Diagnosis

As rheumatic fever can cause so many different symptoms, a checklist known as the "Jones Criteria" is used to help diagnose it.

Your GP will use the Jones Criteria to check for the signs and symptoms strongly associated with rheumatic fever.

These are divided into:

• major signs and symptoms which you would usually expect to see in a case of rheumatic fever
• minor signs and symptoms which can sometimes occur in a case of rheumatic fever

The major signs and symptoms are:

• inflammation of the heart (carditis) which can cause symptoms such as Shortness of breath and chest pain
• pain and swelling ( arthritis ) affecting multiple joints
• jerky involuntary body movements and emotional outbursts ( Sydenham's chorea )
• a painless, non-itchy skin rash (erythema marginatum)
• bumps or lumps that develop underneath the skin (subcutaneous nodules)

The minor signs and symptoms are:

• joint pain, but less severe than arthritic joint pain
• a high temperature (fever), usually over 39C (102F)
• blood tests that show you have high levels of inflammation in your body
• an irregular heart rhythm

A confident diagnosis of rheumatic fever can usually be made if at least two major signs and symptoms are present, or there are two minor, and one or more othermajor, signs or symptoms.

Testing

While some of the signs and symptoms listed above can be assessed by a physical examination, others such as inflammation of the heart need to be tested. Tests used to diagnose rheumatic fever are outlined below.

Electrocardiogram (ECG)

You'll usually need to have an electrocardiogram (ECG) . During an ECG, a numberof small, sticky sensors called electrodes are attached to your arms, legs and chest. These are connected by wires to an ECG machine.

The ECG machine measures your heart's electrical activity, allowing your doctor to check for any abnormal heart rhythms. Heart inflammation is a common complication of rheumatic fever. It's important that any abnormal heart rhythms are detected early so that prompt treatment can be given.

Blood tests

A number of different blood tests may also be used to look for indications of rheumatic fever. These include:

• C-reactive protein (CRP) which tests the level of C reactive protein (CRP) in your blood. CRP is produced by the liver. If there's more CRP in the blood than usual, there's inflammation in the body.
• Antistreptolysin O titre (ASOT) this blood test looks for evidence of antibodies produced by the immune system in response to the streptococcal infection .
• Erythrocyte sedimentation rate (ESR) in an ESR test, a sample of your red blood cells is placed into a test tube of liquid.If the blood is "sticky" due to various substances produced during the immune response, the red blood cells will settle higher up the tube. If these substances aren't present, the blood cells will be lower down the tube.

Prophylaxy*

It is very important to treat the disease as quickly as possible, immediate initiation of therapy holds cardinal important in order to prevent heart damage.

It is important to also note that the treatment of this disease must persist even after the symptoms are gone and the patient feels better. After the rheumatic attack subsides, prophylactic treatment must be initiated, because the disease may repeat itself.

It is recommended to treat with antibiotics for a long time. Following the healing of the disease, antibiotic injections should be performed every 2-3 weeks over several months. Following this the injections are performed once a month.

Prophylactic medication must be followed for the 2-3 years following this disease without interruption. Following the subsequent 2-3 years, prophylactic treatment is usually only conducted during October-March.

Prognosis*

For patients under the age of 15 which have sustained heart damage, uninterrupted treatment is continued for up to 5 years, and is continued with interruptions until the age of 18-25.

If the patient suffers from other throat infections or other infections, bactericidal antibiotics must be immediately used until the patient is fully recovered.

Of special importance to the future of the patient is the removal of any particularly susceptible sites of infection, hence a tonsillectomy (removal of the tonsils) is necessary. Dental extractions, or other dental interventions must be conducted under the protection of antibiotics.

Depending on the intervention, the antibiotics must be used preventatively 2-3 days before the intervention, and must be continued for 5 up to 15 days after.

Children who suffer from persistent, repetitive angina (more than 2-3 times a year) must be especially protected from rheumatic attacks, hence they must undergo a blood test to check for antistreptolysin. Antistreptolysin levels must remain under 200, and if it is higher, a doctor must be immediately consulted.

This is an indication for concern, and a doctor will usually prescribe antibiotics prophylactically in order to avoid any rheumatic attacks.

It is very important for these children patients to live with a certain level of hygiene, in well-aerated environments, take up vigorous physical activities. In this way, the immune capacity of the organism is increased, and it can better defend itself from streptococcal infections.

The prognosis of the disease depends on the scale of damages sustained by the heart, and it is usually more unfavorable in children rather than adults. The younger the patients are, the more severe the heart damage that they sustain is.

The prognosis also depends on how often the disease repeats itself. The disease is most likely to repeat itself in the first 5 years following the initial attack, and will become less frequent after the age of 25.

*Sections provided by medical author Diana Hysi, MD.