Rheumatism or acute rheumatic fever in children and adults is characterized by an inflammatory reaction in the connective tissue. As a rule, the heart or vascular system is most often affected. In this condition, the patient's body temperature rises, multiple symmetrical pains in the movable joints occur, and polyarthritis develops. Only a doctor can confirm the diagnosis and choose the appropriate treatment based on the results of examinations.

With untimely detection of rheumatic fever, acute courses are formed on the skin, heart valves are damaged and other complications appear.

Etiology and pathogenesis

Acute and chronic rheumatic fever is caused by the activity of beta-hemolytic streptococci belonging to group A. The etiology of the disease highlights such negative factors that affect the development of pathology:

• Streptococcal infectious disease of acute or chronic course.
• Tonsillitis.
• Unfavorable living and working conditions.
• Seasonal weather changes.
• Age features. In children of 7-15 years of age, boys and women, rheumatic disease is observed more often than in other people.
• genetic predisposition.

The pathogenesis of acute rheumatic fever is quite complex and goes through several stages:

• mucoid swelling;
• fibrinoid changes;
• granulomatosis;
• sclerosis.

The formation of granulomas occurs in the third stage of the disease.

At the initial stage, the connective tissue swells, increases in size, and collagen fibers are split. Without treatment, the disease leads to fibrioid changes, as a result of which necrosis of fibers and cell elements is noted. In the third stage, rheumatoid arthritis provokes the appearance of rheumatic granulomas. The last stage is sclerosis with a granulomatous inflammatory reaction.

Classification

Acute rheumatic fever is divided into different forms and types, which depend on many indicators. When dividing the disease into types, the criteria for the activity of pathogens, the severity of the disease, and other parameters are taken into account. The table shows the main types of violation:

Classification	View	Peculiarities
By phase	Active	Passes with minimal, moderate or high activity
	Inactive	Clinical and laboratory manifestations are absent
With the flow	Spicy	Sudden onset of acute rheumatic fever with severe symptoms
		The activity of the pathological process of a high degree
	Subacute	Attack lasts 3 to 6 months
		The clinical picture is less pronounced than in acute
	Protracted	Leaks long and can last more than 6 months
		Dynamics and activity are weak
	Latent	Clinical laboratory and instrumental manifestations are not detected
	recurrent	Undulating course with bright exacerbations and short stages of remission
According to clinical and anatomical manifestations	With involvement of the heart	Progressive myocardiosclerosis and rheumatic heart disease
	With damage to other internal organs	The function of blood vessels, lungs, kidneys, subcutaneous structures is impaired

When a repeated fever occurs, the internal organs are significantly damaged, and irreversible processes occur.

Characteristic symptoms

The disease is characterized by inflammation in the membranes of the heart.

In adults and children, acute rheumatic fever is manifested by different clinical signs. It is possible to detect a violation by the following symptoms:

• a sharp and unexpected increase in body temperature;
• symmetrical pain syndrome in the knee, shoulder, elbows and other parts of the body;
• swelling and redness in the tissues near the inflamed joints;
• inflammatory response in the components of the heart.

Pediatrics notes that in adolescent children, the disease manifests itself less acutely than in younger patients. The clinical picture differs depending on the form of acute rheumatic fever:

• Primary. Mostly, signs appear 21 days after infection with streptococci. The patient has a fever, increased sweat production, and a chilly feeling.
• Joint syndrome. It is characterized by swelling, pain in the damaged joint, which worries during exercise and at rest. As a rule, large symmetrical joints are damaged.
• Carditis. It proceeds with pain attacks in the zone of the heart, the heartbeat quickens, shortness of breath occurs even after minor physical activity.
• Rheumatic knots. Small balls are formed above the bone protrusions, which are more typical for children and pass on their own after 21-28 days.
• Annular erythema. The form of acute rheumatic fever is rare, and is characterized by pathological rashes on the skin. Pink spots are arranged in the form of a ring and soon disappear on their own.
• Rheumatic chorea. The nervous system is affected, because of which the muscles twitch in a person, speech becomes slurred and handwriting changes.

How is the diagnosis carried out?

To make a diagnosis, the patient must pass a smear from the oral cavity.

It is sometimes difficult for doctors to identify acute rheumatic fever because the pathological signs are similar to those of other diseases. The examinations take into account different diagnostic criteria. To confirm the diagnosis, a comprehensive diagnosis is required, including such instrumental and laboratory studies as:

• echocardiogram using Doppler mode;
• an electrocardiogram that determines whether there are pathologies of contraction of the muscles of the heart;
• general blood test;
• analysis for antibodies against streptococcus;
• bacteriological smear from the oral cavity to determine the hemolytic streptococcal agent.

Equally important is the differential diagnosis, which makes it possible to distinguish the manifestations of acute rheumatic fever from the symptoms that occur with arthritis and other joint disorders. The doctor must differentiate the deviation from such pathologies:

• mitral valve prolapse;
• endocarditis;
• viral inflammation of the heart tissue;
• benign tumor in the atrium.

How to treat acute rheumatic fever?

Medical treatment

Clarithromycin may be prescribed to treat the disease.

Complex therapy includes the use of drugs for acute rheumatic fever. The main groups of medicines:

• Antibiotics of the penicillin group. Used to eliminate the root cause of the disease. To achieve the result, you need to take funds for at least 10 days.
• Macrolides or lincosamides. Prescribed in case of allergy to penicillin. Roxithromycin or Clarithromycin is often used.
• Hormonal drugs or non-steroidal anti-inflammatory drugs. Required with a bright manifestation of carditis or serositis. Predominantly used "Prednisolone" until the elimination of pathological manifestations.

And also treatment includes the use of other means:

• "Diclofenac";
• "Digoxin";
• "Nandrolone";
• "Asparkam";
• "Inosine".

If during acute rheumatic fever there are disturbances in the work of the heart, then drugs for arrhythmia, nitrates, diuretic drugs are prescribed.

The manual provides information on epidemiology, the clinical picture of the main rheumatic diseases, the criteria for their diagnosis, differential diagnosis, emergency care and treatment, and prevention. Modern views on the etiology, pathogenesis, classification of major rheumatic diseases are reflected. In preparing this manual, materials from the latest scientific and scientific-practical conferences and symposiums, as well as standards and recommendations of the Ministry of Health of the Russian Federation, the Russian Society of Cardiology, the World Health Organization, etc. were used. The manual is intended for interns, residents and doctors studying in the system additional professional education in the specialties: therapy, rheumatology, general medical practice (family medicine).

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The following excerpt from the book Clinic, diagnosis and treatment of major rheumatic diseases (D. I. Trukhan, 2014) provided by our book partner - the company LitRes.

RHEUMATISM. ACUTE rheumatic fever

Definition. long time under rheumatism all diseases were understood in which the organs of support and movement suffered: joints, muscles, soft tissues, etc. In recent decades, instead of the term "rheumatism", the phrase "rheumatic diseases" has been used in this sense.

Another meaning of the term rheumatism"- an independent disease that is associated with streptococcal infection, with damage to the joints, heart, nervous system and other organs. However, in modern medical literature, the use of the term "rheumatism" in this sense has been superseded by the worldwide accepted term "acute rheumatic fever".

Acute rheumatic fever(ARF) is a post-infectious complication of tonsillitis (tonsillitis) or pharyngitis caused by group A beta-hemolytic streptococcus. ARF manifests itself as a systemic inflammatory disease of the connective tissue with a predominant lesion of the cardiovascular system (CVS) (carditis), joints (migratory polyarthritis), central nervous system (CNS) (chorea) and skin (erythema annulare, rheumatic nodules) and develops in predisposed individuals (mainly aged 7–15 years) due to the autoimmune response of the macroorganism to group A streptococcus antigens and cross-reactivity of antibodies (AT ) with similar human tissue autoantigens (phenomenon of molecular mimicry). In ICD-10 corresponds to headings I00 - I02 "Acute rheumatic fever".

Chronic rheumatic heart disease(CRHD) is a disease characterized by damage to the heart valves in the form of marginal fibrosis of the valvular leaflets or heart disease (failure and/or stenosis) formed after ARF. In ICD-10 corresponds to headings I05 - I09 "Chronic rheumatic heart disease".

Epidemiology. The incidence of ARF in Russia is 2.7 cases per 100 thousand of the population, CRHD - 9.7 cases (including rheumatic heart disease - 7.64 cases). The prevalence of CRHD in children reaches 45 cases per 100 thousand of the population, and in adults - 260 cases. Males and females get sick with the same frequency, mainly at the age of 7-15 years.

Physicians' alertness to possible outbreaks of ARF should be constant due to the non-decreasing rates of the primary incidence of CRHD. The vast majority in this category are patients with acquired rheumatic heart disease. By the end of the last decade of the last century, 2.5 thousand more patients with CRHD were diagnosed annually in Russia than at the beginning of registration (1994).

Causes that predispose to possible ARF outbreaks include:

- insufficient treatment of patients with tonsillitis and pharyngitis streptococcal etiology;

- insufficient knowledge of the clinical symptoms of the acute phase of the disease due to the fact that it is rare at present;

- weakening of doctors' alertness in relation to this disease;

- incomplete examination of patients with suspected rheumatic fever;

- change in the virulence of "rheumatogenic" streptococcus.

Etiology. Acute rheumatic fever develops after diseases caused by "rheumatogenic" strains of beta-hemolytic streptococcus (M1, M3, M5, M18, M24), which have high contagiousness, tropism to the nasopharynx, induction of type-specific antibodies. "Rheumatogenic" streptococci contain epitopes that can cross-react with various tissues of the host macroorganism: myosin and sarcolemmal membrane, synovium and brain, i.e., those structures that are involved in the pathological process in ARF.

genetic factors. In families of patients with ARF and CRHD, the propensity for a hyperimmune antistreptococcal response and the prevalence of the disease and rheumatic heart disease are higher than in the general population, especially among family members of the first degree of kinship.

Pathogenesis. In the complex pathogenesis of the development of classical manifestations of ARF, the greatest importance is attached to immune inflammation, immunopathological processes in which streptococcal antigens and antibodies are actively involved, however, the toxic concept also contributes to understanding the initial manifestations of ARF. Thus, the development of ARF is determined by:

- direct toxic damage to the myocardium by "cardiotropic" enzymes of group A beta-hemolytic streptococcus;

- an immune response to arterial hypertension (AH) of group A beta-hemolytic streptococcus, leading to the synthesis of anti-streptococcal antibodies (AT), cross-reacting with antibodies of the affected human tissues (the phenomenon of molecular mimicry).

Pathomorphology. There are four stages of the pathological process in the connective tissue: mucoid swelling, fibroid changes, proliferative reactions, sclerosis. Proliferative reactions are accompanied by the formation of rheumatic granuloma (Ashoff-Talalaev).

Classification.

Clinical forms:

- recurrent rheumatic fever.

Outcomes:

- recovery.

without heart disease;

with heart disease.

Circulatory failure:

- according to the classification of N. D. Strazhesko and V. Kh. Vasilenko (stages 0, I, IIA, IIB, III);

- according to the classification of the New York Heart Association (functional classes 0, I, II, III, IV).

Clinic. Regarding rheumatism, the French doctor E.Sh. Lasegue figuratively expressed himself: “Rheumatism licks the joints, the pleura and even the meninges, but it bites the heart painfully.” The meaning of this statement is that the damage to the joints, pleura and membranes of the brain, although it can manifest itself very clearly, does not have long-term consequences. Damage to the heart, although it can go unnoticed at the beginning of the disease, but leads to the formation of heart defects - disruption of its valves, which have serious complications and significantly worsen the prognosis.

Clinical manifestations of ARF:

- main: carditis, arthritis, chorea, erythema annulare, rheumatic nodules;

- additional: fever, arthralgia, abdominal syndrome, serositis.

At the onset, the clinical picture of the disease depends on the age of the patients. After 2 - 3 weeks. after a sore throat in most children, the disease begins with a sudden rise in temperature to febrile numbers, the appearance of symmetrical migrating pains in large joints (most often knees) and signs of carditis (pain in the left side of the chest, shortness of breath, palpitations, etc.). In the rest of the children, a monosyndromic course is observed with a predominance of signs of arthritis or carditis, rarely chorea.

Acutely, according to the type of outbreak, ARF develops in middle-aged schoolchildren and recruit soldiers who have suffered epidemic tonsillitis caused by group A beta-hemolytic streptococcus.

Adolescents and young people are characterized by a gradual onset - after the clinical manifestations of angina subside, subfebrile temperature, arthralgia in large joints, or only moderate signs of carditis appear.

A recurrent attack of ARF is provoked by an infection caused by group A beta-hemolytic streptococcus and is manifested mainly by the development of carditis.

Objective examination. The temperature reaction varies from subfebrile condition to fever.

Skin examination. The main features of ARF are erythema annulare and subcutaneous rheumatic nodules.

erythema annulare- pale pink ring-shaped rashes (from a few millimeters to 5-10 cm in diameter) on the trunk and proximal extremities, but not on the face, not accompanied by itching, not rising above the skin surface, leaving no traces; characteristic, but rare (4-17% of all cases of ARF) symptom.

Subcutaneous rheumatic nodules- rounded, dense, inactive, painless, small nodules located at the places of attachment of tendons in the area of ​​the knee, ankle, elbow joints or occipital bone; characteristic, but extremely rare (1-3% of all cases of ARF) symptom.

Despite a significant decrease in the frequency of erythema annulare and rheumatic nodules in sick children and their actual absence in adolescents and adult patients, the specificity of these syndromes in ARF remains high, and they retain their diagnostic significance.

Joint examination. In ARF, the articular syndrome is characterized by:

- involvement in the pathological process mainly of the knee, ankle, wrist, elbow joints;

- benign (deformities do not develop), volatility of clinical manifestations, variable, often symmetrical involvement of the joints;

- the predominant form of the lesion is oligoarthritis, less often - monoarthritis;

- polyarthralgia (migratory pain in large joints of varying intensity) are observed in 10-15% of cases, are not accompanied by restriction of movements, pain on palpation and other symptoms of inflammation;

- rapid resolution of articular syndrome while taking non-steroidal anti-inflammatory drugs (NSAIDs).

Study of the cardiovascular system. Carditis- the leading ARF syndrome, which is detected in 90-95% of cases and determines the severity of the course of the disease and its outcome. The leading component of carditis is considered to be valvulitis (mainly of the mitral valve, less often of the aortic valve), which manifests itself as an organic heart murmur, possibly in combination with myocarditis and pericarditis.

Auscultatory symptoms of rheumatic valvulitis

1. Systolic murmur due to mitral regurgitation. It is optimally auscultated at the apex of the heart and carried into the left axillary region. By its nature, a long blowing one is associated with the I tone and occupies most of the systole. It has a different intensity, especially in the early stages of the disease. It does not depend on the position of the body and the phase of breathing.

2. Mesodiastolic murmur(low-frequency) is heard at the apex of the heart in the position of the patient on the left side while holding the breath on exhalation (in the presence of acute carditis with mitral regurgitation). Noise often follows the third tone or drowns it out.

3. Protodiastolic murmur occurs with aortic regurgitation, begins immediately after the second tone, often combined with systolic murmur and has a high-frequency blowing decreasing character. Noise is best heard along the left edge of the sternum after a deep exhalation when the patient is tilted forward.

ARF is not characterized by isolated aortic valve disease, without mitral regurgitation murmur. Heart damage by the type of myocarditis and pericarditis in the absence of valvulitis is considered unlikely in ARF and is an indication for a thorough differential diagnosis with carditis of a different etiology (primarily viral).

The most important feature of valvulitis during the first attack of ARF is a clear positive dynamics under the influence of active antirheumatic therapy. In the vast majority of cases, during treatment, the heart rate is normalized, the sonority of tones is restored, the intensity of systolic and diastolic murmurs decreases, the borders of the heart contract, and the symptoms of circulatory failure disappear.

CNS examination. On examination, they reveal signs of a small chorea(in 6 - 30% of cases): hyperkinesis, muscle hypotension (up to muscle flabbiness with imitation of paralysis), static and coordination disorders, vascular dystonia, psycho-emotional disorders (mood instability, irritability, tearfulness, etc.). Rheumatic chorea (chorea minor, Sydenham's chorea) is diagnosed in 6-30% of sick children and rarely in adolescents. Such lesions are more often observed in girls and girls. In 5-7% of patients, chorea may be the only sign of ARF.

Serous membrane lesions at present, they are rare, only with a severe course of the first attack and / or recurrent rheumatic fever, and are manifested mainly by an abdominal syndrome of varying intensity with rapid regression against the background of anti-inflammatory therapy.

Complications. The outcome of endocarditis is the formation of rheumatic heart disease. The frequency of their development after the first attack of ARF in children is 20-25%. Isolated defects predominate, more often mitral insufficiency. Less often, aortic valve insufficiency, mitral stenosis, and combined defect of the mitral and aortic valves are formed. Approximately 7-10% of children after rheumatic heart disease develop mitral valve prolapse (MVP).

In adolescents who have had the first attack of ARF, heart defects are diagnosed in 30% of cases. In adult patients, this figure reaches 45% of cases.

The maximum incidence of rheumatic heart disease (75%) is observed during the first 3 years of the disease. Repeated attacks of ARF, as a rule, exacerbate the severity of valvular pathology of the heart.

Features of the course of rheumatic fever:

- clinical polymorphism (a variety of forms and variants of the course);

- blurring of clinical and laboratory symptoms (especially in adult patients);

- often occurring latent course, without a bright clinical manifestation;

- rarely noted high activity of the course of the process, more common polyarthralgia, no polyserositis, rheumatic nodules, annular erythema;

- the predominance of neurorheumatism (chorea);

- the predominance of the productive component of inflammation;

- a more favorable course of the first attack of rheumatism (less often ends with the formation of heart disease).

Diagnostics. Laboratory research. The mandatory methods of laboratory research include:

- complete blood count: increased erythrocyte sedimentation rate (ESR) and positive C-reactive protein (CRP);

- bacteriological examination: detection of group A beta-hemolytic streptococcus in a throat swab (it can be both with active infection and with carriage);

- determination of the content of antistreptolysin-O, antihyaluronidase and antideoxyribonuclease B: increased or increasing titers in dynamics.

Additional research methods may be required for differential diagnosis and depend on the specific clinical situation. ( rheumatoid factor (RF), antinuclear antibodies - negative ) .

Instrumental research methods. Mandatory methods include:

- electrocardiography (ECG) to clarify the nature of cardiac rhythm and conduction disorders (with concomitant myocarditis);

- echocardiography (EchoCG) for the diagnosis of pathology of the heart valves and the detection of pericarditis.

The diagnosis of ARF should be considered in cases of fever, carditis and/or articular syndrome after 2 to 3 weeks. after angina of streptococcal etiology. To confirm the diagnosis, you should:

- complete blood count (increased ESR);

– ECG (lengthening of the interval P-Q);

- EchoCG (signs of valve damage);

- bacteriological examination of a throat swab (detection of streptococcus) or determination of the content of antistreptococcal antibodies (titers increased).

When diagnosing ARF, the syndromic principle is used, formulated by the domestic pediatrician A. A. Kisel (1940), who singled out five signs of the disease as diagnostic criteria: carditis, migratory polyarthritis, chorea, erythema annulare, rheumatic nodules, while drawing attention to the importance of their combination .

The American cardiologist T.D. Jones (1944) classified these signs as "large" diagnostic criteria, highlighting additionally "small" clinical and laboratory parameters.

Currently, the Kisel-Jones criteria, revised by the American Heart Association in 1992 and modified by the Russian Association of Rheumatologists in 2003, are used to diagnose ARF (Table 1).

The presence of two major criteria or one major and two minor criteria, combined with evidence of a previous infection with group A streptococci, indicates a high likelihood of ARF.

Examples of clinical diagnosis:

– ARF: carditis (mitral valvulitis), migratory polyarthritis. Circulatory insufficiency (NC) I functional class (FC), corresponds to I01.1 according to ICD-10;

- recurrent rheumatic fever: carditis. Combined mitral heart disease. NK IIA (FC II), corresponds to the heading I01.9 according to ICD-10;

– CRHD: combined mitral-aortic heart disease. NK IIB (FC III), corresponds to the heading I08.0 according to ICD-10.

Table 1

Diagnostic criteria for ARF

disease activity. When determining disease activity, a combination of clinical and laboratory parameters is used.

I degree of activity characterized by monosyndromicity (unexpressed carditis or chorea). Laboratory parameters correspond to the norm or changed slightly.

II degree of activity is determined by the predominance of moderately pronounced symptoms of heart damage in combination with subfebrile body temperature, polyarthralgia or mono-, oligoarthritis, chorea is possible, the ESR value is in the range of 20-40 mm / h. Marked moderate leukocytosis and increased titers of antistreptococcal antibodies.

III degree of activity characterized by fever, acute polyarthritis, myocarditis, high titers of antistreptococcal antibodies, possible pancarditis, serositis, neutrophilic leukocytosis, an increase in ESR above 40 mm/h.

differential diagnosis. The presence of only one of the main criteria for ARF (carditis, arthritis, chorea) dictates the need to exclude other diseases.

Differential diagnosis of rheumatic carditis. The list of nosological forms included in the algorithm for the differential diagnosis of rheumatic carditis is quite wide:

– infective endocarditis (IE);

- non-rheumatic myocarditis;

- idiopathic MVP;

- cardiopsychoneurosis;

- cardiomyopathy;

- myxoma of the heart;

- primary antiphospholipid syndrome (APLS);

- nonspecific aortoarteritis;

- systemic lupus erythematosus (SLE).

Rheumatic carditis is characterized by:

- chronological relationship with A-streptococcal infection of the pharynx (pharyngitis, tonsillitis);

- latent period - 2 - 4 weeks;

- young age of the patient;

- mostly acute or subacute onset;

- polyarthritis or acute arthralgia at the onset of the disease;

- "passive" nature of cardiac complaints;

- the presence of valvulitis in combination with myocarditis or pericarditis;

- high mobility of symptoms of carditis;

– correlation of laboratory and clinical signs of disease activity.

Differential diagnosis of rheumatic fever. The strongholds in the differential diagnosis of rheumatic polyarthritis (before the onset of symptoms of carditis) with other diseases are the short duration and volatility of lesions of predominantly large and medium joints, with a rapid response to anti-inflammatory therapy and complete regression of inflammatory changes. Rheumatic arthritis is differentiated from the following diseases:

- reactive arthritis (ReA);

– rheumatoid arthritis (RA) and juvenile RA;

- Still's syndrome;

- ankylosing spondylitis;

- hemorrhagic vasculitis.

(See relevant sections of the tutorial for details.)

Post-streptococcal arthritis can occur in middle-aged people, develops after a relatively short (2-4 days) latent period from the moment of infection of the pharynx with group A hemolytic streptococcus, persists for a long time (about 2 months), proceeds without carditis, does not respond optimally to therapy NSAIDs and completely regresses without residual changes.

Differential diagnosis of chorea minor. The main difficulties in the differential diagnosis of chorea minor are associated with situations where it appears as the only criterion for ARF. Differential diagnosis is carried out together with a neurologist.

Differential diagnosis of childhood autoimmune neuropsychiatric disorders, associated with infections caused by group A streptococcus. At the end of the 20th century. describes a specific syndrome, abbreviated as PANDAS ( P editorial A utoimmune N europsychiatric D isorders A associated with group A S treptococcal infections). Unlike classical rheumatic chorea, it is characterized by pronounced psychiatric disorders - obsessive-compulsive disorders (combination of obsessive thoughts and obsessive movements), rapid relief of neuropsychiatric symptoms only with adequate antistreptococcal therapy.

Treatment. Objectives: eradication of group A beta-hemolytic streptococcus, relief of the inflammatory process, prevention of the formation of rheumatic heart disease in patients with carditis, compensation of heart failure in patients with rheumatic heart disease.

Non-drug therapy includes adherence to bed rest for 2-3 weeks, a diet rich in vitamins and protein (at least 1 g per 1 kg of body weight), with restriction of salt and carbohydrates.

Physiotherapy treatment not shown.

Etiotropic therapy. Antibacterial therapy. Benzylpenicillin is used for 10 days in adults and adolescents at a dose of 0.5 - 1.0 million IU 4 times / day / m, in children - at a dose of 100 - 150 thousand IU 4 times / day / m. In the future, long-acting penicillins are used in the secondary prophylaxis regimen. In case of intolerance to penicillins, macrolides or lincosamides are indicated (for details, see the section "Prevention").

pathogenic therapy. Anti-inflammatory therapy. Glucocorticosteroids(GCS) is used for ARF occurring with severe carditis and / or polyserositis. Prednisolone is prescribed for adults and adolescents at a dose of 20 mg / day, for children - at a dose of 0.7 - 0.8 mg / kg in 1 dose in the morning after meals until a therapeutic effect is achieved (on average, within 2 weeks). Then the dose is gradually reduced (by 2.5 mg every 5 to 7 days) until complete withdrawal. The total duration of the course is 1.5 - 2.0 months.

NSAIDs is prescribed for mild valvulitis, rheumatoid arthritis without valvulitis, minimal process activity (ESR less than 30 mm / h), after high activity subsides and GCS is canceled, with repeated ARF against the background of rheumatic heart disease.

Diclofenac sodium appoint adults and adolescents at a dose of 25 - 50 mg 3 times / day, children - at a dose of 0.7 - 1.0 mg / kg 3 times / day until normalization of inflammatory activity (on average, within 1.5 - 2.0 months). If necessary, the course of treatment with diclofenac can be extended up to 3-5 months.

With polyarthritis (polyarthralgia), an additional appointment of NSAIDs for external use is possible. The drug of choice is 5% ibuprofen cream or gel, registered in the Russian Federation under the trade name long.

With chorea that occurs without other symptoms of ARF, the use of corticosteroids and NSAIDs is practically ineffective. The appointment of psychotropic drugs is shown: neuroleptics (chlorpromazine 0.01 g / day) or tranquilizers from the benzodiazepine group (diazepam - 0.006 - 0.010 g / day). With severe hyperkinesis, a combination of these drugs with anticonvulsants (carbamazepine - 0.6 g / day) is possible.

Treatment of heart failure. Approaches to the treatment of congestive heart failure in patients with ARF and rheumatic heart disease have a number of features. In particular, with the development of heart failure as a result of acute valvulitis (more often in children), the use of cardiotonic drugs is not advisable, since in these cases a clear therapeutic effect can be achieved using high doses of prednisolone (40-60 mg / day). At the same time, in patients with rheumatic heart disease in heart failure and without obvious signs of carditis, the appointment of GCS is not justified due to the aggravation of myocardial dystrophy.

The main groups of drugs used in the treatment of heart failure in patients with ARF and rheumatic heart disease:

- diuretics: loop (furosemide), thiazide (hydrochlorothiazide), thiazide-like (indap), potassium-sparing (spironolactone, triamterene);

- blockers of slow calcium channels from the group of long-acting dihydropyridines (amlodipine, felodipine);

- beta-blockers (carvedilol, bisoprolol, metoprolol);

- cardiac glycosides (digoxin).

Doses and regimens for the use of drugs are similar to doses and regimens for the treatment of congestive heart failure of a different etiology.

When choosing drugs used to treat heart failure in patients with carditis associated with rheumatic heart disease, their possible interaction with anti-inflammatory drugs should be taken into account. The question of the advisability of using angiotensin-converting enzyme (ACE) inhibitors in patients with rheumatic heart disease against the background of rheumatic heart disease requires further study, since the combined use of NSAIDs and ACE inhibitors can lead to a weakening of the vasodilating effect of the latter.

Surgery. Indications for surgical treatment of patients with rheumatic heart disease are pronounced clinical manifestations of heart disease or its complications (heart failure III-IV FC according to the classification of the New York Heart Association, pulmonary hypertension, left ventricular systolic dysfunction, angina pectoris, atrial fibrillation, etc.). The nature of the surgical intervention (commissurotomy, valve replacement) depends on the morphology of valvular changes and the patient's condition.

Employability examination. Approximate terms of temporary disability in ARF without heart damage are 20-40 days, in ARF with carditis, polyarthralgia - up to 30-45 days, in ARF with fever, severe carditis with heart failure, polyserositis - up to 60-95 days, with CRHD with damage to the valvular apparatus and the presence of chronic heart failure - up to 70 - 80 days. In the future, a medical and social examination (MSE) is carried out.

Forecast. There is virtually no immediate life-threatening condition associated with ARF (with the exception of the extremely rare cases of pancarditis in childhood). Basically, the prognosis depends on the state of the cardiovascular system (the presence and severity of the defect, the severity of heart failure). The timing of the start of therapy is very important, since with late treatment (as well as in its absence), the likelihood of developing rheumatic heart defects increases dramatically.

Prevention. A vaccine is being developed that contains epitopes of the M-protein of "rheumatogenic" strains of group A beta-hemolytic streptococcus that do not cross-react with human antigens.

Measures aimed at increasing the level of natural immunity and adaptive capabilities of the body in relation to adverse environmental conditions are of particular importance. These include:

- early hardening;

- a complete fortified diet;

– maximum use of fresh air;

– rational physical culture and sports;

– prevention of crowding in dwellings, preschool institutions, schools, colleges, universities, public institutions;

- a set of sanitary and hygienic measures that reduce the possibility of streptococcal infection of groups, especially children. Currently, the basis of primary prevention is antibiotic therapy for acute and chronic recurrent infections of the upper respiratory tract (tonsillitis and pharyngitis) caused by group A beta-hemolytic streptococcus. Beta-lactam antibiotics are considered the drugs of choice.

used intramuscularly once. In adults and children over 12 years old, the dose is 2.4 million units, in children weighing more than 25 kg - 1.2 million units, in children weighing less than 25 kg - 600 thousand units. Situations when it is advisable to prescribe drugs:

- questionable patient adherence to oral antibiotics;

- the presence of ARF in the anamnesis of the patient or close relatives;

- unfavorable social and living conditions;

- outbreaks of infection caused by group A beta-hemolytic streptococcus in preschool institutions, schools, boarding schools, colleges, military units.

Amoxicillin administered orally for 10 days for adults at a dose of 0.5 g 3 times / day, for children - at a dose of 0.25 g 3 times / day.

Phenoxymethylpenicillin inside 1 hour before meals for 10 days. In adults, the dose is 0.5 g 3 times / day, in children weighing up to 25 kg - 0.125 g 3 times / day, in children weighing more than 25 kg - 0.25 g 3 times / day. Given the presence of a dosage form in the form of a suspension, phenoxymethylpenicillin is recommended mainly for young children.

- azithromycin inside 1 hour before meals for 5 days. In adults, the dose of the drug is 0.5 g on the first day, then 0.25 g / day, in children - 12 mg / kg / day.

- other macrolides for 10 days: clarithromycin, midecamycin, roxithromycin, spiramycin, erythromycin. Erythromycin is characterized by the most frequent, compared with other macrolides, the development of adverse reactions, especially from the gastrointestinal tract (GIT).

Reserve preparations (for intolerance to beta-lactams and macrolides):

- lincomycin inside 1-2 hours before meals for 10 days for adults at a dose of 0.5 g 3 times / day, for children at a daily dose of 30 mg / kg in 3 doses;

- clindamycin inside for 10 days for adults at a dose of 0.15 g 4 times / day, for children at a daily dose of 20 mg / kg in 3 divided doses.

Antimicrobial therapy of chronic recurrent tonsillitis (pharyngitis) caused by group A beta-hemolytic streptococcus includes the use of amoxicillin + clavulanic acid (oral for 10 days for adults at a dose of 0.625 g 3 times / day, for children - at a daily dose of 40 mg / kg in 3 reception) or cefuroxime (orally for 10 days for adults at a dose of 0.5 g 2 times / day, for children - at a daily dose of 20 mg / kg in 2 doses).

secondary prevention. The goal of secondary prevention in ARF patients is to prevent recurrent attacks and disease progression. Secondary prevention begins in the hospital immediately after the end of etiotropic antistreptococcal therapy.

The duration of secondary prevention for each patient is set individually and is determined by the presence of risk factors for recurrent ARF attacks in accordance with the recommendations of the World Health Organization (WHO). These factors include:

- age of the patient;

- the presence of HRPS;

– the time elapsed after the first attack of the ORL;

– the number of previous attacks;

- family history, aggravated ARF or CRHD;

- socio-economic and educational status of the patient;

– increased risk of streptococcal infection in the region;

- the profession and place of work of the patient (school teachers, doctors, people working in crowded conditions).

As a rule, the duration of secondary prevention should be:

- for people who have had ARF without carditis (with arthritis, chorea) - at least 5 years after the last attack or up to 18 years of age (according to the principle "whichever is longer");

- for persons who have cured carditis without the formation of heart disease - at least 10 years after the last attack or up to 25 years of age (according to the principle "which is longer");

- for patients with heart disease, including after surgical treatment - for life.

Benzathine benzylpenicillin (extencillin)- the main drug used for the secondary prevention of ARF. The drug is used in / m 1 time in 3 weeks. (21 days) in adults and adolescents at a dose of 2.4 million units, in children weighing less than 25 kg - at a dose of 600,000 units, in children weighing more than 25 kg - at a dose of 1.2 million units. Studies conducted at the Institute of Rheumatology of the Russian Academy of Medical Sciences and the State Scientific Center for Antibiotics have shown that this drug (extencillin) has clear pharmacokinetic advantages compared to bicillin-5 in terms of the main parameter - the duration of maintaining an adequate antistreptococcal concentration of benzylpenicillin in the blood of patients. Currently, bicillin-5 (a mixture of 1.2 million units of benzathine benzylpenicillin and 300 thousand units of benzylpenicillin procaine) is considered as not meeting the pharmacokinetic requirements for preventive drugs, and is not considered acceptable for full-fledged secondary prevention of ARF.

According to the international classification of diseases, acute rheumatic fever (ARF) is a systemic connective tissue disease with a predominant localization of the process in the cardiovascular system, which develops in connection with acute A-streptococcal infection in persons predisposed to it, mainly at the age of 7–15 years.

Chronic rheumatic heart disease is a disease characterized by damage to the heart valves in the form of post-inflammatory marginal fibrosis of the valvular leaflets or heart disease (failure and/or stenosis) formed after ARF.

Epidemiology

Acute rheumatic fever occurs all over the world. research in the second half of the twentieth century. the relationship between the primary incidence of ARF and the socio-economic development of the country has been proven. According to WHO (1989), the prevalence of ARF among children in different countries of the world is 0.3-18.6 per 1000 school-age children. In recent years, the frequency of ARF in the world has been declining.

In our country, the prevalence of ARF has been clearly decreasing over the past 25 years. Currently, it remains in the range of 0.2-0.8 per 1000 children. However, despite significant advances in the treatment and prevention of ARF, this problem has not yet been completely resolved and remains relevant.

According to the Ministry of Health of the Russian Federation, in 1994 (compared to 1993) there was an increase in the primary incidence of ARF from 0.06‰ to 0.16‰ among children and from 0.08‰ to 0.17‰ among adolescents. This suggests that negative social phenomena may contribute to true ARF outbreaks.

Rheumatic heart disease in the developing world remains a fairly common cause of death from cardiovascular diseases under the age of 35, exceeding even the death rates from diseases such as hypertension and coronary heart disease.

Etiology and pathogenesis

The development of ARF is preceded by a nasopharyngeal infection caused by group A β-hemolytic streptococcus. These microorganisms colonize the mucous membrane of the upper respiratory tract and produce a huge amount of enzymes that contribute to tissue damage. After the incubation period (2–4 days), a generalized response begins - fever, deterioration of health, headache, tonsillitis. After stopping the inflammation of the upper respiratory tract, some patients develop ARF. The study of the characteristics of this streptococcus revealed that the development of ARF after infection of the upper respiratory tract is associated only with virulent strains belonging to several serotypes of A-streptococcus containing M-protein, a specific protein that is part of the streptococcal cell wall and suppresses its phagocytosis. Currently, more than 90 varieties of the M-protein have been identified. The rheumatogenic strains M-5, M-6, M-18 and M-24 have been isolated. They have the following properties: affinity for the nasopharynx, large hyaluronic capsule, mucoid colonies on blood agar, short chains in broth cultures, induction of type-specific antibodies, high contagiousness, large M-protein molecules on the surface of strains, a characteristic genetic structure of the M-protein. In addition, they have epitopes that cross-react with various host tissues: myosin, synovium, brain, and sarcolemmal membrane.

A significant role in the pathogenesis of the disease belongs to the genetic predisposition. This is evidenced by the fact that after acute A-streptococcal nasopharyngeal infection with ARF, no more than 0.3% of individuals in the population and up to 3% in closed groups fall ill. The genetic features of ARF are clinically confirmed by its high familial aggregation, as well as the identification of genetic markers: associations of ARF with certain blood groups (A and B), erythrocyte acid phosphatase phenotypes, and loci of the HLA system (DR5–DR7, Cw2–Cw3).

Recently, much attention has been paid to B-lymphocyte alloantigen, which is determined using monoclonal antibodies D8/17. The high frequency of its detection in patients with ARF and rheumatic heart disease (92–100%) compared with control groups (10–15%) allowed a number of authors to raise the question of it as a diagnostic criterion for ARF.

In response to a streptococcal infection, a stable hyperimmune reaction develops in the body with the production of antistreptococcal antibodies - antistreptolysin-O, antistreptohyaluronidase and others involved in the formation of circulating immune complexes. In this case, the pathological effect of streptococcus can manifest itself both as a direct damaging effect of the microorganism itself, and as a toxic effect of antibodies produced by the microorganism and cross-reacting with its own tissues (molecular mimicry). In the development of the main clinical manifestations of ARF, an important role is played not only by immunopathological mechanisms, but also by inflammation, which is mediated by such mediators as lymphomonokines, kinins, and chemotaxis factors. This leads to the formation of a vascular-exudative phase of acute inflammation, the outcome of which is systemic disorganization of the connective tissue, vasculitis with an outcome in moderate fibrosis.

The main pathomorphological diagnostic sign of rheumatic heart disease is rheumatic granuloma (Aschoff-Talalaevskaya granuloma), consisting of large irregularly shaped basophilic cells of histiocytic origin, giant multinucleated cells of myogenic origin with eosinophilic cytoplasm, cardiohistocytes with a characteristic arrangement of chromatin in the form of a caterpillar, lymphoid and plasma cells.

Acute rheumatic fever or rheumatism is an inflammatory disease of the connective tissue caused by group A beta-hemolytic streptococcus in genetically predisposed individuals. Most often, children and young people from 7 to 20 years old get sick.

The term " rheumatism" was officially replaced by " acute rheumatic fever to emphasize that this is an acute inflammatory process that begins after a streptococcal infection (tonsillitis, pharyngitis, scarlet fever) and is its complication.

Cause of rheumatism

The trigger for the development of rheumatism is group A beta-hemolytic streptococcus. Streptococcal infection has a direct toxic effect on the heart and triggers an autoimmune process when the body produces antibodies against its own tissues, primarily the heart and cells of the vascular wall. But this can only happen in an organism genetically predisposed to rheumatic fever. Girls and women (up to 70%) and first-degree relatives get sick more often.

In economically developed countries, the incidence of rheumatism is negligible. Among the social conditions contributing to the occurrence of the disease include:

Crowding during living and learning;
- low level of sanitary culture and medical care;
- Poor material and living conditions, insufficient food.

Symptoms of rheumatism

In typical cases, the first attack of rheumatic fever begins 2-3 weeks after a streptococcal infection. Suddenly or gradually, against the background of general malaise, the body temperature rises to 37 degrees, the temperature quickly rises to 38-39 degrees. Temperature rises in rheumatism are accompanied by chills, sweating. There are signs of polyarthritis (inflammation of the joints): swelling, redness of the joints, pain at rest and during movement. Rheumatism affects large joints (knee, ankle, elbow, shoulder). Rheumatic polyarthritis is characterized by: symmetry (both knee or both ankle joints are simultaneously affected), the sequence and volatility of the lesion (inflammation quickly passes from one joint to another). Complete reversibility of joint inflammation, restoration of joint function within 2 days after taking NSAIDs (aspirin).

The temperature increase in rheumatism lasts 2-5 days and normalizes when the arthritis subsides. Sometimes at the beginning of the disease, unstable rashes appear on the skin of the trunk and extremities. They look like pink rings - annular erythema. Rashes appear and disappear without leaving traces. A characteristic, for rheumatism, but extremely rare symptom (up to 3% of cases) is subcutaneous rheumatic nodules. They have a size from a grain to a pea, dense, painless, localized on the affected joints, the back of the head.

The main manifestation of rheumatism is heart damage - carditis, the severity of which depends on the outcome of rheumatic fever. There are prolonged stabbing, aching pains in the region of the heart, shortness of breath with little physical exertion, palpitations, and disturbances in the work of the heart. The outcome of carditis in 25% of cases is the formation of heart disease.

Rheumatic chorea is a manifestation of damage to the nervous system. There are chaotic involuntary twitching of the limbs and mimic muscles, grimacing, slurring of speech, impaired handwriting, inability to hold a spoon and fork while eating. Symptoms completely disappear during sleep. Chorea with rheumatism lasts 2-3 months.

The duration of rheumatic fever averages 6-12 weeks. This is the period during which the acute inflammatory process goes through all stages. Rheumatic fever lasting more than 6 months is considered to be protracted. A new episode of rheumatism often occurs in the first 5 years after the first attack, and over time, its likelihood decreases. The emergence of new attacks depends on the occurrence of repeated streptococcal infections.

Diagnosis of rheumatism.

1. Complete blood count - signs of inflammation (leukocytosis - an increase in the number of leukocytes and accelerated ESR).
2. Biochemical analysis of blood - an increase in the content of fibrinogen, C-reactive protein - indicators of the acute phase of inflammation.
3. Serological studies reveal antistreptococcal antibodies in high titers.
4. Bacteriological examination: detection of group A beta-hemolytic streptococcus in throat swabs.
5. Electrocardiography - reveals violations of the heart rhythm and conduction, an increase (hypertrophy) of the heart.
6. Doppler echocardiography reveals signs of damage to the heart valves, pumping function and myocardial contractility, the presence of pericarditis.

Diagnosis of rheumatism is undoubted in the presence of a formed heart disease. In the absence of heart disease, the following criteria are used:

The presence of 2 major criteria or 1 major and 2 minor criteria, combined with evidence of a previous streptococcal infection, suggests a high likelihood of rheumatism.

Treatment of rheumatism.

Success in the treatment of rheumatic fever and the prevention of heart disease development is associated with early detection of the disease and individualized treatment. Therefore, it is necessary to contact your doctor (family doctor, pediatrician, therapist) when the first signs of inflammation appear. Treatment of rheumatic fever is carried out in a hospital. If carditis is suspected, bed rest is mandatory. In rheumatism, a diet rich in vitamins and protein is prescribed, with restriction of salt and carbohydrates. Etiotropic (antistreptococcal) treatment of rheumatism is carried out - antibiotics are prescribed according to the developed schemes.

Anti-inflammatory treatment - hormones (glucocorticoids - prednisolone) and NSAIDs (non-specific anti-inflammatory drugs - aspirin, diclofenac), depending on the degree of activity of the process.

The next stage - patients undergo rehabilitation (restorative) treatment in a specialized center (sanatorium).

The third stage is dispensary observation by a family doctor (pediatrician, therapist). Every year the patient is examined by a rheumatologist, an ENT doctor, laboratory tests, ECG, echocardiography are carried out.

Complications of rheumatism.

The main complications include:

1. Formation of heart disease.
2. Development of congestive heart failure.
3. Violation of the heart rhythm.
4. Thromboembolism.
5. The occurrence of infective endocarditis (inflammation of the inner lining of the heart).

Chronic rheumatic heart disease (heart disease) is a disease in which the valves of the heart, its partitions are affected, leading to dysfunction of the heart, the formation of heart failure. Occurs after rheumatic carditis. The progression of heart disease can occur under the influence of repeated attacks of rheumatic fever. All patients with heart defects are consulted by cardiac surgeons and are subject to referral for surgical treatment to specialized clinics.

Primary prevention of rheumatism is the prevention of the onset of rheumatic fever in a healthy child. It includes measures aimed at increasing immunity (good nutrition, hardening, physical education), prevention of streptococcal infections (improvement of people who surround the child, elimination of crowding), timely and complete treatment of streptococcal diseases.

Secondary prevention of rheumatism is the prevention of recurrence and progression of rheumatic fever that has already occurred. It includes: dispensary observation, timely treatment of foci of chronic infection, administration of benzathine benzylpenicillin intramuscularly 1 time in 3 weeks. The duration of secondary prevention for each patient is set strictly individually, but not less than 5 years after the last attack, for patients who have had rheumatic fever without carditis and for life for patients with a formed heart disease.

Consultation of a doctor on the topic of rheumatism:

Question: How is the treatment and prevention of rheumatism in pregnant women carried out?
Answer: The occurrence of acute rheumatic fever in pregnant women is extremely rare, but if a disease occurs, a woman must be urgently hospitalized in the therapeutic department of a hospital or in a maternity hospital specialized in cardiovascular pathology. Secondary prophylaxis with penicillin in pregnant women who have had rheumatic fever is necessary, especially in the first trimester of pregnancy, when the likelihood of an exacerbation of the disease is high.

Therapist Vostrenkova I.N.

Acute rheumatic fever (abbreviation - ARF) is a severe inflammatory process with damage to the structures of the heart, joints, skin, nervous system and nodes of the subcortex of the brain. It can have very negative consequences if treatment is not started on time. Read about the pathogenesis and etiology of acute rheumatic fever in children and adults, the medical history, the formulation of the diagnosis and diagnostic criteria in our today's material.

Features of the disease

Fever occurs as a complication after infection of the lymphatic tissue of the tonsils (tonsillitis,), pharynx (scarlet fever), provoked by the aggression of beta-hemolytic streptococcus from group A. It mainly affects children 7-16 years old. The pathogenesis is associated

• with toxin-releasing streptococcal enzymes that cause poisoning of cells in the tissues of the heart.
• with the similarity of the antigenic complexes of the pathogen and myocardial tissue, which provokes immunity to aggression against "native" cells, which are perceived as foreign.

The video below provides useful information about rheumatism and ARF:

ORL classification

Standard classification of acute rheumatic fever in children and adults:

Classifying parameters	Forms
View	Acute (ORL) and recurrent (PRL) forms of ARF
Symptoms	Basic: carditis, rheumatic arthritis, chorea, erythema, subcutaneous rheumatic nodules. Additional: feverish state (fever, chills); joint, abdominal (in the abdomen) pain; inflammatory processes in the serous membranes of the pleura, myocardium, peritoneum (serositis)
The degree of involvement of the heart muscle	without myocardial damage (rarely) or the development of rheumatic heart disease in a chronic form with the formation of a defect (or without it)
Degree of heart dysfunction (failure)	operation classes 0; I; II; III; IV

Causes

Allocate the main causes and additional factors for the development of fever.

Aggression of beta-hemolytic streptococcus A-type

Rheumatic fever typically develops 3 to 4 weeks after scarlet fever, tonsillitis, or pharyngitis, caused by certain strains of Gram-positive streptococcus that are highly contagious. After the introduction of the pathogen into the blood, the normal functioning of the body's immune complexes is disrupted.

M-proteins of the cell of a streptococcal microorganism are similar in structure to the proteins of the tissue of the myocardium, joints and synovial membranes (the inner layer of the articular cavity). For this reason, the immune system, reacting to the penetration of a foreign agent into the body, attacks its own cells, provoking inflammatory processes.

hereditary factor

The study of the pathogenesis of rheumatic fever confirms that the highest incidence of the disease, subsequent complications and heart defects is observed in individual families. Hereditary predisposition to ARF, caused by the presence of a specific antigen in the body, was found in almost all patients and only in every 6-7 of those who were not ill.

Acute rheumatic fever has its own symptoms, which we will discuss next.

Symptoms

General signs

In more than half of children and adolescents, the onset of an attack of rheumatic fever manifests itself:

• an unexpected and sharp jump in temperature of the type of "flash";
• the appearance of symmetrical pain in the knee, elbow, hip joints, usually changing localization;
• swelling and redness of the tissues around the inflamed joints;
• signs - inflammation of the structures of the heart (pain behind the sternum, high fatigue, with and increasing frequency, stretching of the heart cavities, lowering pressure).

Sometimes the course of the pathology comes with pronounced symptoms of only arthritis or only rheumatic heart disease (rarely).

In young patients 15-19 years old, the onset of the disease is usually not as acute as in younger children:

• the temperature, as a rule, does not reach 38.5 C;
• arthralgia (pain) in large joints is not accompanied by severe inflammation and swelling;
• manifestations of carditis - moderate.

Specific symptoms for different forms of the disease

Rheumoarthritis

Rheumoarthritis gives symptoms at the first attack of ARF in 70-100% of patients. This:

• severe pain, swelling of the hip, wrist, elbow, ankle, knee joints due to the accumulation of effusion in the joint bag (synovitis);
• limited mobility due to pain;
• the specificity of arthritis caused by ARF is the “migratory” nature of inflammation (in some joints, pain and swelling disappear in 1–4 days, giving way to a severe lesion of others), as well as the rapid reversibility of symptoms when exposed to anti-inflammatory pharmacological drugs.

Carditis

Carditis is commonly seen in ARF in 85-95% of patients. Sometimes the severity of symptoms is muffled, but in any case, the following are detected:

• heart rhythm disorder;
• shortness of breath, ;
• , sweating and extreme fatigue.
• , quickly losing elasticity and the ability to fully open and close tightly, passing blood (even with erased symptoms and moderate and mild rheumatic carditis).

Abnormal changes in the valves are often combined with, (inflammation of the tissues of the heart muscle and the outer shell), which leads to a violation of cardiac electrical conductivity, the appearance of noise, muffled tone, and expansion of the cavities.

The specificity of rheumatic heart disease (as well as rheumatoid arthritis), which is significant in the diagnosis of ARF, is the clearly visible disappearance of all symptoms of the pathology after intensive therapy.

With active and timely treatment, there is a restoration of the normal rhythm of heart contractions and myocardial boundaries, sonority of tones, a decrease in the degree of abnormal noise, and the disappearance of signs of impaired blood supply.

Rheumatic chorea

Rheumatic chorea (synonyms - small chorea, the dance of St. Vitus, known since the Middle Ages) is a pathology that develops when inflammation processes spread to the brain tissue. It manifests itself (inflammation) of small cerebral vessels and symptoms of damage to the central trunks of the brain and spinal cord and peripheral nerves.

The target of pathology is mainly young children (15 - 30%), less often - adolescents in the pubertal period, 35 - 65 days after the child suffered an acute infection with a streptococcal microorganism. It is more often found in female children.

The symptomatology of chorea minor combines syndromes:

• motor restlessness, uncontrolled twitching (hyperkinesis) of muscles, arms and legs, grimacing, disappearing during sleep;
• slurred speech, fatigue, change in gait, inability to hold small objects;
• muscle hypotension (strong relaxation, similar to paralysis), dysfunction of swallowing, physiological functions;
• apathy, tearfulness, aggressiveness, irritability, sleep disturbance.

Usually these symptoms of chorea are combined with carditis and rheumatic fever, but in rare cases (in 5 to 7 children out of 100 cases), chorea is the only obvious symptom of rheumatic fever. In cases where other signs of ARF are absent, the diagnosis of chorea minor is made after the exclusion of other possible causes of neuropsychiatric disorder.

erythema annulare

Erythema annulare in ARF manifests itself at the peak of the disease in the form of pink ring-shaped spots 50-100 mm in size, which appear on the skin of the chest, arms, legs and back, then disappear. In addition to them, rashes spread in the form of small nodules - painless dense dark red formations that occur under the skin in the periarticular tissues - above the vertebrae, protrusions of the heels, ankles, and the back of the head. They are found only in children. Disappear within 25-30 days.

Erythema and rheumatic nodules are rare but very specific features of rheumatic fever and are therefore important for an accurate diagnosis. Next, the differential diagnosis of acute rheumatic fever will be considered.

Diagnostics

Diagnosis of ARF is often difficult, since the underlying manifestations (excluding erythema and nodules) are not unique to this pathology, but also occur in other diseases. With mild symptoms of carditis, to determine the diagnosis, do:

• using . This study makes it possible to assess changes in the structure of the heart, coronary blood flow, to identify the degree and nature of valve damage, inflammation of the pericardium (the outer lining of the heart);
• , which allows you to determine in time whether there are violations in the rhythm of contractions of the heart muscle.

Lab tests

In an acute attack, ARF is determined by:

• in the blood - an increase in ESR (more than 40 mm / h) and CRP (the amount of C-reactive protein that is formed in the liver during acute inflammation), sometimes - an increase in leukocytes, neutrophils;
• increased concentration of antibodies (AT) against streptococcus (in 82% of patients);
• hemolytic streptococcal agent during bacteriological examination of a smear taken from the oral cavity.

Differential Diagnosis

The classic features of ARF are not common, so for accurate diagnosis it is necessary to distinguish ARF from other pathological conditions with similar manifestations.

If there is no clear connection between streptococcal aggression and the occurrence of rheumatic heart disease, the presence of other possible pathologies of the heart is detected:

• - infection of the valves;
• viral myocarditis (inflammation of the heart tissue);
• (benign formation in the atrium).

It's important to know:

• Chorea in ARF should be distinguished from encephalitis, a PANDAS neuropsychiatric disorder caused by streptococcal infections.
• Arthritis, carditis and skin erythema are also manifested in lymoborreliosis, when infection occurs from a tick bite (pathogen - spirochete).
• To distinguish ARF from Lyme disease, it is required to identify the presence of antibodies to spirochete in the blood of the diseased.

About treatment in the clinic and at home, as well as emergency care for acute rheumatic fever, read below.

Treatment

In the treatment of ARF, a complex scheme is provided, which includes:

• etiotropic therapy (elimination of the cause);
• pathogenetic (correction of dysfunction of organs, stabilization of metabolic processes, increase in the body's immune resistance), symptomatic (mitigation of symptoms).

Usually, all patients (especially children) are placed in a hospital with the appointment of strict bed rest for 3 weeks. The inclusion of proteins in the diet, restriction of salt is envisaged.

Medical

• To eliminate the cause of the disease - to destroy beta-streptococcus - antibiotics of the penicillin group are used (from the age of 14, benzylpenicillin at a dosage of 2–4 million units; children under 14 years old from 400 to 600 thousand units). The course is not less than 10 days. Or a more “advanced” amoxicillin is used.
• With penicillin allergy, drugs from a number of macrolides (Roxithromycin, Clarithromycin) or lincosamides are prescribed. After completing the course of injections, antibiotics are prescribed in long-acting tablets.
• Pathogenetic therapy of ARF consists in the use of hormonal drugs and NSAIDs. With severe carditis and serositis, Prednisolone is used for at least 18-22 days at a dose of 20-30 mg per day until a pronounced therapeutic effect is obtained. After that, the dosage of glucocorticosteroid is slowly reduced (2.5 mg per week).

Elimination of symptoms:

1. In the treatment of rheumatoid arthritis, chorea is prescribed, which reduces inflammation of the joints, in a daily dosage of 100-150 mg per course lasting 45-60 days.
2. If signs of rheumatic heart disease are observed, means are necessarily prescribed to stimulate myocardial activity (Digoxin).
3. Hormones specifically affect metabolic processes, therefore, given the degree of dystrophic changes in the heart, medications are used:

• Nandrolone course of 10 injections of 100 mg once a week;
• Asparkam 2 tablets 3 times a day for a course of 30 days;
• Inosine three times a day 0.2 - 0.4 g, a course lasting 1 month.

1. With emerging edema, indicating fluid retention in the tissues, diuretics such as Lasix are used. Use immune system stimulants.

Heart defects formed during rheumatic heart disease are treated with drugs for arrhythmia, nitrates, moderate use of diuretics. The duration and specificity of cardiotherapy depends on the degree of violation of the structure of the myocardium, the severity of symptoms and the degree of insufficiency of heart function.

Surgical

If a severe heart defect is detected during the diagnosis of ARF, the task is to perform an operation on the valves, the possibility of plastic surgery and valve prosthetics is assessed.

Physiotherapy

Simultaneously with the use of medications, the treatment of ARF provides for a course of physiotherapy:

• UHF heating,
• application of therapeutic mud and paraffin applications,
• infrared radiation,
• use of oxygen and radon baths,
• therapeutic massage (after recovery).

Prevention

• Prevention of the development of ARF or primary prevention consists in the early detection and treatment of infectious lesions of the pharynx, the causative agent of which is streptococcus with antibiotics (Amoxicillin, Cefadoxil, Ofloxacin, Azithromycin).
• For re-infection, use Amoxicillin with clavulanic acid. If this therapy fails or causes allergic reactions, Lincomycin, Clindomycin are prescribed.
• Secondary prevention is necessary to prevent a recurrence of ARF in patients who have already had the disease. Long-acting antibacterial agents are prescribed - bicillin (Extencillin and Retarpen), which reduce the likelihood of ARF recurrence by 5-20 times.
• For those patients who had ARF without carditis, the duration of antibiotic treatment is at least 5 years. If carditis was diagnosed, which was cured without consequences - at least 10 years.
• For patients with myocardial disease (including those who underwent surgery) - for life.

Complications of acute rheumatic fever

Rheumatic fever can have a favorable outcome, and the patient recovers if the diagnosis was carried out quickly, and the treatment was timely and competent. Possible complications that threaten ARF patients:

• the transition of ARF to the chronic form of rheumatic heart disease (CRHD), the formation of myocardial defect, deformation, atrophy of the valve leaflets with or without significant impairment of their function;
• prolapse (in every tenth sick child) or (narrowing of the lumen of the atrioventricular orifice) of the mitral valve, aortic valve insufficiency;
• violation of the rhythm of heart contractions with the development of chronic arrhythmia,;
• an increase in the likelihood of endocarditis (inflammation of the inner lining of the myocardium when harmful microbes penetrate into the general bloodstream, and then onto damaged valves).

Forecast

There is no risk of death in acute rheumatic fever (except in extremely rare cases of pancarditis - a general inflammation of the layers of the heart - in children). The incidence of heart defects after experienced rheumatic pathology in children reaches 25%.

The prognosis of the disease depends on:

• the state of the myocardium - the presence and severity of heart disease formed during carditis;
• the degree of insufficiency of the pumping function of the myocardium;
• on how quickly treatment was started, since the risk of malformations increases significantly with a late start of therapy.

The disease can end in complete recovery (high probability) without the formation of heart and valvular defects with timely and competent therapy.

This video will talk about ARF and rheumatic heart disease: