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Rheumatic heart disease at autopsy with characteristic findings (thickened mitral valve, thickened chordae
tendineae, hypertrophied left ventricular myocardium).
Modified Jones criteria were first published in 1944 by T. Duckett Jones, MD.[3] They have been
periodically revised by the American Heart Association in collaboration with other groups.[4]
According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the
major criteria, or one major criterion plus two minor criteria, are present along with evidence of
streptococcal infection: elevated or rising antistreptolysin O titre or DNAase.[1] Exceptions are
chorea and indolent carditis, each of which by itself can indicate rheumatic fever.[5][6][7]
Major criteria
Polyarthritis: A temporary migrating inflammation of the large joints, usually starting in the
legs and migrating upwards.
Carditis: Inflammation of the heart muscle (myocarditis) which can manifest as congestive
heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur.
Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons.
They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.
Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as
macules, which spread outward and clear in the middle to form rings, which continue to spread
and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically
spares the face and is made worse with heat.
Sydenham's chorea (St. Vitus' dance): A characteristic series of rapid movements without purpose of
the face and arms. This can occur very late in the disease for at least three months from onset of
infection.
Minor criteria
Fever of 38.238.9 C (101102 F)
Leukocytosis
ECG showing features of heart block, such as a prolonged PR interval[8] [9] (Cannot be
included if carditis is present as a major symptom)
Nose bleeds
Micrograph showing an Aschoff body (right of image), as seen in rheumatic heart disease. H&E stain.
Rheumatic fever is a systemic disease affecting the peri-arteriolar connective tissue and can occur
after an untreated Group A Beta hemolytic streptococcal pharyngeal infection. It is believed to be
caused by antibody cross-reactivity. This cross-reactivity is a Type II hypersensitivity reaction and is
termed molecular mimicry. Usually, self reactive B cells remain anergic in the periphery without T cell
co-stimulation. During a Streptococcus infection, mature antigen presenting cells such as B cells
present the bacterial antigen to CD4-T cells which differentiate into helper T2 cells. Helper T2 cells
subsequently activate the B cells to become plasma cells and induce the production of antibodies
against the cell wall of Streptococcus. However the antibodies may also react against the
myocardium and joints,[10] producing the symptoms of rheumatic fever.
Group A streptococcus pyogenes has a cell wall composed of branched polymers which sometimes
contain M protein that are highly antigenic. The antibodies which the immune system generates
against the M protein may cross react with cardiac myofiber protein myosin,[11] heart muscle
glycogen and smooth muscle cells of arteries, inducing cytokine release and tissue destruction.
However, the only proven cross reaction is with perivascular connective tissue.[citation needed] This
inflammation occurs through direct attachment of complement and Fc receptor-mediated recruitment
of neutrophils and macrophages. Characteristic Aschoff bodies, composed of swollen eosinophilic
collagen surrounded by lymphocytes and macrophages can be seen on light microscopy. The larger
macrophages may become Anitschkow cells or Aschoff giant cells. Acute rheumatic valvular lesions
may also involve a cell-mediated immunity reaction as these lesions predominantly contain T-helper
cells and macrophages.[12]
In acute rheumatic fever, these lesions can be found in any layer of the heart and is hence called
pancarditis. The inflammation may cause a serofibrinous pericardial exudate described as "bread-
and-butter" pericarditis, which usually resolves without sequelae. Involvement of the endocardium
typically results in fibrinoid necrosis and verrucae formation along the lines of closure of the left-
sided heart valves. Warty projections arise from the deposition, while subendocardial lesions may
induce irregular thickenings called MacCallum plaques.
Prevention
Prevention of recurrence is achieved by eradicating the acute infection and prophylaxis with
antibiotics. The American Heart Association recommends that daily or monthly prophylaxis continue
long-term, perhaps for life.[22]
Treatment
This section needs additional citations for verification. Please help improve this article by adding
citations to reliable sources. Unsourced material may be challenged and removed. (February 2012)
The management of acute rheumatic fever is geared toward the reduction of inflammation with anti-
inflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for
strep throat should also be treated with antibiotics. Aspirin is the drug of choice and should be given
at high doses of 100 mg/kg/day. One should watch for side effects like gastritis and salicylate
poisoning. In children and teenagers, the use of aspirin and aspirin-containing products can be
associated with Reye's syndrome, a serious and potentially deadly condition. The risks, benefits and
alternative treatments must always be considered when administering aspirin and aspirin-containing
products in children and teenagers. Ibuprofen for pain and discomfort and corticosteroids for
moderate to severe inflammatory reactions manifested by rheumatic fever should be considered in
children and teenagers. Steroids are reserved for cases where there is evidence of involvement of
heart. The use of steroids may prevent further scarring of tissue and may prevent development of
sequelae such as mitral stenosis. Monthly injections of longacting penicillin must be given for a
period of five years in patients having one attack of rheumatic fever. If there is evidence of carditis,
the length of therapy may be up to 40 years. Another important cornerstone in treating rheumatic
fever includes the continual use of low-dose antibiotics (such as penicillin, sulfadiazine, or
erythromycin) to prevent recurrence.
Vaccine
No vaccines are currently available to protect against S. pyogenes infection, although there has
been research into the development of one. Difficulties in developing a vaccine include the wide
variety of strains of S. pyogenes present in the environment and the large amount of time and
people that will be needed for appropriate trials for safety and efficacy of the vaccine.[23]
Infection
Patients with positive cultures for Streptococcus pyogenes should be treated with penicillin as long
as allergy is not present. This treatment will not alter the course of the acute disease.
The most appropriate treatment stated in the Oxford Handbook of Clinical Medicine for rheumatic
fever is benzathine benzylpenicillin.
Inflammation
Patients with significant symptoms may require corticosteroids. Salicylates are useful for pain.
Heart failure
Some patients develop significant carditis which manifests as congestive heart failure. This requires
the usual treatment for heart failure: ACE Inhibitors, diuretics, beta blockers, and digoxin. Unlike
normal heart failure, rheumatic heart failure responds well to corticosteroids.
Epidemiology
Disability-adjusted life year for rheumatic heart disease per 100,000 inhabitants in 2004.[24]
no data
less than 20
2040
4060
6080
80100
100120
120140
140160
160180
180200
200330
Rheumatic fever is common worldwide and responsible for many cases of damaged heart valves. In
Western countries, it became fairly rare since the 1960s, probably due to widespread use of
antibiotics to treat streptococcus infections. While it has been far less common in the United States
since the beginning of the 20th century, there have been a few outbreaks since the 1980s. Although
the disease seldom occurs, it is serious and has a case-fatality rate of 25%.[25]
Rheumatic fever primarily affects children between ages 5 and 17 years and occurs approximately
20 days after strep throat. In up to a third of cases, the underlying strep infection may not have
caused any symptoms.
The rate of development of rheumatic fever in individuals with untreated strep infection is estimated
to be 3%. The incidence of recurrence with a subsequent untreated infection is substantially greater
(about 50%).[26] The rate of development is far lower in individuals who have received antibiotic
treatment. Persons who have suffered a case of rheumatic fever have a tendency to develop flare-
ups with repeated strep infections.
The recurrence of rheumatic fever is relatively common in the absence of maintenance of low dose
antibiotics, especially during the first three to five years after the first episode. Heart complications
may be long-term and severe, particularly if valves are involved.
Survivors of rheumatic fever often have to take penicillin to prevent streptococcal infection which
could possibly lead to another case of rheumatic fever that could prove fatal.
References
1 Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N (2007). Robbins Basic
Pathology (8th ed.). Saunders Elsevier. pp. 4036. ISBN 978-1-4160-2973-1. [One]
1 Jones, T Duckett (1944). "The diagnosis of rheumatic fever". JAMA 126 (8): 4814.
doi:10.1001/jama.1944.02850430015005. [Three]
1 Ferrieri, P; Jones Criteria Working, Group (2002). "Proceedings of the Jones Criteria
workshop". Circulation (Jones Criteria Working Group) 106 (19): 25213.
doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554. [Four]
1 Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP, FACEP. Retrieved 2007-
07-14. [Five]
1 "Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update". JAMA
(Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki
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1 Aly, Ashraf (2008). "Rheumatic Fever". Core Concepts of Pediatrics. University of Texas.
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1 Abbas, Abul K.; Lichtman, Andrew H.; Baker, David L.; et al (2004). Basic immunology:
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1 Fa KC, da Silva DD, Oshiro SE, et al. (May 2006). "Mimicry in recognition of cardiac
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1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas,
Abul K. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, Mo: Elsevier
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1 Brice, Edmund A. W; Commerford, Patrick J. (2005). "Rheumatic Fever and Valvular Heart
Disease". In Rosendorff, Clive. Essential Cardiology: Principles and Practice. Totowa, New
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59259-918-9. [Fourteen]
1 Caldas, AM; Terreri, MT; Moises, VA; Silva, CM; Len, CA; Carvalho, AC; Hilrio, MO (2008).
"What is the true frequency of carditis in acute rheumatic fever? A prospective clinical and
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cardiology 29 (6): 104853. doi:10.1007/s00246-008-9242-z. PMID 18825449. [Fifteen]
1 Ramasawmy, R; Spina, GS; Fae, KC; Pereira, AC; Nisihara, R; Messias Reason, IJ;
Grinberg, M; Tarasoutchi, F et al. (2008). "Association of Mannose-Binding Lectin Gene
Polymorphism but Not of Mannose-Binding Serine Protease 2 with Chronic Severe Aortic
Regurgitation of Rheumatic Etiology". Clinical and Vaccine Immunology : CVI 15 (6): 932
936. doi:10.1128/CVI.00324-07. PMC 2446618. [Twentyone]
1 "Initiative for Vaccine Research (IVR) - Group A Streptococcus". World Health Organization.
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1 "WHO Disease and injury country estimates". World Health Organization. 2009. Retrieved
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