Rheumatic fever leads to cardiac risks, doctors say [Archives:2007/1052/Health]

May 21 2007

Compiled by Jamal Al-Najjar
According to Yemen's Ministry of Public Health and Population, rheumatic fever has become a major health problem in Yemen, aggravating one year after another. Although it can infect both children and adults, children are more subjected to the disease, which, if left untreated, brings about one of the most severe cardiac diseases called rheumatic heart disease.

Rheumatic fever develops in children and adolescents following Group A beta hemolytic streptococcal pharyngitis (i.e., Streptococcus pyogenes, tonsillitis is part of pharyngitis). The organisms attach to the epithelial cells of the upper respiratory tract and produce a battery of enzymes allowing them to damage and invade human tissue.

After an incubation period of two to four days, the invading organisms elicit an acute inflammatory response, with three to five days of sore throat, fever, malaise, headache and an elevated leukocyte count. Rheumatic fever and rheumatic heart disease occur in children from ages 5 to 15 and kill approximately 90,000 patients worldwide every year.

Infection leads to rheumatic fever several weeks after the sore throat has resolved. Only infections of the pharynx initiate or reactivate rheumatic fever.

Direct contact with oral or respiratory secretions transmits the organism, with crowding enhancing such transmission. Patients remain infected for weeks after symptomatic resolution of pharyngitis and may serve as a reservoir for infecting others. Penicillin treatment shortens the clinical course of streptococcal pharyngitis and, more importantly, prevents major sequelae (complications from streptococci bacteria).

Acute rheumatic heart disease often produces pancarditis (inflammation of the whole heart). Endocarditis is manifested as mitral and aortic valve insufficiency. The mitral valve is most commonly and severely affected (65-70 percent of patients) and the aortic valve is second in frequency (25 percent). The tricuspid valve is deformed in only 10 percent of patients and almost always associated with mitral and aortic lesions, while the pulmonary valve rarely is affected. Severe valve insufficiency during the acute phase may result in congestive heart failure and even death in 1 percent of patients.

Chronic manifestations due to residual and progressive valve deformity occur in between 9 and 39 percent of adults with previous rheumatic heart disease. Fusion of valve apparatus resulting in stenosis (narrowing of the valve) or a combination of stenosis and insufficiency develops two to 10 years after an episode of acute rheumatic fever, with recurring episodes possibly causing progressive damage to the valves. Fusion occurs at the level of valve commissures (bands of fibers that join symmetrical parts), cusps, chordal attachments or any combination thereof.

Associated atrial fibrillation or left atrial thrombus formation from chronic mitral valve involvement and atrial enlargement may be observed.

Rheumatic heart disease is the major cause of morbidity from rheumatic fever and the major cause of mitral insufficiency and stenosis in the world. Variables correlating to valve disease severity include the number of previous attacks of rheumatic fever, the length of time between the disease's onset and the initiation of therapy, and gender, as the disease is more severe in females than in males. Insufficiency from acute rheumatic valve disease resolves in 70 to 80 percent of patients who adhere to antibiotic prophylaxis.

Tonsillitis, which causes rheumatic fever, is contagious, usually spreading by contact with the throat or nasal fluids of one already infected. Be sure to keep sick children's drinking glasses and eating utensils separate and wash them in hot, soapy water. Additionally, all family members should wash their hands frequently. After a bout of tonsillitis caused by strep bacteria, throw away the sick child's toothbrush and replace it with a new one.

Because 3 percent of patients infected with tonsillitis are prone to rheumatic fever and, subsequently, rheumatic heart disease, great attention should be paid to how people can deal with tonsillitis in order to prevent it and its complications.

Tonsillitis is an inflammation of the tonsils in the mouth, often, but not necessarily, causing sore throat and fever. Symptoms also may include pain in the tonsil area, inability to swallow and/or painful swallowing. White spots also may appear on the tonsils. These white spots may be raised and they can't be scraped off.

Tonsillitis is caused by a virus, as well as by streptococci bacteria, such as the one that also causes strep throat (a bacterial infection of the tissues in the back of the throat). In rare instances, fungi or parasites also can cause tonsillitis.

Tonsillitis has three main types: acute, sub-acute and chronic. Acute tonsillitis can be either bacterial or viral in origin. Sub-acute tonsillitis, which can last between three weeks and three months, is caused by the bacterium Actinomyces. Chronic tonsillitis, which can last for long periods if untreated, is almost always bacterial.

The main symptom of tonsillitis is a sore throat, which usually appears red and inflamed, along with the tonsils. Tonsils may have spots on them or pus covering them in patches or entirely. Fever also is common.

When a sore throat due to infection of the tonsils is associated with cold-like symptoms, such as a runny nose, nasal congestion, sneezing or coughing, a virus most likely is the cause. When the sore throat is accompanied by a sudden and severe fever and swollen lymph nodes, the infection more likely is bacterial. If you have these symptoms, you should see a health professional to be tested for strep throat. Abdominal pain and headache also can indicate a bacterial infection.

A rapid strep test can be conducted in a doctor's office along with a throat culture to determine whether the tonsillitis is caused by streptococcus bacteria. If the patient has symptoms characteristic of strep throat (sore throat, fever and swollen lymph nodes), he or she should be tested for strep. An accurate history of throat infections is necessary to determine whether the tonsillitis is chronic, which affects the choice of appropriate treatment.

Generally, tonsillitis usually will go away on its own if left untreated. If the infection is viral, treatment focuses on managing symptoms. Gargling with salt water, drinking warm tea and other home remedies can help relieve discomfort. Non-prescription pain relievers like acetaminophen (Tylenol) also may be given to adults and children 6 months or older. Aspirin shouldn't be given to anyone age 20 or below due to its link to Reye's syndrome.

If tonsillitis is determined to be caused by strep throat bacterium, the patient then will require antibiotic medication.

Additionally, surgical removal of the tonsils (a tonsillectomy) is generally only recommended as a treatment when a child has serious complications, recurrent infections or chronic infections that don't respond to treatment and interfere with daily functioning. However, a tonsillectomy should only be performed after careful consideration of the child's medical history and overall health by the child's doctor.

The immune system's role in fighting tonsil bacteria

The immune system is the body's natural defense system to help fight infections. It's composed of antibodies, white blood cells and other chemicals and proteins that attack and destroy substances like bacteria and viruses that they recognize as foreign and different from the body's normal healthy tissues.

The immune system also is responsible for allergic reactions and allergies, which may occur when the system incorrectly identifies a substance (an allergen), such as pollen, mold, chemicals, plants or medications, as harmful.

Sometimes the immune system also mistakenly attacks the body's own cells, which is known as an autoimmune disease.

Strep throat is a bacterial infection of the tissues in the back of the throat (pharynx) and the tonsils or adenoids. Tissues become irritated and inflamed, causing a sudden, severe sore throat.

Strep throat symptoms include a sore throat accompanied by:

– A fever of 38.5 C (101 F) or higher

– Pain or difficulty swallowing

– White or yellow spots or coating on the throat and tonsils

– Swollen lymph nodes in the neck

In children, strep throat also may produce body aches, headache, stomachache, nausea, vomiting or listlessness. However, strep throat doesn't occur with cold symptoms, such as sneezing, a runny or stuffy nose or coughing.

While strep throat usually resolves itself within a few days, it is treated with antibiotics to prevent complications, such as rheumatic fever, from occurring.

Complications from tonsillitis

In chronic or recurrent cases of tonsillitis (generally defined as seven instances of tonsillitis within the preceding year, five instances in each of the preceding two years or three instances in each of the preceding three years), or in acute cases where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy can be performed to remove the tonsils. Patients whose tonsils have been removed still are protected from infection by the rest of their immune system.

Bacteria feeding on mucus accumulating in pits (referred to as “crypts”) in the tonsils produce whitish-yellow deposits known as tonsilloliths. These “tonsil stones” emit a very pungent odor due to the presence of volatile sulfur compounds.

Tonsilloliths occurring in the crypts of the tonsils may only be cured completely by a tonsillectomy or by resurfacing the tonsil with a laser, but practicing good oral hygiene and using a water pick may help lessen the symptoms. However, it's still possible to get tonsilloliths after removing the tonsils unless a complete tonsillectomy is performed.

In very rare cases, diseases like rheumatic fever can occur. Such complications are extremely rare in developed nations, but remain a significant problem in poorer nations.

If you get tonsillitis, here are some tips that can help you feel better:

– Drink plenty of fluids

– Eat smooth foods, including flavored gelatin, soups, ice pops and applesauce

– Avoid hard, crunchy or spicy foods

– Use a cool-mist vaporizer or humidifier in the room where you spend the most time

Caring for a child with tonsillitis

A child with tonsillitis needs plenty of nourishment and rest. If your child finds swallowing so painful that eating is difficult, try serving liquids and soft foods such as nutritious soups, milkshakes, smoothies, popsicles or ice cream.

Make sure that your child drinks lots of fluids and gets plenty of rest, and take his or her temperature regularly. Give a nonprescription pain reliever, such as acetaminophen or ibuprofen, for throat pain.

Sources: www.emedicine.com, Yahoo Health and Wikipedia.