RHEUMATIC FEVER
Rheumatic fever is an illness of children and young adults, with major symptoms of arthritis and carditis, a prolonged course and a tendency to recur. It is triggered by infection with specific strains of group-A streptococcus which possess antigens that cross react with human connective tissue Particularly heart valve glycoprotein. Its prevalence in western world, has Progressively declined to very low levels, but it remains a major problem in undeveloped countries. The underlying cause is hypersensitivity reaction to gp-A streptococci. Rheumatics fever follows an attack of streptococcal pharyngitis after 2-3 weeks. In India Rheumatic valvular disease accounts for a major proportion of cardiac morbidity occurring below 40 yrs of age.

Epidemiology
It is more common in the developing countries
Age:- It usually affect children. Peak incidence below 5 to 15 years.
Sex:- Both Sexes are usually affected.
Social & economic factors:- Over crowding, poor living conditions under nutrition etc are main predisposing factors. So it is more common in low socio economy.
Genetical:- Familial predisposition is noticed in many cases.
Other:- Untreated cases of gp-A. Streptococeal pharyngitis/tonsillitis.

Pathogenesis
In 80% of cases the disease follows streptococeal tonsilits & in 80% of subject show a case in Aso titre within 2 months. The pathogenesis is due to an ‘antigenic mimicry’ between tumor and gp-A streptococcal antigens. The antigens contained in the streptococcus show a similarity to several tissue antigens in the humanbody especially myocardial sarcolemma. Antibodies produced against the streptococeal antigens cross react with tissue antigens resulting in a type-II antigen antibody reaction and conservent inflammation. Leisions are most evident in the connective tissue.

Pathology
Pathological process consist of an
1. Exudative stage - seen in acute phase
2. Proliferative stage - is more prolonged process
1) Exudative
- fibrinoid necrosis of the connective tissue is seen.
- There is oedema of the collagen fibres which later undergo fragmentation.
2) Proliferative
The hall mark of this stage is the formation of ‘Aschoff bodies’ There are small granulomas consisting of a central zone of fibrinoid necrosis surrounded by round cells, epithelial cells, Aschoff giant cells and fibroblasts.

Heart All the layer are affected causing
- Endocarditis
- Myocarditis
- Pancarditis
Endocarditis Endocarditis affect the valvular or mural endocardium. When valvular endocardium heals it results in scarring & deformity of the valves. Mitral valve is most commonly attacked followed by Aortic valve. - Scarring after mural endocarditis may be seen as M Callum’s patch in the perstenor wall of the left atinum.
Myocardium Affection of myocardium may be mild or severe.
Pericardium Leision in the pericardium is a fibrinous inflammation. The pericardium shows a ‘bread & butter’ appearance macroscopically. Pericardial effusion may develop. Adhesive pericarditis may follow rarely.
Joints It affect large synovial joints producing acute synovits. Effusion may develop which clear up completely without any residual deformity. It was said that “RF licks the joints & bites the heart”.
Other organs Rheumatic granutomas found in the subcutaneous tissue as subcutaneous nodules. Respiratory involvement is maintested as pneumonia. The basal ganglia of the brain are affected It cases aseptic focal encephalits.
Clinical features Rf is a systemic illness typically presenting with fever, anorexia, lethargy migratory polyarthritis. About 2/3 of patients give a history of prior sorethroat. Arthritis occurs about 75% of cases other symptoms include skin rashes cardits (40-60%) & neurological manifestations. In some cases no acute bout is recognized at all. The patient will be presenting with established heart disease.

1) Migratory polyarthritis 75% of patients larger joints affected. Objective signs are usually limited to minor warmth & swelling but the pain may be exeruciating. Characteristically one joint maybe affected for 2 to 3 days then the inflammatory process moves to another region. Arthralgia without objective signs may occur in other joints or maybe the only feature. Symptoms may vary from a minor discomfort to severe pain. If left untreated joint pain usually settle over 1 to 4 weeks.
2) Cardits This is the most important manifestation of rheumatic fever. 40 - 60% of patients have evidence of cardits. It present as
* Breathlessness (due to heart failure / pericardial effusion)
* Palpitation/chest pain (due to pain or pancarditis)
Other symptoms
* Tachycardia
* Cardiac enlargement
* New or changed cardiac murmurs.
Murmur
A soft systolic murmur is common but non specific. A soft mid - diastolic called carey coombs murmur also occurs. It is due to valvulitis with nodules forming on the mitral valve leaflets. There may be pericardial friction rub which is often intermittent.

ECG changes
In ECG - P.R & Q.T intervals may be prolonged.
3) Sydenham’s chorea (st vitus dance)
Rare About 5% CNS involvement may manifest late after the initial infection (6 month or more). They produce spasmodic unintentional movements and possibly altered speech. Spontaneous recovery is usual though it may be followed by chromic cardiae disease.

SKIN LEISIONS
1. Erythema marginatum
Occurs in 10-20% of children = Rf. It starts as red macular which fade in the centre, but remain red of the edges.
2. Subcutaneous nodules
uncommon, but associated with more severe cardits. They are small (0.5cm) from painless, best felt over the bone or tendons. Typically the nodules are much smaller than those of R.A. other systemic manifestations are rare, but include pleuricy, pleural effusion & pneumonia.

Diagnosis
There is no single test in Rf. The diagnosis made on the basis of the clinical pattern with support from lab test due to the variety of signs & symptoms in 1944 Duckett Jones, proposed a criteria to assist the clinician in standadizing the diagnosis, which was modified by American Heart association later.

It consist of major & minor criteria.
Major                Minor
1. Cardits        Clinical
2. Arthrits        Fever
3. Chorea       Arthralgia

4. Subcutaneous nodules        Elevated acute phase reactants (ESR, C-reactive protein
5. Erythema marginatum        prolonged PR internal in ECG
Plus Supporting evidence of recent gp-A streptococcal infection (ed Aso titre). Two major or one major & 2 minor criteria will diagonose the condition of Rf.

Lab investigations
Acute phase reactants. 2 most useful accute phase reactants are ESR & C-reactive protein, which should be measured weekly.
Streptococceal serology Streptococcal titres should be measured on 3 occasions at 2 weekly interval.
Multiple test are desirable which include.
Aso titre (>200 units in adult
>300 units in children
Anti - DNAse (>320)
Antilyaluroindase (>300

D/D
1. Still’s disease (Juvenice RA)
Accute arthrits = Hlo preceeding sorethroad
2. Henoch - Scholin purpura
3. A/c osteomyelitis
4. A/c leukemia
5. Streptococcal tonsilitis.
Treatment
Genaral Strict bed rest until the symptoms subside & accute phase reactants come to normal
Medicinal Amm.m, carb-s, kat s, Lac. c, puls, stellania, kalmia, Litrrium, Abrotanum, streptococcin etc.

CASE Study
Name : XXX
Address : NARIKUNY
Age/sex : 17 years Male
Date of Admission : 18th November
Religion : Hindu
Occupation : Student

Presenting complaints
1. Pain in all the joints (1 month)
stiching type of pain <Night damp, after exertion
Associated with weakness oedema, cold air, Night, high rise of temperature with chillness and bitter taste in mouth.
2. Pain in head (1 month)
Both temple stitching type of pain.
Associate with blurring of vision and lachrymation.
3. Pain in chest (1 month)
Central in position <on exertion.

History of Presenting Complaints
Complaints started when the patient was 14 yeras of age as fever & Sorethroat. Then he developed pain in rt ankle joint with swelling. Then gradually this pain & Swelling shifted to other joints. Then he took allopathic medicines with temperory relief. Then recurrance occur & he was under homoeopathic treatment for 2 yrs he was taken Kreosotum, Tuberculinum Rhus tox etc. Then 1 month back the complaints get aggravated after getting wet (pt has to stand in cold water for a longtime). Then he was admitted here on 18th Nov. ‘03 as fever, joint. pain and chill.

Past History No relevant history in the past.

Family History Father had rheumatic heart disease, diabetic mellitus and HTN. He died 2 years back as renal failure. Patient is the 2nd child. Brother had primary complex.
Personel history Born & brought up at Narikuny Studied up to 8th std. Stopped due to his complaints
Habits & Hobbies No habit of drinking / smoking/ chewing.
Life situation Low socio-economic status.

Treatment history Took allopathic treatment in the past. Under Homeopathic treatment for 2 years
Patient as a person Developmental landmarks – Normal
Physical characteristics Get complaints in damp wet weather

General modality
<Night, Exertion, Damp wet weather
Appetite : - (increased), irregular food habits
Prefers hot food. Desires :- Meat Chicken
Thirst (increased) prefers warm drinks
Sleep(decreased) due to his complains, Prefers to lie on his abdomen, Prefers covering.
Dreams :- Dream about his father
Bowels (R) Urine (N) Sweat(increased)
Mind Mild & timid in character Sensitive. H/o grief. Depressed after his father’s death

EXAMINATION
General Ill built & nourished Dark in complexion
No conjunctival pallor, No cyanesis, Not icteric.
No clubbing. No pedal oedema. No lymphadenopathy
Painless hard nodules present on lateral aspect of ritght knee joint.
BP –110/70 Tongue:- Moist & clear, Blackish
Pulse rate – 55/mt
Resp. rate- 17/mt
Temp: 38oC

SYSTEMIC EXAMINATION
CVS Pulse – 55/mt Normal rhythm, character & volume JVP is not raised
Inspection No deformities of chest No dilated veins & swelling can be seen No visible pulsations. Apex beat is not visible
Palpation No thrill or palpable impulses
Auscultation Normal heart sounds heard on all areas. No abnormal heart sounds

JOINT EXAMINATION
Inspection No redness or dialated vessels in any joints 2 nodular swellings present on lateral aspect of right new joint painless, non tender, hard non movable in charactor.
Palpation No tendernes No stiffnes all joints Normal movements possible in all joints.
CNS No abnormality detected
RESPIRATORY SYSTEM No abnormality detected
GIT No abnormality detected

ANALYSIS OF SYMPTOMS
Disease symptoms Patient symptoms
1. Pain in joints Desires warm drinks & food
2. Subcutaneous nodules Desires meat
3. Pain in head with bluring of vision Sweat increased
Thirst increased
Prefers to lie on abdomen
Desires covering
Mild disposition
History of Grief
Stitching type of pain
Evaluation

Mental general    Physical general       Common particular
Mildness          Desires warmth          pain in joint pain
Grief               Desires Meat                 joint <damp
Sensitive         Sweat increased         Headache <Night
Thirst ®­ed                                     blurring of vision
                      Desires covering      subcutaneous nodules
                                                 Stitching type of pain
MIASMATIC EXPRESSION
Psora Syptrilis Sycesis Tubercular
Sensitive Bone pain F/H heart disease Desires Meat
Mild <Night Subcutaneous H/o 1Ocomplex
Desires warmth Sweet ®­ed Nodules in brother
Desires covering <damp
Stitching type of pain
Blurring of vision <cold

LAB INVESTIGATION
Investigation
Blood – TC –7400cell/m DC – P60 L38 E21 ESR®95 mm/hr.
Urine
Albumin Nil
Sugar Nil
Pus cells 1-2/HPF
EP cell 2-5/HRF
20-11-03
Blood – ASO +VE (200Tu)

Prov. Diagnosis
Rheumatic fever

Differential diagnosis
1. Juvenile polyarthritis
2. Rheumatoid Arthritis
3. Septic arthritis
Diagnosis Rheumatic fever
Repertorisation

Rubrics- kent
1. Mind - Sensitive
2. Mind - Mildness
3. Mind - grief
4. Stomach - Desires - warm drinks
5. Stom - Desires - Meat
6. Ext. - pain - wandering
7. Ext. - pain - Night
8. Ext. - Arthritis nodosities
9. Head pain - blindness with

Management General - Bed rest
Medicinal
19/11/2003 R Pul 0/3 / 4d.
joint pain, fever with chillness
itter taste dysuria tem-102o F
20/11/2003
Temp - 99oF
pain >ed R Repeat
21/11/2003
>ion of Symptoms R -SL - 2d