Rheumatic fever is a preventable condition that disproportionately affects women and children in South Africa and other lower and middle-income countries in Africa, the East and the Pacific, prompting the national Department of Health, along with the Heart and Stroke Foundation South Africa (HSFSA) and the Children’s Heart Disease Research Unit (CHDRU) at the University of Cape Town to raise awareness in events like Rheumatic Fever Week.
Why the concern?
Rheumatic fever is an abnormal immune response to a common group of bacteria, group A streptococcus, which most of us know simply as the “strep bacteria” infection. These can cause a range of illnesses, including strep throat, scarlet fever or impetigo (skin sores).
Most people recover with no lingering effects, but for some – most commonly children of five years to 15 – the immune system gets confused when it reacts to the infection, causing a generalised inflammatory illness: acute rheumatic fever (ARF).
Symptoms of ARF are typically joint pain (especially in the knees, ankles, elbows and wrists), fever, fatigue, shortness of breath, skin rash and, occasionally, nodules (painless lumps) near joints and chorea (uncontrollable jerky movements). These usually set in within three weeks of a strep throat infection.
A single episode of ARF can be enough to damage the heart valves, causing rheumatic heart disease (RHD). And left untreated, RHD can lead to worsening valve damage, stroke, heart failure and even death.
“A sore throat can damage your heart,” says paediatric cardiologist Professor Liesl Zuhlke, director of the CHDRU.
What can you do?
The key is to prevent infection by strep bacteria, which means washing hands often, especially after coughing or sneezing and before preparing food. This is especially important for those at increased risk – children, especially in crowded conditions such as schools and daycare centres, and adults who spend time with them (mothers and caregivers).
You can’t catch rheumatic fever from those who have it (it’s not contagious – it’s an immune response, not an infection), but those with strep infection can spread the strep bacteria to others who may be susceptible, says Professor Pamela Naidoo, CEO of the HSFSA.
If you have symptoms of ARF (see above), get tested. Diagnosis is usually with a throat swab or blood test. Treatment is centered on managing symptoms with medicines to reduce pain, fever and general inflammation but, importantly, all patients should get antibiotics that treat group A strep infections, note the Centers for Disease Control.
“It’s vital that parents and caregivers do not take their child’s raised body temperature for granted,” says Prof Naidoo. “They should seek medical advice and not use remedies given or told to them by people they know versus a medical practitioner.”
It’s also essential to be alert for signs that ARF may have damaged the heart valves, causing rheumatic heart disease (RHD): shortness of breath, weakness and chest pain. With rheumatic heart disease, the valves become inflamed and, in time, scarred, narrowing or leaking, making it harder for the heart to work and leading to heart failure.
Dealing with RHD
Diagnosing RHD begins with being checked for a strep infection (that throat culture or blood test), and a physical exam, where your health provider listens for a heart murmur (caused by blood leaking around a damaged valve) or a heart rub (caused by inflamed heart tissues rubbing against each other).
Tests may then include an echocardiogram to check the chambers and valves of your heart; an electrocardiogram to check its electrical activity and detect abnormal rhythms; a chest X-ray to check your lungs and see if your heart is enlarged; and a cardiac MRI, to examine your heart valves and muscle.
Early treatment is crucial and will depend on how much damage has been done to your heart valves, says Prof Naidoo. It usually includes antibiotics that must be continued long term to prevent future strep infections which will worsen the condition, and anti-inflammatories to reduce inflammation and prevent further heart damage. In severe cases, it may include surgery to repair or replace a badly damaged valve.
A recent pan-African study led by University of Cape Town researchers and published in the Journal of the American Medical Association Cardiology identified a genetic susceptibility to RHD in black Africans, suggesting they are more at risk. It also warns that in spite of being preventable with antibiotics, RHD “remains rampant” in communities where there is overcrowding and poor access to healthcare.
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