Reactive Arthritis After Rheumatic Fever and Streptococcal Infection
1. WHAT IS ROMATIC FEVER?
1.1 What is it?
Rheumatic fever is a disease caused by a throat infection caused by a bacterium called streptococcus. Of the various streptococcal groups, only group A causes rheumatic fever. Although inflammation caused by streptococci is one of the common causes of pharyngitis (throat infection) seen in school-age children, not all children with pharyngitis develop rheumatic fever. The disease can cause inflammation and damage to the heart; it first manifests itself as instant pain and swelling in the joints and then causes abnormal involuntary movement disorder called chorea which develops due to carditis (inflammation in the heart) or inflammation in the brain. In addition, skin rash and nodules may be seen.
1.2 How common is it?
In the absence of antibiotics, rheumatic fever was more common in hot climatic countries. After the use of antibiotics in the treatment of pharyngitis has increased, the incidence of the disease has decreased, but it still affects many children between the ages of 5 and 15 all over the world and causes heart disease in a small number of cases. It is considered among the rheumatic diseases of children and adolescents because it affects the joints. Rheumatic fever is not equally common all over the world.
The incidence of rheumatic fever varies from country to country: there are countries where no cases have been seen, and countries with moderate or high cases (more than 40 cases per 100,000 people per year). There are more than 15 million cases of rheumatic heart disease in the world; it is estimated that there are 282,000 new cases and 233,000 deaths each year.
1.3 What are the causes of the disease?
This disease is the result of abnormal immune response to throat infection caused by bacteria called Streptococcus pyogenes or Group A β hemolytic Streptococcus. Before the onset of the disease, a sore throat and then a period of varying duration, no symptoms are seen.
Antibiotics are needed to treat throat infections, stop the stimulation of the immune system and prevent new infections, as new infections can cause new disease attacks. The risk of recurrent attacks is higher within 3 years of the onset of the disease.
1.4 Is it hereditary?
Rheumatic fever is not an inherited disease because it cannot be passed on directly from parents to children. Nevertheless, there are cases where several members of the family suddenly have rheumatic fever. This may be due to the possibility of streptococcal infection spread from person to person, together with genetic factors. Streptococcal infection can be transmitted through the respiratory tract and saliva.
1.5 What caused this disease in my child? Can it be prevented?
The environment and streptococcus strains are important factors in the development of the disease, but it is difficult to predict who will actually get the disease. Arthritis and cardiac inflammation are caused by an abnormal immune system response to streptococcal proteins. The likelihood of developing the disease increases when certain types of streptococci infect a susceptible person. The crowd is an important environmental factor because it paves the way for the spread of infections. Prevention of rheumatic fever is possible by rapidly diagnosing and treating antibiotic throat infections caused by streptococci in healthy children (recommended antibiotic penicillin).
1.6 Is it contagious?
Rheumatic fever is not contagious, but pharyngitis due to streptococcus is contagious. Streptococci are transmitted from person to person, and therefore there is a relationship between the crowded home, schools or gyms and infection. It is important to stop the spread of the disease by carefully washing your hands and avoiding close contact with people with streptococcal throat infection.
1.7 What are the main symptoms?
Rheumatic fever is usually manifested by a combination of symptoms that may be specific to each patient. It is followed by pharyngitis or tonsillitis due to streptococcal untreated with antibiotics.
In pharyngitis or tonsilitis, there are fever, sore throat, headache, red palate and tonsils and inflamed secretions and swollen, sore lymph nodes in the throat. However, these symptoms may be mild or absent in school-age children and adolescents. After the acute infection is resolved, there will be a period of 2-3 weeks without any symptoms. The child may then experience fever and the following symptoms.
Arthritis
Arthritis often affects several large joints at the same time, or it can travel from one joint to another, affecting one or both at the same time (knees, elbows, wrists or shoulders). This is called "mobile and transient arthritis." Arthritis of the hands and spine is less common. Joint pain may be severe, although there is no apparent swelling. After taking antiinflammatory drugs, the pain quickly disappears. Aspirin is the most commonly used anti-inflammatory drug.
carditis
Carditis (inflammation of the heart) is the most serious form of the disease. Acceleration of heartbeats during rest or sleep may raise suspicion of rheumatic carditis. Abnormal findings and murmur are the main indicators of cardiac involvement. The degree of murmur can range from mild to severe. Severe murmur may indicate inflammation of the heart valves (endocarditis). If there is inflammation (pericarditis) in the membrane surrounding the heart, fluid will accumulate around the heart, but this usually does not cause any complaints and will resolve itself. In the most severe cases of myocarditis, the contraction of the heart is impaired and weakened. Cough, chest pain, pulse and breathing is manifested by an increase. It may be necessary to consult the cardiologist and further examination. Rheumatic heart valve disease may be the result of the first episode of rheumatic fever, but is usually the result of recurrent fevers and may become a problem in later adulthood, and should be prevented.
Korea
The word Korean means "dance" in Greek. Korea is caused by inflammation of parts of the brain that control the coordination of movements. It affects 10 to 30% of patients with rheumatic fever. Unlike arthritis and carditis, it develops in the later stages of the disease, 1 to 6 months after a throat infection. Early symptoms may be the deterioration of the handwriting of school-age patients due to involuntary tremor, problems in dressing and self-fulfillment, and even problems with walking and feeding. Involuntary movements can be deliberately suppressed for short periods of time, lost in sleep, or increased with stress and fatigue. Loss of concentration in students affects anxiety and school success due to anxiety disorder prone to crying. If it is mild, it may be considered as behavior disorder and may be overlooked. It is self-limiting, but supportive treatment and follow-up is still required.
Skin rashes
Less common symptoms of rheumatic fever are skin rashes. "Erythema marginatum" appears as red rings, while "subcutaneous nodules" are generally painless, mobile grain size hardness under normal skin on the joints. These findings occur in less than 5% of cases and may be overlooked because of their latent and transient appearance. These symptoms do not occur alone, but with myocarditis (inflammation of the heart muscle). Fever, fatigue, loss of appetite, pallor, abdominal pain, and nosebleed are the other complaints that can be noticed at first sight by parents in the early stages of the disease.
1.8 Is the disease the same in every child?
The disease most commonly manifests as murmur in older children or adolescents with arthritis and fever. Younger patients come with complaints of carditis and mild joint severity.
Korea may be the only symptom or may be associated with a cardiogram, but a cardiologist needs close monitoring and examination.
1.9 Is the disease in children different from the disease in adults?
Rheumatic fever is a disease of school-age children and young individuals up to 25 years of age. It is rarely seen before the age of 3 years, and more than 80% of the patients are between 5 and 19 years old. Nevertheless, if the precautionary measures are not taken continuously, it may show up later in life.
2. DIAGNOSIS AND TREATMENT
2.1 How is it diagnosed?
Clinical signs and investigations are particularly important because there is no specific test or symptom for diagnosis. Arthritis, carditis, chorea, changes in the skin, fever, abnormal findings in streptococcal infection tests, and changes in the rhythm of the heartbeat on the electrocardiogram (called Jones criteria) may help to diagnose. Diagnosis requires evidence of a previous streptococcal infection.
2.2 Which diseases are similar to rheumatic fever?
The disease called streptococcal reactive arthritis is also seen after streptococcal-induced pharyngitis, but it shows arthritis properties for a long time and the risk of carditis is lower. Childhood idiopathic arthritis is another disease similar to rheumatic fever, but the duration is longer than 6 weeks. Arthritis can also occur in diseases such as reactive arthritis caused by Lyme disease , leukemia, or other bacteria or viruses. Ordinary murmurs (common murmurs without heart disease), congenital or other acquired heart conditions, rheumatic fever may be considered.
2.3 What is the importance of tests?
Some tests are required for diagnosis and follow-up. Blood tests are important to confirm the diagnosis during attacks.
As with many other rheumatic diseases, symptoms of systemic inflammation are seen in almost all patients except chorea. In most patients, there is no sign of a throat infection, and streptococci in the throat have been cleared by the immune system from the onset of the disease. If the family and / or patient cannot remember the details of a throat infection, blood tests are available to detect streptococcal antigens. The increase in the amount of these antigens (anti-streptolysin O (ASO) or DNAse B) can be detected in blood tests at 2-4 weeks intervals. The high amount is indicative of a recent infection, but this has nothing to do with the severity of the disease. Nevertheless, only patients with chorea have normal results in the test, making diagnosis difficult.
Abnormal ASO or DNAse B test results indicate previous exposure to the immune system-stimulating bacteria, and therefore alone, are not sufficient to diagnose rheumatic fever patients without symptoms. Antibiotic treatment is not usually required.
2.4 How is carditis diagnosed?
A new murmur caused by heart valve inflammation is the most common feature of carditis and is usually detected during a medical examination during a cardiac listening. An electrocardiogram (breakdown of the heart's electrical activity into a paper strip) may be appropriate to understand how much the heart is affected. Chest x-ray is also important for controlling heart enlargement.
Doppler echocardiogram or cardiac ultrasound are also very sensitive to carditis. All these procedures are absolutely painless and the only discomfort is that the child has to stop without moving throughout the test.
2.5 Is healing / healing possible?
Rheumatic fever is a major health problem in some parts of the world, but it can be prevented by treating streptococcal pharyngitis as soon as it is diagnosed (primary prevention). Acute rheumatic fever can be prevented if antibiotic treatment is initiated within 9 days of onset of pharyngitis. Symptoms of rheumatic fever are relieved by NSAIDs.
Research is currently underway to produce a vaccine for protection against streptococcus: prevention of initial infection will provide protection against abnormal immune response. This approach may be the rheumatic fever prevention method of the future.
2.6 What are the treatments?
No new treatment has been proposed in the past few years. Aspirin remains the main drug of treatment; The mechanism of action is not fully known and is thought to be due to its anti-inflammatory properties. Other nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis It is recommended to be used for 6 to 8 weeks or until the disease disappears.
Bed rest for severe carditis and orally for 2-3 weeks Treatment with corticosteroids (prednisone) is recommended, and if the symptoms and blood tests confirm that inflammation is controlled, the dose of the drug is gradually reduced and discontinued.
In Korean cases, family support may be required for personal care and school life. Drug treatment with steroids, haloperidol or valproic acid is initiated to control movements in chorea and the patient is closely monitored for side effects. Common side effects include; drowsiness and tremors that can be easily controlled by dose adjustment. In some cases of chorea, discomfort may persist for several months despite appropriate treatment.
Once diagnosed, long-term protection with antibiotics is recommended to prevent recurrence of acute rheumatic fever.
2.7 What are the side effects of drug treatment?
Salicylates and other NSAIDs are generally well tolerated in short-term symptomatic treatment. The risk of penicillin allergy is very low, but its use during the first few injections should be monitored. The main things to be aware of; painful injections and rejection of pain-feared patients. Therefore, it is recommended to educate the patient about the disease, topical anesthetics and relaxation before injections.
2.8 How long should the secondary protection last?
The risk of recurrence in the 3-5 years after the onset is higher and the risk of carditis-related damage increases with each episode. During this period, regular antibiotic therapy to prevent new streptococcal infections is recommended to all patients with rheumatic fever, regardless of the severity of the disease, even the mild ones may be exacerbated.
Most doctors agree that preventive antibiotic therapy will continue for at least 5 years after the last attack or until the child is 21 years old. In noncardiac cardiac injury, it is recommended to continue secondary preventive treatment for 10 years or until the patient is 21 years of age, whichever takes longer. If heart damage is present, secondary preventive treatment is recommended for 10 years or up to 40 years of age; If valve replacement is required as a result of the disease, treatment may continue until the age of 40 years.
Prevention of bacterial endocarditis with antibiotics is recommended for all patients who have their teeth or undergo surgery even if they have heart valve damage. This is necessary because the bacteria can progress from other parts of the body, especially the mouth, and cause infection in the heart valve.
2.9 What can be said about non-standard / complementary therapies?
There are many complementary and alternative therapies available, which can be confusing for patients and their families. The dangers and benefits of trying these treatments should be considered carefully, as their proven benefits are minimal and can be costly in terms of time and burden on the child. If you want to explore complementary and alternative therapies, it is reasonable to discuss these options with your pediatric rheumatologist. Some treatments may interfere with standard drug treatments. Most physicians will not be opposed to complementary therapies unless you follow medical advice. It is very important that you do not stop taking your prescription medications. When medications such as corticosteroids are required to control the disease, it can be very dangerous to stop taking them while the disease is still active. Please discuss any drug treatment issues with your child's physician.
2.10 What regular checks are required?
Regular checks and periodic tests may be necessary in the long-term course of the disease. Close follow-up is recommended in cases with carditis and chorea. After regression of symptoms, it is important to establish a controlled program for preventive treatment and to monitor for cardiac damage by long-term follow-up under the supervision of a cardiologist.
2.11 How long will the disease last?
Acute symptoms of the disease decrease within a few days or weeks. However, acute rheumatic fever attacks are always at risk of recurrence, and if the heart is affected, the symptoms may last a lifetime. Continuous antibiotic therapy prevents recurrence of streptococcal pharyngitis for many years.
2.12 What is the possible long-term prognosis?
The severity and severity of symptoms are unpredictable. Although the occurrence of carditis in the first episode is a potential risk factor for damage, complete recovery may be seen in some cases after carditis. In the most severe heart damage, heart surgery may be required to replace the valve.
2.13 Is it possible to fully recover?
If the carditis did not cause serious damage to the heart valve, it is possible to heal completely.
3. DAILY LIFE
3.1 How does the disease affect the daily life of the child and the family?
With proper care and regular checks, most children with rheumatic fever lead a normal life. However, family support is recommended during carditis and chorea exacerbations.
The main problem; Antibiotic prevention is to ensure lifelong compliance with preventive treatment. Primary health care should address this issue, and especially adolescents should be trained to comply with treatment.
3.2 How is school life affected?
If heart damage is not observed during regular checks, no special advice is given on routine school life and daily activities; children can participate in all activities. Families and teachers should do their best to ensure that the child normally participates in school activities, not only for academic achievement, but also for the acceptance and recognition of both peers and adults. In acute stages of chorea, there may be some limitations in school life, and parents and teachers have to deal with them for 1 to 6 months.
3.3 Does it affect sports?
Playing sports is an indispensable part of every child's daily life. One of the goals of treatment is to allow children to live as normal a life as possible and not to see themselves differently from their peers. Therefore, all activities can be performed as tolerated. However, in the acute phase, limited physical activity or bed rest may be necessary.
3.4 How should nutrition be?
There is no evidence that nutrition affects the disease. In general, the child should maintain a balanced and normal diet suitable for his age. A healthy and balanced diet containing sufficient protein, calcium and vitamins is recommended for a child of growing age. Since corticosteroids cause an appetite, patients taking these medications should avoid over-eating.
3.5 Does the climate affect the course of the disease?
There is no evidence that climate can affect the way in which the disease occurs.
3.6 Can the child be vaccinated?
The physician will decide on which vaccines the child can have. In general, vaccines do not appear to increase disease activity and cause serious adverse events in patients. On the other hand, attenuated live vaccines are generally avoided because there is a risk of hypothetically triggering infection in patients receiving high doses of immunosuppressive drugs or biological agents. Non-live vaccines appear safe for patients, even for patients receiving immunosuppressive drugs. However, most studies will not be able to fully evaluate the rare injury due to the vaccine.
In a patient on immunosuppressive medication, physicians should recommend the measurement of pathogen-specific antibody concentrations after vaccination.
3.7 What can be said about sexual life, pregnancy and birth control?
There is no restriction on sexual activity or pregnancy due to illness. However, patients taking these drugs should always be very careful about their possible toxic effects on the fetus. Patients are advised to consult their physician about contraception and pregnancy.
4. REAGENT ARTHRITIS AFTER STREPTOCOCCIN INFECTION
4.1 What is it?
Cases of streptococcal arthritis have been described in children and young adults. This is commonly referred to as "reactive arthritis" or "reactive arthritis that develops after streptococcal infection" (PSRA).
PSRA primarily affects children aged 8 to 14 years and young adults aged 21 to 27 years. It usually develops 10 days after a throat infection. It differs from acute rheumatic fever-induced arthritis (ARF), which mainly affects large joints. In PSRA, large and small joints and axial skeleton are affected. It usually takes longer than ARF - about 2 months, sometimes longer.
Abnormal laboratory test results (C-reactive protein and / or erythrocyte sedimentation rate) with mild fever and inflammation are available. Inflammatory markers are lower than in ARF. PSRA diagnosis includes arthritis with evidence of recent streptococcal infection; It is based on abnormal results from streptococcal antibody tests (ASO, DNAse B) and the absence of symptoms of ARF according to the "Jones criteria".
PSRA is a discomfort other than ARF. Carditis is not likely to occur in patients with PSRA. At present, the American Heart Foundation recommends preventive antibiotic therapy for one year after symptoms appear. In addition, these patients should be carefully monitored for evidence of clinical and echocardiographic carditis. If heart disease occurs, the patient should be treated like ARF, otherwise preventive treatment may be discontinued. Cardiologist follow-up is recommended.
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