Rheumatic fever
Rheumatic fever, or acute rheumatic fever, is a complication that develops a few weeks after an untreated streptococcal throat infection.
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Medicines commonly prescribed for Rheumatic fever
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 600 mgActive substance: ibuprofenManufacturer: Fairmed Healthcare GmbhPrescription requiredDosage form: CAPSULE, 600 mgActive substance: ibuprofenManufacturer: Hc Clover Productos Y Servicios S.L.Prescription requiredDosage form: TABLET, 600 mgActive substance: ibuprofenManufacturer: Pharmex Advanced Laboratories S.L.Prescription required
Rheumatic fever, or acute rheumatic fever, is a complication that develops a few weeks after an untreated streptococcal throat infection. It is uncommon, and it is worth knowing about for two reasons. First: it can almost always be avoided by dealing with an ordinary sore throat in good time. Second: its main mark is left not on the joints, which is what usually brings people to a doctor, but on the heart — and that shows itself many years later, when the fever itself has long been forgotten.
Where it comes from
It all starts with a throat infection caused by group A beta-haemolytic streptococcus. The throat itself gets better, but two to four weeks later, sometimes as long as five, an entirely different illness appears: fever, painful joints and sometimes the heart involved as well.
The microbe is not to blame: by the time this begins it has usually gone from the body. The immune response is to blame. Some streptococcal proteins resemble the body's own proteins — in the linings and valves of the heart, in the joints, in the skin and in particular parts of the brain. Antibodies made against the infection mistake those tissues for something foreign and start attacking them. That is why inflammation flares up in several unconnected places at once.
Far from everyone who has a streptococcal throat infection goes on to develop it: it is a handful of cases in many thousands, and why those particular people is not fully understood, though heredity plays some part. It mainly affects children and teenagers, roughly between five and fifteen. In Europe it became rare once sore throats began to be treated with antibiotics, but worldwide it remains a common cause of heart disease in young people.
Treating the sore throat in time prevents it
This is the most useful thing on the page. Rheumatic fever is one of very few serious conditions that really is prevented by simple, short treatment one step earlier.
With an important qualification: antibiotics are not needed for every sore throat. Most sore throats are viral, antibiotics do nothing for them, and taking them indiscriminately does harm. The question is a different one — whether this particular throat infection is streptococcal. Points in favour are a high temperature, pus on the tonsils and enlarged tender glands in the neck, together with the absence of a runny nose and cough. The definite answer comes from a throat swab or a rapid test done in the consulting room.
If streptococcus is confirmed and a doctor prescribes an antibiotic, everything then hinges on one thing: the course has to be finished. The throat stops hurting within a couple of days, and that is exactly where the tablets tend to be abandoned. But what protects against rheumatic fever is not relief of symptoms; it is complete clearance of the streptococcus, and that takes the whole prescribed period. An interrupted course leaves precisely the situation out of which the illness arises.
One more reason not to put it off: treatment started even a few days after the sore throat began still prevents rheumatic fever. So if a sore throat is dragging on, it is worth seeing a doctor on the fourth or fifth day too.
How it is recognised
Two to four weeks after the throat infection a combination of signs appears, of which the most characteristic is the way the joints behave.
- Migrating pain in the large joints. A joint swells, reddens and hurts so much that it can barely be touched — and a day or two later it settles, and the same thing starts in another one. The ankles, knees, wrists and elbows are affected most often. This "creeping" from joint to joint over a few days is what sets rheumatic fever apart from ordinary arthritis, and it is hardly ever seen in anything else.
- Fever, weakness, loss of appetite and sweating.
- Breathlessness, palpitations, chest pain or tightness and getting tired quickly on ordinary exertion — signs that the heart is involved.
- Firm painless nodules under the skin, the size of a pea, usually over the elbows, the knees, the back of the head or along the spine.
- A pale pink rash in rings or wavy lines on the trunk and at the top of the limbs, without itching, which comes and goes. On darker skin it is barely visible.
- Sweeping involuntary movements, which are covered separately below.
The diagnosis is made from these signs taken together with tests: markers of inflammation, evidence of recent streptococcal infection and, always, an echocardiogram, because the heart can be involved without causing any complaint at all.
Chorea: movements mistaken for messing about
This is the most underrated sign, and one that parents and teachers ought to know about.
Chorea appears later than the rest, sometimes months after the sore throat, when the connection is no longer obvious. The child develops sudden, sweeping, irregular movements of the hands, feet and face that they can neither predict nor stop: they pull faces, drop things, their handwriting deteriorates, their walk becomes clumsy. The movements get worse with excitement and disappear during sleep. Mood changes alongside: tearfulness, irritability, absent-mindedness and a drop in schoolwork.
From the outside it looks a great deal like clowning around, a nervous tic or "he's started playing the fool" — and children get told off for it at home and at school, sometimes for months. In fact it is the neurological manifestation of rheumatic fever, and no amount of willpower lets a child control it.
It also matters that chorea can be the only manifestation of the illness: by that point there are no painful joints and no fever left. So any new involuntary movements in a child are a reason to see a doctor, not to discipline them. Chorea itself passes within a few months and leaves no trace, but by then the heart may already be involved and needs checking.
When help is needed urgently
Call an ambulance (in Europe, the single number 112) if any of these appear:
- breathlessness at rest, or so bad that lying down is impossible and you have to sit up;
- severe chest pain;
- a fast or irregular heartbeat with dizziness, or loss of consciousness;
- increasing swelling of the legs and abdomen together with breathlessness.
A doctor should be seen the same day, without putting it off, if a child or adult develops painful swollen joints with a fever after a recent sore throat, if a single joint has become hot and acutely painful, if involuntary movements have started, or if someone who has already had rheumatic fever gets another sore throat. A single hot joint with a high temperature is always assessed urgently for another reason too: that is how a pus-forming joint infection can present, which is a different illness needing immediate treatment.
How it is treated
Treatment has three parts, and all three are needed at once.
The first is an antibiotic to clear the streptococcus, even if the throat stopped hurting long ago. The second is anti-inflammatory treatment: usually non-steroidal anti-inflammatory drugs, which quickly settle the joint pain and the fever; if the inflammation of the heart is severe, steroids are used. The third is rest: physical activity is restricted, and where the heart is involved bed rest is kept up until the inflammation subsides. For chorea, medicines that reduce the involuntary movements are sometimes added.
The joints recover completely and are never left deformed, which is an important difference from other kinds of arthritis. The acute phase lasts around three months on average, sometimes longer. After it the person feels well — and that is where the part people most often underestimate begins.
What happens to the heart
The inflammation of rheumatic fever reaches the heart valves, most often the mitral valve and less often the aortic. While the acute phase lasts, nothing may be felt. But scar tissue gradually forms where the inflammation was: the leaflets of the valve thicken, become distorted and stick together. The valve stops either opening fully or closing tightly, and the heart has to work under a load.
The key feature is time. Valve damage builds up over years, sometimes decades, and throughout that period the person feels normal. The first complaints come when the heart can no longer keep up: breathlessness on exertion and later at rest, tiredness, an irregular rhythm, ankles swelling by the evening. It is not unusual for that to be the moment when it emerges that the cause was a sore throat back in childhood.
Hence a practical conclusion: after rheumatic fever you should stay under a cardiologist and have an echocardiogram from time to time — for life, not just for the first year. If valve damage does develop, it can be dealt with: a valve today can be widened, repaired or replaced, and the earlier this is done the better the result. One more thing worth knowing: a damaged valve is more easily infected by bacteria that get into the bloodstream, so healthy teeth and regular dental visits matter especially for anyone with rheumatic valve disease.
Why antibiotics are taken for years afterwards
This is the part many people do not know about, or give up on halfway. After rheumatic fever an antibiotic is prescribed not as a short course but for years, as continuous prophylaxis.
The reasoning runs like this. In someone who has had the illness once, the immune system reacts to streptococcus in the same faulty way. Any new streptococcal throat infection can set off another episode, and each one damages the valves more than the last. The heart suffers less from the first attack than from the repeats. Prophylaxis breaks that chain.
It is given either as injections of a long-acting antibiotic every few weeks or as daily tablets; the choice is discussed with the doctor, and injections are usually more dependable because they do not rely on remembering. How long it goes on depends on whether the heart was involved and on age: it is measured in years, and with established valve disease it may be lifelong. The exact durations and medicines are set out in national guidelines and will be named by your doctor.
The commonest mistake is a simple one: the person feels well and stops. Yet prophylaxis works precisely because the person is well — it does not treat anything, it keeps the illness from coming back. Stopping is always discussed with a doctor first. And do tell every doctor and every dentist you see that you have had rheumatic fever.
Online consultation
The most useful reason to get in touch is the earliest one in time: a sore throat, and no clarity about whether an antibiotic is needed. The doctor will ask about fever, pus on the tonsils, cough and a runny nose, judge how likely streptococcus is and say whether a swab is worth taking and how urgently. This is one of those cases where a short conversation genuinely changes the outcome.
The rest sorts out well remotely too: what tests already done actually mean, how long-term prophylaxis works if it has been prescribed, and when the echocardiogram is due to be repeated. If a child develops involuntary movements, or if joints swell after a sore throat, an in-person examination is needed the same day, and with the signs listed above, an ambulance.
This material is for information only and does not replace medical advice.
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