Essay: Rheumatic fever

Rheumatic fever remains a significant cause of cardiovascular disease in the world today. Despite a documented decrease in the incidence and prevalence of the disease in industrialized countries, rheumatic fever remains a medical and public health issue in both industrialized and both developing countries. The most devastating effects of this disease are amongst children and young adults from ages 5 and 15 years old. It is considered a rare disease after age 40, unless it is recurrent. Rheumatic fever is an inflammatory disease of connective tissues affecting the heart, major joints ,and brain. It is caused by a complication of inadequately treated group A streptococcal bacteria (GAS) throat infection (pharyngitis). (Lemone et, al. 2006) This infectious illness tend to spread in crowded conditions, settings such as schools, daycare and military training facilities. (CDC, 2018)
Fast Facts about rheumatic fever has declined significantly in developed countries, such as the United States due to better and affordable health care and technological advances. It is no longer a nationally notifiable disease. However, it is more prevalent in developing countries due to poverty and poor access to health care. (WHO) Rheumatic fever remains a significant cause of cardiovascular disease worldwide. According to the Center of Diseases, Global Estimates of the Burden of Disease 2016 results:
● 470,000 new cases of acute rheumatic fever each year,
● 282,000 new cases of rheumatic disease each year,
● approximately 30 million people are living with rheumatic heart disease
● 305,000 people die each year from rheumatic heart disease or its complications. (CDC, 2016)
Risk Factors
School-age children ages 5 through 15 years old are most often affected by rheumatic fever due to inadequate or lack of antibiotic treatment of streptococcal pharyngitis. Group A streptococcal disease is an infectious disease that tend to spread wherever large groups of people are gathered, such as schools ,and daycare center. Other factors such as malnutrition, those who are immunodeficient and having poor access to health care can also increase the risk factors of contracting group A strep disease.
There is also a possibility of a genetic factor in the susceptibility of rheumatic fever according to a study done with 435 twin pairs (monozygotic vs dizygotic twin pairs) from six independent studies. The conclusion of the study was that rheumatic fever is an autoimmune disorder with high heritability which is stronger in monozygotic twins than dizygotic twins.
Manifestations
Rheumatic fever affects the heart, skin ,and joints. Other common signs and symptoms are fever, fatigue, and joint pain.(fig. 1) A major cardiovascular system manifestation is carditis which includes cardiomegaly, tachycardia, and chest pain. With the onset of mitral valve disorders, heart murmurs, pericardial friction rub, congestive heart failure ,and a prolonged PR interval that is shown on an electrography.(fig.7) Integumentary manifestations includes subcutaneous painless lumps called nodules that appears under the skin ,and erythema marginatum which is a non-pruritic, non-painful macular lesions that appears on the trunk and proximal extremities. (fig. 3 & 4). Musculoskeletal polyarthritis which is arthritis of the large joints: elbows, wrists, knees ,and ankles. Central nervous system manifestation such as chorea, also called Sydenham’s chorea or St. Vitus dance. This is a neurological disorder characterized by non-rhythmic, purposeless involuntary movement that is associated with muscle weakness. (CDC, 2018)
Diagnostics Lab Test
Throat culture, which is not definitive of strep throat, because it may have cleared up before manifestations of rheumatic fever. Elevated WBC, with greater than 10% bands (bandemia). Antistreptococcal antibodies, begin when antistreptococcal antibody levels are at their peak; thus, these tests are useful for confirming previous GAS infection; antistreptococcal antibodies are particularly useful in patients who present with chorea as the only diagnostic criterion. Acute-phase reactants. C-reactive protein and erythrocyte sedimentation rate are elevated in individuals with rheumatic fever due to the inflammatory nature of the disease; both tests have high sensitivity but low specificity for rheumatic fever. Heart reactive antibodies: Tropomyosin is elevated in persons with acute rheumatic fever. Rapid detection test for D8/17: This immunofluorescence technique for identifying the B-cell marker D8/17 is positive in 90% of patients with rheumatic fever and may be useful for identifying patients who are at risk of developing rheumatic fever.
Chest radiography will indicate cardiomegaly, pulmonary congestion, and other findings consistent with heart failure. (fig.12) Last but not least an EKG which will represent a prolonged PR interval. (fig.7)
Treatments
There are both medical and surgical treatments of rheumatic fever. Medical treatments is directed towards eliminating the GABHS pharyngitis (if still present) suppressing inflammation from the autoimmune response, and providing supportive treatment of congestive heart failure (CHF). Examples such as anti-inflammatory, salicylates and Steroids-for the inflammatory symptom. If moderate to severe carditis is present as indicated by cardiomegaly, third-degree heart block, or CHF, add PO prednisone to salicylate therapy. Anticonvulsants, indicated for Sydenham chorea, valproic acid (Depakene) or carbamazepine (Carbatrol, Tegretol, others). Antibiotics, Penicillin, Erythromycin or another antibiotic to eliminate remaining strep bacteria.- May continue low doses for 5-7yrs.
Surgical treatments is performed to decrease valve insufficiency, the mitral valve in particular, may be replaced with a biological component or mechanical prosthetic. Approximately 40% of patients with acute rheumatic fever subsequently develop mitral stenosis as adults.
Nursing management
As a nurse, it is important to obtain a complete up-to-date history of recent sore throat or upper respiratory infection from the parents child. Al.so to obtain a review the body systems by obtaining an head-to-toe examination to identify signs and symptoms such as, erythema marginatum, subcutaneous nodules, swollen or painful joints, or signs of chorea. The goal is to educate the family about the cause and course of rheumatic fever. Important the patient must be educated in case of any future dental procedure, patient must be on prophylactic antibiotics before and after the procedure. Importantly, reduce pain, prevent injury, provide diversional activities and sensory stimulation, provide patient comfort and ensure patient safety.
If untreated or undertreated, rheumatic fever may slowly progress to valvular damage such as stenosis (stiffening of the valve, resulting in regurgitation), myocarditis, endocarditis and eventually heart failure.
The relationship between Endocarditis and Rheumatic fever is that they both are caused by streptococcal infections that are untreated. According to Centers for Rare disease disorders, “Rheumatic Fever is an infectious disease that occurs following streptococcal infections of the throat (strep throat). Patients initially experience a moderate fever, a general feeling of ill health (malaise),a sore throat ,and fatigue. If not treated vigorously by antibiotics, strep throat can lead to rheumatic fever. Major complications may include inflammation of the lining of the heart cavities (endocarditis). “When inflammation occurs within the heart the new term is called “carditis”. Inflammation occurs in majority of people who develop Rheumatic fever. The heart consist of 3 layers called the pericardium, myocardium, and the endocardium.(fig.8). The focus here will be the endocardium which is a thin delicate layer of tissue that lines the cardiac chambers and covers the heart chambers.(Lemone 2006).
The function of the endocardium is to provide protection to the valves. Endocardial inflammation causes swelling, damage to valves, stenosis, murmurs. When bacteria collects and enters the innermost layer of the heart they begin to vegetate and spread to the valves and this process results in valve stenosis or regurgitation. Subacute bacterial endocarditis develops more slowly and usually occurs in people with previous heart valve damage such as valve replacements. Acute bacterial endocarditis has an abrupt onset(MI) and typically affects people with no previous history of heart problems. Patients develops flu like symptoms, Janeway lesions, Splinter hemorrhages under nails, and heart murmurs.
Endocarditis can be prevented but there are some risk factors associated to this disease. People that have a history of intravenous drug abuse, artificial heart valve replacements, poor dental health, congenital heart defects, prolonged use of catheter, syphilis, and dialysis shunts are at risk. A person may develop symptoms two weeks after infection or they may experience a delayed symptoms.
Infective endocarditis develops when pathogens enter the bloodstream. The initial lesion is a sterile platelet-fibrin vegetation that attaches on damaged endothelium. (Lemone et. al, 2006). Acute and subacute are two types of infective endocarditis. In acute endocarditis, the lesions develop on healthy valves. On the other hand, subacute endocarditis develop on already damaged valves, mainly mitral valves but can become systemic over time. These organisms that have invaded the blood colonize and vegetate. The vegetations enlarge as more fibrin are attracted to the site and cover the infecting organism. The covering protects the bacteria from the immune system. More so, the vegetations expand while loosely attached to edges of the valve causing the friable ones to shear off, embolizing and traveling through the bloodstream to other organs. When they lodge in small vessels, they may cause hemorrhages, infarcts, or abscesses. Finally, the vegetations scar and deform the valves and cause turbulence of blood flowing through the heart. Heart valve function is affected, either by obstructing forward blood flow, or closing incompletely. (Lemone et. al, 2006).
According to Mayo Clinic, “Endocarditis signs and symptoms can vary from person to person. They may develop slowly or suddenly, depending on what germs are causing the infection and whether you have any underlying heart problems.” A high temperature and flu like symptoms develop, accompanied by cough, shortness of breath, and joint pain. Heart murmurs are heard in 90% of persons with infective endocarditis. More so, an existing murmur may worsen, or a new murmur may develop. Other signs and symptoms include; splenomegaly, especially in chronic disease, petechiae, splinter hemorrhage, Osler’s nodes, Janeway lesions, and Roth’s spots. (Lemone et. al, 2006).
Blood cultures, echocardiography, and serologic immune testing are the main diagnostic tests that are done to diagnose endocarditis. Blood cultures are positive for bacteria or other pathogens. “This is the most important test the doctor will perform.” (Mayo Clinic, 2018). They are considered positive when a pathogen is identified from two or more separate blood cultures. Echocardiography is used to visualize vegetations that have developed on the valves. Serologic immune testing tests for circulating antigens to assess for typical infective organism. Other tests that might be done are CBC, ESR, serum creatinine, chest x-ray, (fig. 12) and an electrocardiogram.
Following positive blood cultures, antibiotic therapy is initiated with drugs known to be effective against the most common infecting organism: staphylococci, streptococci, and enterococci. The first administration may include nafcillin, penicillin and gentamicin. The treatment is geared to specific organism. For example, staphylococcal and enterococcal infections are treated with a combination of penicillin and gentamicin. Furthermore, intravenous drug therapy is continued for 2 to 8 weeks, depending on the drug used, infecting organism, and the results of repeat blood cultures. On a side note, the patient with prosthetic valve endocarditis requires extended treatment, usually 6 to 8 weeks. Combination therapy using vancomycin, rifampin, and gentamicin is used to treat these resistant infection. (Lemone, 2006).
The most common indication for surgery is when the damaged valves do not respond to medical therapy. When the infection has not responded to antibiotic therapy within 7 to 10 days, the infected valve may be replaced to facilitate eradication of the organism. Some patients with infective endocarditis require surgery to replace severely damaged valves, remove large vegetations at risk for embolization, and remove a valve that is a continuing source of infection that does not respond to antibiotic therapy. (Lemone et. al, 2006).
As a nurse Assessments are very important in proper care. When assessing a person history is vital information to their diagnosis. A patient with endocarditis are more at risk for developing future bacterial infections. Women are more twice as like to develop this bacterial infections than men (Mayo Clinic). Lung assessments should be done on every patient regardless of their diagnosis, but more importantly with a patient that has endocarditis, CHF, and MVP due to mitral and aortic leakage and stenosis. Lung sounds are best heard at the apex. Following Auscultating a murmur can be heard due to valve closure insufficiency, a friction rub, Loud S1 and split s2 may be heard upon auscultation. In assessments a patient’s own words are very valuable subjective information to their care. Assessing a patient PQRST on how they feel a patient can describe their own perception and quality of their overall wellbeing. Vital signs such as temperature are very important with patients with infections due to the inflammatory response of the body.
Therefore, as a nurse implementations are critically important factors in treating a patient with endocarditis. Monitoring vitals such as temperature, heart rate, heart sounds, O2 saturation, and a head to toe skin assessments are very important. Observing for signs of low oxygen perfusion due to valve stenosis and regurgitation. Providing patient with proper education regarding the use of prophylactic antibiotic (Pcn, Erythromycin) use before and after dental procedures, heart surgery and to prevent the recurrence of RF/ Endocarditis. Bed rest with clustered nursing care can improve a patient’s condition. Neuro status and capillary refill should be assessed PRN or every shift to make sure cardiovascular system is perfusing adequately. Instruct patient to take NSAID as needed for joint pain and take the full dose of prescribed antibiotics.
Rheumatic heart diseases and Infective Endocarditis are both related in that rheumatic fever, in most cases can lead to infection of all the layers of the heart including the endocardium which may lead to endocarditis. As a registered nurse a proper medical history of a suspected patient should taken and proper nursing intervention to ensure our patients live the longest best life possible. .