What are the clinical manifestations of rheumatic fever?

The cause of rheumatic fever may be viral infection, changes in immune function or genetic factors, which may all lead to rheumatic fever. Generally, rheumatic fever manifests itself in symptoms such as pale complexion, fever, sweating and abdominal pain. It is best to choose to rest in bed for at least two weeks, and then engage in appropriate activities according to the situation.

1. General symptoms include fever, malaise, fatigue, poor appetite, pale complexion, sweating and abdominal pain, and some patients may suffer from pleurisy and pneumonia.

2. Carditis The most characteristic manifestation of acute rheumatic fever is carditis, which is the only persistent organ damage. During the first attack, the myocardium, endocardium and pericardium may all be affected, with myocarditis and endocarditis being the most common. Pancarditis may also occur with an incidence of 40% to 50%. Symptoms usually appear within 1 to 2 weeks of onset.

(1) Myocarditis: Mild cases may be asymptomatic, while severe cases may be accompanied by varying degrees of heart failure; tachycardia at rest, disproportionate to the elevated body temperature; enlarged heart with diffuse apical beats; low and dull heart sounds with a gallop rhythm; a mild systolic murmur at the apex and a mid-diastolic murmur in the aortic valve area.

(2) Endocarditis: It mainly invades the mitral valve and/or aortic valve, causing regurgitation. Mitral regurgitation is manifested by a blowing-like holosystolic murmur of grade 2-3/6 at the apex, which is transmitted to the axilla, and sometimes a mid-diastolic murmur caused by the relative stenosis of the mitral valve can be heard. In case of aortic regurgitation, a diastolic sighing murmur can be heard at the third intercostal space on the left side of the sternum. In the acute stage, valve damage is mostly congestive edema, which may gradually disappear during the recovery period. Multiple recurrences can cause permanent scarring of the heart valve, leading to rheumatic valvular heart disease.

(3) Pericarditis: When the amount of effusion is small, it is difficult to detect clinically. Typical symptoms include pain in the precordial area and a pericardial friction sound at the base of the heart. When the amount of effusion is large, the precordial pulsation disappears, the heart sounds are distant, and there are manifestations of pericardial tamponade such as distended jugular veins and hepatomegaly. Clinical manifestations of pericarditis indicate severe carditis.

5% to 10% of children with rheumatic carditis develop congestive heart failure during their first attack, and the incidence is even higher during recurrences. Recent cases of rheumatic fever accompanied by heart failure suggest the presence of active carditis.

3. Arthritis occurs in 75% of children with the first attack, affecting large joints, most commonly the knees, ankles, elbows, and wrists, with symptoms of redness, swelling, heat, pain, and limited mobility. It may affect several joints at the same time, or move from one joint to another; the arthritis eventually subsides without leaving deformities.

4. Chorea, also known as Sydenham's chorea, is characterized by purposeless, involuntary, rapid movements of the whole body or parts of the muscles, such as sticking out the tongue, twisting the mouth, squinting, shrugging the shoulders, shrinking the neck, speech disorders, dysgraphia, and incoordination of fine movements. It worsens when excited or concentrating, and disappears after falling asleep, accompanied by muscle weakness and emotional instability. It accounts for 10% of children with rheumatic fever and often appears several months after other symptoms. If the rheumatic fever attack is mild, chorea may be the first symptom. The course of the disease is about 3 months.

5. Skin symptoms are seen in 5% of children.

(1) Annular erythema: It is a less common pink rash with a distinct annular or semi-annular border. The size varies greatly and the center is pale. It appears on the trunk and proximal limbs and is transient or appears and disappears from time to time and is persistent. It may last for several weeks.

(2) Subcutaneous nodules: Rare, often accompanied by severe carditis, they are hard, painless nodules that are not adherent to the skin, 0.1 to 1.0 cm in diameter, and appear on the extensor surfaces of joints such as the elbows, knees, wrists, and ankles, or on the protruding parts of the scalp on the occipital region, forehead, and thoracic and lumbar spines.