adulthood and for at least ten years; without previous carditis, it should be until the age of 40 21 years of age and for at least five years.

forecast

The prognosis is primarily determined by the disease of the heart (carditis) and its consequences (tendency to recur and rheumatic heart valve defects ). The lethality is given as 2 to 5%. All other symptoms usually heal without consequences. An increased prevalence of mental disorders after minor chorea, particularly obsessive-compulsive disorder and depression, has been observed .

About 50% of patients with acute rheumatic fever develop chronic rheumatic heart disease.

history

Hippocrates already described rheumatic fever and thus distinguished between gout and acute rheumatoid arthritis. The resulting lumps under the skin were recognized in 1810 by William Charles Wells and described in a work on rheumatism and the heart. The connection between febrile rheumatoid arthritis and rheumatic, serofibrous changes in the heart tissue was published in 1835 by the French clinician Jean-Baptiste Bouillaud , who had recognized that rheumatic fever can affect not only the joints but also the internal organs. The French Ernest-Charles Lasègue is said to have said "Acute rheumatism licks the joints, but it bites the heart".

literature

• S2k guideline rheumatic fever - poststreptococcal arthritis of the German Society for Pediatric Cardiology (DGPK). In: AWMF online (as of 2013)
• George Edward Murphy: The evolution of our knowledge of rheumatic fever. An historical survey with particular emphasis on rheumatic heart disease. In: Bulletin of the History of Medicine 14, 1943, pp. 123-147.

Individual evidence

1. ↑ Ludwig Heilmeyer , Wolfgang Müller: The rheumatic diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 309-351, here: pp. 312-321.
2. ↑ Barbara I. Tshisuaka: Pitcairn, David. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 1165.
3. ↑ A. Dajani et al .: Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. In: Pediatrics , Volume 96, Number 4 Pt 1, October 1995, pp. 758-764, ISSN  0031-4005 . PMID 7567345 .
4. ↑ onlinelibrary.wiley.com. Retrieved November 25, 2017
5. ↑ Ludwig Heilmeyer , Wolfgang Müller: The rheumatic diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 309-351, here: p. 312.
6. ↑ Wolfgang Miehle: Joint and spinal rheumatism. Eular Verlag, Basel 1987, ISBN 3-7177-0133-9 , p. 44.

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !