Rheumatic Fever In Children: Signs, Symptoms And Treatment

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Rheumatic fever in children is a disease that requires prompt medical attention. It is also called acute rheumatic fever (ARF), an autoimmune, inflammatory disease. It is often a result of delayed sequelae of strep throat infections (acute pharyngitis).

Rheumatic fever may cause inflammation of the body’s tissues, especially the heart and joints. This fever, a complication of a strep infection, may also lead to cardiac complications.

Read on to know more about the causes of rheumatic fever, its signs, diagnosis, risks, treatment, prevention, and complications.

Signs And Symptoms Of Rheumatic Fever In Children

The symptoms of rheumatic fever may vary in each child and usually manifest one to five weeks after strep bacteria infection. The following are the common symptoms of rheumatic fever (1) (2).

  1. Fever: High body temperature may occur due to inflammation in the body
  1. Migratory polyarthritis: Joint inflammation, including soreness, swelling, and redness of joints, can be seen in most children. The ankle and knee joints are frequently affected.
  1. Rheumatoid nodules: Small and firm bumps (nodules) are often seen under the skin over the bony areas. These nodules are usually painless and freely movable.
  1. Sydenham chorea or St Vitus dance: This is a rare neurological disorder with sudden onset (random-appearing) of involuntary movements. These unusual, jerky movements usually affect the hands, face, and feet in children. Handwriting changes can be seen in children with chorea of the hands.
  1. Carditis: This is one of the most common complications of acute rheumatic fever due to the inflammation of the heart muscles and tissues. Pericardial friction rubs, new onset of murmurs, valvulitis, pericardial effusion, and heart failure are some clinical signs of carditis.
  1. Unusual behaviors: Some children with Sydenham chorea can show unusual behaviors such as outbursts of unusual laughter or crying.
  1. Polyarthralgia: Some children may have polyarthralgia (multiple joint pains) during rheumatic fever. ARF may cause migratory polyarthralgia involving the large joints.
  1. Skin rashes: Children may develop red rashes with irregular edges on the arms, legs, and torso during rheumatic fever.
  1. Stomach pain: In some rare cases, children with rheumatic fever may experience stomach pain or abdominal pain. The exact cause of abdominal pain in rheumatic fever is not known.
  1. Fatigue: Children with rheumatic fever may experience a lack of energy or become overly tired.
  1. Weight loss: Some children may have unexplained weight loss followed by a strep infection.

These symptoms may also be seen in other medical conditions. Thus, it is recommended to seek medical care if your child has any symptoms of rheumatic fever for appropriate diagnosis and treatment. You may also see a doctor if your child has a new onset of symptoms or the existing symptoms worsen.

Risks And Causes Of Rheumatic Fever In Children

Rheumatic fever is caused by an autoimmune reaction to the Group A Streptococcus (GAS or group A strep) bacteria. It generally occurs if scarlet fever or strep throat is not treated well (3).

Rheumatic fever is common in children between five and 15 years of age.

When a child gets a strep infection, such as strep throat, their immune system builds antibodies against the bacteria. These antibodies can attack one’s tissues since some bodily tissues may contain proteins similar to strep bacteria. Rheumatic fever usually affects the heart, joints, skin, and central nervous system.

The following factors may increase a child’s risk for developing rheumatic fever (3).

  • Frequent strep throat infections
  • Family history of rheumatic fever
  • Untreated or inappropriately treated step infections
  • Overcrowding
  • Poor sanitation

Rheumatic fever is not a contagious disease. However, strep infection can be spread from an infected person to others by direct contact and respiratory droplets (3).

Complications Of Rheumatic Fever

Long-term heart damage called rheumatic heart disease may occur if the rheumatic fever is not treated promptly. The heart complications of rheumatic fever may include (4)

  • Heart failure due to stenosis (narrowing) or regurgitation (backflow or leaking) of the heart valves.
  • Bacterial endocarditis, an infection of the heart’s inner lining.
  • Rupture of the heart valve, which may occur in rare cases. This is a medical emergency.

Diagnosis Of Rheumatic Fever

Children with rheumatic fever usually have a history of strep infection. The symptoms can also be suggestive of the diagnosis in most cases. However, blood tests and throat culture are often ordered. Blood tests can determine the presence of infection or inflammation in the body.

Heart murmurs or pericardial rub sounds are often heard on a stethoscope in children with rheumatic heart disease. Murmurs are sounds heard due to turbulent blood flow in the heart, while rubs are sounds heard due to friction of the heart against the pericardium during inflammation (5).

The following tests are also often done to determine cardiac manifestations of rheumatic fever in children (5).

  • Chest X-ray (CXR) helps visualize the lungs and size of the Some children may have enlarged hearts due to complications.
  • Electrocardiogram (ECG) records the electrical activity of the heart and helps determine abnormal heart rhythms (arrhythmias) and cardiac muscle damages in some cases.
  • Echocardiogram (echo) is an ultrasound of the heart that helps visualize the heart chambers and valves. It helps assess the structures and functions of the heart, such as stenosis of the valves and backflow of blood.
  • Cardiac MRI, needed only in few cases, gives accurate picture of the heart and helps identify any issues in the heart muscles and valves.

Children with rheumatic heart disease are often referred to pediatric cardiologists for detailed evaluation and management. Those with acute rheumatic fever receive medications to prevent complications. Learn more about the treatments for rheumatic fever in the next section

Treatment Of Rheumatic Fever In Children

The treatment options for rheumatic fever are aimed at controlling inflammation, relieving symptoms, destroying remaining bacteria in the body, and preventing recurrence. The following treatments are usually given for children with rheumatic fever (6)(7).

  • Anti-inflammatory medications: Anti-inflammatory drugs, such as naproxen (Anaprox DS), are often given to reduce fever, pain, and inflammation.
  • Corticosteroids: These are prescribed if the symptoms are severe and the child does not respond to treatment with anti-inflammatory medicines.
  • Antibiotics: Penicillin G benzathine or antibiotics are prescribed to eliminate the remaining bacteria in the body during the initial stage of treatment. After the child completes the initial course of antibiotics, preventive treatment with antibiotics (antibiotic prophylaxis) is prescribed for a longer duration to prevent complications.
  • Anticonvulsant (antiseizure) medications: Anticonvulsants are usually recommended for children with Sydenham chorea. Depakine (valproic acid) and Tegretol or Carbatrol (carbamazepine) are some antiseizure medications prescribed for chorea.

You may do the follow-up visits and follow the preventive measures as recommended by the doctors since rheumatic fever may lead to heart disease after several years. Activity restrictions and bed rest are often recommended until the symptoms improve. The duration of recovery may vary depending on the severity of inflammation and cardiac involvement.

According to the American Heart Association, antibiotic prophylaxis is usually prescribed for five years or until the age of 21 years in most cases of rheumatic fever without carditis. And in cases of rheumatic fever with carditis, antibiotic prophylaxis is recommended for up to 10 years or until the age of 21. This can be daily antibiotic tablets or intramuscular shots every few weeks (7).

Prevention Of Rheumatic Fever

The following ways can help prevent rheumatic fever in children (1).

  • Practice good hand hygiene and cough and sneeze etiquette to prevent the spread of strep infections such as strep throat.
  • Appropriate and prompt antibiotic treatment of strep infection in children can prevent rheumatic fever.
  • Complete the prescribed course of antibiotic treatment and do the follow-ups as recommended by the doctor.
  • Follow recommended secondary prevention (antibiotic prophylaxis) if the child had rheumatic fever. This helps prevent complications such as rheumatic heart disease and recurrence of rheumatic fever in the future.

Getting a group A strep infection does not provide immunity for the future, and children can get rheumatic fever more than once. So, you may strictly adhere to the secondary prevention methods.

Frequently Asked Questions

1. How long does rheumatic fever last?

Rheumatic fever may last for about three months until you can make a complete recovery with timely and effective treatment. However, you may be advised to continue the antibiotics for several years to prevent it from recurring (8).

2. Does rheumatic fever affect the brain?

Yes. Rheumatic fever is a complication of strep throat and scarlet fever infection and could affect the brain, joints, heart, and skin (9).

Your child may have a rheumatic fever if they have a skin rash, fever, stomach ache, and other symptoms such as migratory polyarthritis, polyarthralgia, and rheumatic nodules. You should get prompt medical help to avoid complications, including bacterial endocarditis, heart failure, or a heart valve rupture. Since rheumatic fever in children usually appears one to five weeks after a strep bacteria infection, proper infection management can help prevent the disease. Following the suggested secondary prevention methods, practicing good hand hygiene, following cough and sneeze etiquette, and completing the specified course of antibiotic therapy after infection could also help.

Key Pointers

  • Inflammation or redness of the joints, fever, nodules near the bony areas, or stomach pain are a few common signs of rheumatic fever in children.
  • It could be due to repetitive strep throat infections.
  • Rheumatic fever may affect the heart in the long term, leading to the rupture of heart valves or heart failure.
  • The treatment usually includes antibiotics, anti-inflammatory medications, or corticosteroids.

References:

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Dr Bisny T. Joseph

Dr. Bisny T. Joseph is a Georgian Board-certified physician. She has completed her professional graduate degree as a medical doctor from Tbilisi State Medical University, Georgia. She has 3+ years of experience in various sectors of medical affairs as a physician, medical reviewer, medical writer, health coach, and Q&A expert. Her interest in digital medical education and patient education made... more

Dr. Supriya Mahajan

(DNB, PDCC)
Dr. Supriya Mahajan is a pediatrician and pediatric hepatologist with nine years of experience. She completed her MBBS from Shyam Shah Medical College and diploma from the National Board of Education, New Delhi. She went on to gain specialization in the gut and liver-related diseases in children from the Institute of Liver and Biliary Sciences and MRCPCH 1, 2 from... more

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