Wednesday, September 24, 2008

Rheumatic Fever

Rheumatic fever is caused by Group A Streptococci, a bacteria, that causes many different kind of infections, including pharyngitis (infection of the throat). If patients with pharyngitis, due to Grp A Strep, don't receive antibiotics against Grp A Strep, rheumatic fever can develop. Rheumatic fever isn't seen in the US as much any more because the majority of pts receive antibiotics for throat infections. In PNG, most pts don't come to the doctor for throat pain. I think in my 1 yr here, of all the patients I have seen, and I have seen quite a few, I have only treated 2 patients for pharyngitis. As a result we see a lot of patients with sequelae of rheumatic fever, mainly rheumatic heart disease, especially kids. Once they have rheumatic heart disease we can't reverse it, we just support them with medicines for heart disease.
Bepi, is a patient I saw recently who has acute rheumatic fever. I had seen her a few weeks ago, and her main complaint was joint pain of her L hand. She had a fever, and was having some shortness of breath. I examined her, and got a chest xray, where I found a huge heart (on R). It was like she had 2 hearts, it was so big. I did an ultrasound and found she had a pericardial effusion, which accounted for some of her cardiomegaly. She had a sed rate of 68. She came back this week and her jt pain has now resolved on her hand, but is now in her lower extremity. She also has 2 distinct heart murmurs. On repeat CXR, the cardiomegaly is significantly reduced (on L), and her US shows a minimal pericardial effusion. This is quite a change in a few weeks time.
For the medical folks out there, the Jones criteria is used to diagnose rheumatic fever, it consists of arthritis, carditis, subcutaneous nodules, erythema marginatum, and syndenham chorea. You need 2 for the diagnosis and she has carditis and arthritis. She also has some of the minor criteria, elev sed rate and fever. We don't have the ability to do an ASO to check for evidence of strep infection, but given all we have, we assume it would be elevated and are treating accordingly. She currently is resting on the ward to try and give her heart a rest.