Symptoms of Rheumatic Fever

This is a very painful affection, involving various joints, and generally affecting the heart. The cause is not exactly known, although it is thought to be a form of streptococcal infection. The disease often develops after exposure to wet and cold, when living conditions are unhygienic or damp, after tonsillitis, or with septic conditions of the mouth such as carious teeth or pyorrhoea.

The disease is somewhat different in adults and children, and is most common in adults between 15 and 35 years. There is probably an inherited tendency to the disease.

Symptoms.

There may be an attack of tonsillitis or sore throat before the disease starts. The principal characteristics are: sudden onset with high fever, with a soft rapid pulse; furred tongue; profuse sweat, which has a sour smell and seems to increase the weakness without relieving the pain; scanty and high-coloured urine with brick-dust sediment; and swelling of the joints, with redness, great tenderness and severe pain, which is particularly agonising when the patient attempts to move. There is also loss of appetite, vomiting, constipation, and there may be sleeplessness from pain.

This affection often changes suddenly from one part of the body to another, or from one set of joints to another, several joints often being affected at once. The joints most commonly affected are the knees, ankles, wrists, elbows, and shoulders; the spine, jaw and fingers are only rarely attacked. The affected joints are hot, swollen, red and very painful on movement.

Rheumatic fever causes inflammation of the heart muscle (rheumatic carditis) and often attacks the lining of the valves of the heart (endocarditis), causing incompetence or obstruction, mitral stenosis being a common result. The heart muscle itself also suffers from increased strain which may ultimately prove fatal. In any case the heart is liable to suffer permanent damage.

The course is variable and the affection may subside quickly or may persist for weeks or months. Recurrent attacks are common, with increasing damage to the heart.

The complications of rheumatic fever involve lung inflammation (pneumonia and pleurisy), chorea, rashes, rheumatic nodules especially on the elbows, wrists, shoulder-blades and spine, and permanent injury to the valves of the heart, or dilatation of the heart muscle.

The immediate mortality from rheumatic fever is low, but the indirect eventual mortality from heart injury is high.

In children the expectation of recurrence is 25 per cent, while in young adults it is less than 4 per cent.

Rheumatic fever in children is more insidious than in adults, since the joint swellings and pain are often mild and are not noticed.

Treatment

General Care

The patient should preferably be nursed in hospital and must be kept recumbent, resting in bed for a prolonged period, and for at least a month after the temperature becomes normal.

About two months is a minimum period of rest, which must be extended to six or eight months if the heart is affected. An aperient should be given at the onset.

A light diet of milk and cereals, with fluids and lemonade is advised for two weeks, and good nursing is essential, the patient being kept between blankets, and disturbed as little as possible.

Once the fever and the swelling in the joints are eased a good general diet should be given with ample fresh fruit and vegetables, and average helpings of meat or fish: up to two pints of milk daily is usually given.

To relieve pain in the joints, they should be wrapped in cotton wool and lightly bandaged in position.

When the acute pain subsides, passive movements of the joints should be given by the physiotherapist daily.

Drug Treatment

As it is thought tha the disease is due to the sensitivity of the patient to the toxins of the streptococcus organism which causes the sore throat and tonsillitis, the patient is put on penicillin injections at first and then maintained on penicillin tablets for weeks or months according to the individual case. Removal of tonsils is therefore seldom such a problem as it formerly was.

Salicylic acid and its salts, the salicylates, or aspirin, is the specific treatment; when given at the commencement of an attack, salicylates often arrest the course of the malady. This drug exerts such a beneficial influence that it is recognised as a specific.

From 1-2 to 2 grammes of sodium salicylate (aspirin added if gastric trouble) should be given every two to three hours to adults until relief is obtained and temperature falls.

This usually takes place in from twelve to thirty-six hours. The dosage of the salicylate preparation may then be reduced to about half the above amounts. In most cases the fever and swelling will abate within the above time; if not entirely arrested, the disease is very much shortened.

Vertigo, headache, or ringing in the ears indicate that the salicylate administration should be reduced. Paracetamol tablets may be needed if the pain is very severe at night.

Convalescence

After the long period of rest in bed, return to activity must be gradual. It is usually best for a child to go for a while to a convalescent home, preferably the sanatorium type, where he will have adequate super-vision. If there is obvious heart damage the child must never engage in strenuous sports and should be educated for a sedentary job.

On the other hand undue fuss and care may create a neurosis. Choice of occupation should be guided by the doctor.

Submitted By
Dr Bhuya is a general practioner.

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