ACUTE Rheumatic Fever (ARF) is an inflammatory process that affects the body, and is usually initiated by a throat infection, commonly called “strep throat”.

During this process, the joints, tissues beneath the skin and the heart may become inflamed. This infection mainly affects children and a new infection rarely affects adults who have never had rheumatic fever in the past, but can affect people with a history of rheumatic heart disease. For the majority of persons who develop rheumatic fever, the inflammation settles and leaves no permanent damage. Less than 30 per cent of people, however, are left with permanent damage to the heart called Rheumatic Heart Disease (RHD). RHD affects mainly the heart valves, leading to narrowed or leaking heart valves.

Rheumatic fever is almost non-existent in the developed world but is still a significant public health problem worldwide, mainly through its effects in developing countries such as Jamaica, South Africa, India, etc. It is estimated that there are over 15 million cases of RHD worldwide, with 282,000 new cases and 233,000 deaths annually.

Paediatric cardiac surgeon Dr Sherard Little published a study in 2014 confirming that rheumatic valvular heart disease accounts for in excess of 80 per cent of all valvular surgeries performed at the University and Bustamante Children’s hospitals over a seven-year period of review.

While the Ministry of Health has established and continues to run programmes to lower the incidence and prevalence of ARF and RHD in Jamaica, it continues to be a significant health problem. ARF appears to be associated with overcrowding in homes and poor socio-economic conditions overall.

ACUTE RHEUMATIC FEVER: WHAT SYMPTOMS OR SIGNS TO LOOK FOR?

It is important to note that ARF may go unnoticed. The symptoms are sometimes so subtle that it may be passed off as the flu. So we do see a small percentage of people who show up with Rheumatic Heart Disease, who have never been diagnosed with Acute Rheumatic Fever.

For those with symptoms, the main symptom is joint pains or full-blown arthritis (joint swelling and limited joint movement). The joints involved are usually the large joints of the knees, ankles, hips, elbows and the pain may not affect all joints at the same time, but may move from one joint to the next. Other symptoms include fever, general feeling of being tired, and in some rare instances abnormal movement of the hand.

HOW DO WE CONFIRM THE DIAGNOSIS OF ARF?

Confirming the diagnosis of ARF will require ECG, blood tests, along with a detailed history of your symptoms and examination. We also have to establish that you had a recent “strep throat” infection, because these same symptoms could be due to some other process, and not ARF.

HOW DO WE TREAT ARF?

Acute Rheumatic Fever requires rest and anti-inflammatory medication such as aspirin. In addition, we would give antibiotics to clear the body of the streptococcus infection. Once the pain, and signs of inflammation settle, we would stop the anti-inflammatory medication, however you will need follow-up. In severe cases, where the heart is involved and there is heart failure, we treat the heart failure as well. An echocardiogram (ultrasound of the heart) is also done, to establish if there is any damage to the heart valves.

WHAT NEXT AFTER TREATING THE ARF

This is extremely important: All persons who have been diagnosed with ARF will need follow-up and long-term antibiotics (mainly penicillin injection into the muscle) for at least 10 years from their first infection or at least age 18 years old – whichever is longer. So, for a child who had ARF diagnosis at seven years old, they would continue antibiotics until age 18 years old. If they had it at age 10, they would continue until age 20 years old. This is because the risk of repeat infection and heart damage is high.

WHEN CAN THE FOLLOW-UP AND LONG-TERM ANTIBIOTICS STOP?

Once the doctor determines that you have completed an adequate course (10 years duration or at least age 18 years old), another echocardiogram is done to determine if there is any evidence of heart damage (RHD). If the echocardiogram is normal, and there is no evidence of heart damage, no further follow-up or antibiotics are needed.

ALL PERSONS WITH RHD REQUIRE LIFE-LONG FOLLOW-UP

Rheumatic Heart Disease can lead to heart failure and, in some cases, the heart valves may need to be changed by open heart surgery, to prevent these severe consequences of heart failure, stroke, and in some cases death.

Dr Claudine Lewis is an adult cardiologist and medical director at Heart Smart Centre in Montego Bay. She is also a cardiologist at the Cornwall Regional Hospital and an associate lecturer with the University of the West Indies. Questions may be sent to questions@heartsmartcentre.com and for additional information call 684-9989 or visit the website www.heartsmartcentre.com