Rheumatic Fever (RF) / Rheumatic Heart Disease (RHD) is a major public health problem. RF/RHD is the most common cardiovascular disease in children and young adults. It is both a biological and a social problem.

What is Rheumatic Heart Disease?
RHD is a condition in which permanent damage to heart valves are caused by RF. The heart valve is damaged by a disease process that generally begins with a sore throat caused by bacteria called streptococcus, and if untreated may eventually cause RF.

Why is Rheumatic Fever a concern?
Rheumatic Fever (RF) can damage body tissue by causing them to swell. More than half of the time, RF leads to scarring of the heart valves. This scarring can narrow the heart valve and make it harder for the valve to open or to close completely. In turn, heart has to work harder to pump blood to the rest of the body. This valve damage can lead to a condition call RHD, which, in time, can lead to congestive heart failure. RF can continue to cause new problems for as many as 40 or 50 years after initial infection.

What causes RHD?
Rheumatic Fever (RF) causes Rheumatic heart disease. RF is not an infection itself, but rather the result of untreated or inadequately treated infection caused by streptococcus. When the body senses the infection, it sends antibodies to fight it. Sometimes, these antibodies attack the tissues of joints or heart instead. When antibody attacks heart valves, it damages heart valves.

Who is at risk for RF?
It is most common among children aged 5 to 15, but adults may have this condition as well. Immuno-compromised people are also more likely to have RF. According to a study in Bangladesh, peak age period of the incidence of the disease was found in the age group of 11-12 years (34 percent) and majority (83.5 percent) of the cases belonged to the middle and poor classes. There was slightly higher incidence in male. In Bangladesh the prevalence of the disease was found to be 4 per 1000 children. RF is a systemic illness. However no history of sore throat can be obtained in about 30-50 per cent cases of rheumatic fever patients.

Signs and symptoms of RF
The symptoms of RF usually start about one to six weeks after streptococcal bacterial infection. The following are most common symptoms. However, the symptoms may vary person to person. The symptoms are joint inflammation, small nodules under the skin, red rash on the chest, back or stomach, stomach pain or loss of appetite, uncontrolled movement, weight loss, fever, shortness of breath, fatigue or feeling very tired. Joint inflammation includes swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees and ankles. The inflammation moves from one joint to another over several days. The symptoms of rheumatic fever may resemble other conditions or medical problems. Always consult a paediatrician for advice.

When to seek medical advice?
If a child (even adult) suffers from a sore throat along with a fever that lasts for more than 24 hours or a severe sore throat without cold symptoms and without much fever. It is especially if he/she has been close to someone with sore throat, consult a physician. Although most of the time sore throat does not lead to rheumatic fever, you can usually prevent RF by using antibiotics to treat sore throat. Also see your doctor if you have recently had a sore throat and high fever and you are experiencing difficulty breathing or chest pain.

Prevention
RF may be prevented by treating sore throat infections, or by identifying strep. infection and treating them quickly with appropriate antibiotics and not let it progress to reference.

Treatment
RF must be treated right away. If you have a sore throat that lasts longer than 3 days, or if you have a fever and headache along with your sore throat, you should see your doctor. If you do not have a sore throat but have a fever and a skin rash, this could also mean a strep. infection, and you should see the doctor. RF fever can result from an untreated strep. infection, so it is very important to treat the infection before it leads to a worse condition.

Lifestyle changes
If RF has led to rheumatic heart disease or damage to your heart valves, your doctor may recommend that you take antibiotic medicines continuously for many years. In any case, you should always tell your doctor or dentist about your history of RF before you have a surgical or dental procedure. Such procedures may cause bacteria to enter the bloodstream and infect your heart valves.

Medicines
If your doctor tells you that you have strep. infection, he or she will prescribe an antibiotic medicine. It is important that you take the medicine as the doctor tells you. Do not stop taking the medicine just because you start to feel better. Many people find that they feel better after a couple of days of therapy, so they stop taking their medicine. Even if your sore throat does not come back, without the antibiotics in your bloodstream, the streptococcal bacteria can still multiply and affect your heart and other organs.

Surgical procedures
In some patients, doctor may recommend surgery to repair or replace the damaged heart valve. Amongst RHD in Bangladesh, mitral stenosis (Stenotic valve) and mitral incompetence (Leaky valve) comprised the highest (35 percent) incidence and next to it was the mitral stenosis (13 percent) and mitral incompetence (9 percent). Aortic valve is also involved in minority of cases.

Dr Md Habibe Millat, MBBS, FRCS(Edin) is Senior Specialist Registrar of Department of Cardiothoracic Surgery, Cork University Hospital, Ireland.