Acute rheumatic fever (ARF)


Acute rheumatic fever (ARF) typically follows 2 to 3 weeks after a group A streptococcal pharyngitis infection, that occurs most commonly in children and has rheumatologic, cardiac, and neurologic manifestations. ARF can develop as a complication of inadequately treated strep throat or scarlet fever. Strep throat and scarlet fever are caused by an infection with the group A streptococcus (GAS) bacteria. Acute rheumatic fever can cause permanent damage to the heart, such as damaged heart valves and heart failure. Treatments can reduce damage from inflammation, lessen pain and other symptoms and prevent the recurrence of rheumatic fever.

What happens when you get an infection? Your immune system comes into action to disable and clean up the bacteria. The immune system makes an abundance of proteins called antibodies, made by white blood cells (B cells). The antibodies recognize and combat infectious organisms (germs) in the body. When an antibody recognizes the foreign proteins of an infectious organism, it recruits other proteins and cells to fight off the infection. This cascade of attack is called inflammation. Sometimes these antibodies make a mistake, identifying normal, naturally-occurring proteins in our bodies as being “foreign” and dangerous. When these antibodies make incorrect calls, identifying a naturally-occurring protein as ‘foreign’, they are called autoantibodies. In an immune response to the body’s own cells, inflammatory reactions occur without a pathogen being involved. Then the immune response of the body to the group A streptococcus (GAS) bacteria can sometimes cause acute rheumatic fever.

The peak age for acute rheumatic fever is 4 to 18 years in children and adolescents, though it can develop in younger children and adults. Although a strep throat is common, acute rheumatic fever is rare in Europe, the United States and other developed countries due to the use of antibiotics, improved hygiene and better nutrition. However, rheumatic fever remains common in many developing nations. Worldwide, as many as 20 million new cases of ARF occur each year.


Acute rheumatic fever can occur after an infection of the throat with group A streptococcus (GAS) bacteria. See on image a Streptococci bacteria.
The infection with the group A streptococcus bacteria of the throat causes strep throat or, less commonly, scarlet fever. Group A streptococcus bacteria infections of the skin or other parts of the body rarely trigger rheumatic fever.

The immune system
The link between strep infection and rheumatic fever isn’t clear, but it appears that the bacteria trick the immune system. The strep bacterium contains a protein similar to one found in certain tissues of the body. So immune system cells that would normally target the bacterium may treat the body’s own tissues as if they were infectious agents, particularly tissues of the heart, joints, skin and central nervous system. Your immune system comes into action to disable and clean up the bacteria. The immune system makes an abundance of proteins called antibodies. Antibodies are made by white blood cells (B cells). The antibodies recognize and combat infectious organisms (germs) in the body. Antibodies develop in our immune system to help the body fight infectious organisms. When an antibody recognizes the foreign proteins of an infectious organism, it recruits other proteins and cells to fight off the infection. This cascade of attack is called inflammation.
Sometimes these antibodies make a mistake, identifying normal, naturally-occurring proteins in our bodies as being “foreign” and dangerous. When these antibodies make incorrect calls, identifying a naturally-occurring protein as foreign, they are called autoantibodies. Autoantibodies start the cascade of inflammation, causing the body to attack itself. In an immune response to the body’s own cells, inflammatory reactions occur without a pathogen being involved. Then the immune response of the body to the streptococcus bacterium can sometimes cause acute rheumatic fever.

If prompt treatment is given with an antibiotic to eliminate strep bacteria and takes all medication as prescribed, there’s little chance of developing rheumatic fever. If there are one or more episodes of strep throat or scarlet fever that aren’t treated or not treated completely, you might develop rheumatic fever.

Risk factors
Type of strep bacteria. Certain strains of strep bacteria are more likely to contribute to rheumatic fever than are other strains.
Family history
. Some people carry a gene or genes that might make them more likely to develop rheumatic fever. Genetics may contribute, as evidenced by an increase in family incidence.
Environmental factors. A greater risk of rheumatic fever is associated with overcrowding, poor sanitation and other conditions that can easily result in the rapid transmission or multiple exposures to strep bacteria.

Image ID 80482372 © Katerynakon |


The onset of acute rheumatic fever usually occurs about two to four weeks after a strep throat infection. Rheumatic fever symptoms vary and they can change during the course of the disease.
The earliest and most common feature is a painful migratory arthritis, which is present in approximately 80% of patients. Large joints such as knees, ankles, elbows, or shoulders are typically affected. The signs and symptoms, resulting from inflammation in the heart, joints, skin or central nervous system can include:
inflammation in your joints, most often in the knees, ankles, elbows and wrists, migrating pain in several joints and red, hot or swollen joints.
high fever.
chest pain.
no desire to eat.
small painless bumps under your skin (subcutaneous nodules).
heart complaints.
You may suffer from a rapid heartbeat if you rest or sleep during the day, when coughing you may have chest pain, but also a heart murmur and rapid breathing may indicate this. Approximately 50% of people with acute rheumatic fever run a risk of, for example, inflammation of the heart muscle (myocarditis), the pericarditis or the heart valve (bacterial endocarditis) during the first attack.
stomach ache.
problems with your nervous system.
These complaints can occur 1 to 6 months after the throat infection. You notice that your muscles become weak. You can suffer from jerky, uncontrollable body movements of your arms, legs and your face. These uncoordinated, random movements are called ​​Sydenham Chorea or St. Vitus Dance. Sydenham Chorea or St. Vitus Dance is a syndrome with emotional fluctuations, weak muscles and uncontrolled movements. These movements usually occur in adults, especially pregnant women. It then takes effort to write, dress, eat and sometimes walk. The nervous system abnormalities heal within 2 to 6 months. If you are tense or tired, these symptoms can also occur when you are asleep. You can also suffer from outbursts of unusual behavior, such as crying or inappropriate laughing.
sweating a lot more than you normally do.
skin problems. A blotchy pink skin with flat or slightly raised, painless rash with a ragged edge, especially on your trunk, your upper arms and your upper legs (erythema marginatum). You can also suffer from subcutaneous nodules on the stretch side of your joints.

Inflammation caused by rheumatic fever can last a few weeks to several months. In some cases, the inflammation causes long-term complications. Acute rheumatic fever can cause permanent damage to the heart. Carditis (with progressive congestive heart failure, a new murmur, or pericarditis) may be the presenting sign of unrecognized past episodes and is the most lethal manifestation. It usually occurs 10 to 20 years after the original illness. Problems are most common with the valve between the two left chambers of the heart (mitral valve), but the other valves can also be affected, which can lead to:
• Valve stenosis, in which the narrowing of the valve decreases the blood flow.
• Valve regurgitation, in which the leak in the valve allows blood to flow in the wrong direction.
• Damage to heart muscle, in which the inflammation can weaken the heart muscle, affecting its ability to pump.
The damage to the mitral valve, other heart valves or heart tissues can cause problems with the heart later in life, which can lead to:
• An irregular and chaotic beating of the upper chambers of the heart (atrial fibrillation).
• An inability of the heart to pump enough blood around in the body (heart failure).

Image ID 13149889 © Sebastian Kaulitzki |


Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your school conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

Diagnosis rests on a combination of clinical manifestations that can develop in relation to group A streptococcal pharyngitis. These include Sydenham chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory poly-arthritis.

Physical examination
An echocardiogram can be made using sound waves to produce live-action images of the heart. Heart abnormalities can be detected.
An electrocardiogram (ECG or EKG) records electrical signals as they travel through the heart. Patterns are sought among these signals that indicate inflammation of the heart valves (endocarditis) or poor heart function.

Blood tests
• Checking on increased level of antistreptolysin O (ASO). If already diagnosed with a strep infection, your doctor might not order additional tests for the bacterium. If a test is ordered, it will most likely be a blood test that can detect antibodies to the strep bacterium circulating in the blood. The actual bacterium might no longer be detectable in the throat tissues or blood.
In about 80% of people with acute rheumatic fever, an increased level of antistreptolysin O (ASO) can be seen in the first 2 months of the disease. That is a reaction to the streptococcal infection. When you come into contact with harmful bacteria, your body produces antibodies to defend itself against these bacteria. Your body produces antibodies specific to the bacteria they fight, in this case in response to a toxin known as streptolysin O. Streptolysin O is a toxin produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Usually, when you have a strep infection like strep throat, you receive antibiotics that kill the strep bacteria. But some people don’t have any symptoms during a strep infection and may not know they need treatment. When this happens, an untreated infection can lead to future complications. These complications are known as post-streptococcal complications. The antistreptolysin O (ASO) test is a blood test that checks for a strep infection. The ASO test can help your doctor determine if you recently had a strep infection by measuring the presence of antistreptolysin antibodies in your blood.
Sedimentation speed. Blood tests also measure the degree of inflammation through the sedimentation rate of the red blood cells. The erythrocyte sedimentation rate (ESR) is measured by a laboratory test. An erythrocyte sedimentation rate (ESR) test is also called a sedimentation rate test or sed rate test. The test measures the sedimentation rate of red blood cells (erythrocytes) through the speed at which the red blood cells settle, due to gravity, in an upright, narrow tube of blood. The upper part of the blood in the tube is the plasma, which becomes visible as a column of clear, yellowish liquid after the sedimentation of the red blood cells. The length of this column of plasma is measured after one hour and expressed in millimetres per hour (mm/hour). This blood test does not diagnose one specific condition. Instead, it helps your doctor to determine whether you are experiencing an inflammation. This can be the result of infections (bacteria, viruses), tumors and autoimmune diseases (such as arthritis).
C-reactive protein (CRP) is a substance produced by the liver in response to inflammation. A high level of CRP in the blood is a marker of inflammation. High CRP levels can also indicate that there’s inflammation in the arteries of the heart, which can mean a higher risk of heart attack. However, the CRP test is an extremely nonspecific test and CRP levels can be elevated in any inflammatory condition.
Anemia. There is often a low hemoglobin level in the blood due to the chronic inflammations. The hemoglobin level of the blood indicates whether there is sufficient production and filling of red blood cells. Hemoglobin is responsible for the oxygen transport in the blood and a too low hemoglobin level leads to (severe) fatigue.


The goals of treatment for acute rheumatic fever are to destroy the remaining group A streptococcal (GAS) bacteria, relieve the symptoms, control the inflammation and prevent recurrences of the disease.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs, such as diclofenac, naproxen and ibuprofen. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
• Antibiotics. The doctor will prescribe penicillin or another antibiotic to eliminate remaining strep bacteria. After the full antibiotic treatment is completed, the doctor will begin another course of antibiotics to prevent recurrence of rheumatic fever. Preventive treatment will likely continue through age 21 or until a minimum five-year course of treatment is completed, whichever is longer. If you get a new attack of acute rheumatic fever, you have a chance of recurrence of the symptoms and risk of new heart defects. People who have had heart inflammation during rheumatic fever might be advised to take the preventive antibiotic treatment for 10 years or longer. If your heart valves are already damaged by an attack of acute rheumatic fever, then you will often have to take antibiotics for the rest of your life.
• Aspirin or acetylsalicylic acid (ASA), is commonly used as a pain reliever for minor aches and pains and to reduce fever. It is also an anti-inflammatory drug and can be used as a blood thinner. People with a high risk of blood clots, stroke, and heart attack can use aspirin long-term in low doses.
• An NSAID, an anti-inflammatory analgesic, such as naproxen (Naprosyn) and ibuprofen. These are drugs that are effective against inflammation, swelling, pain, stiffness and fever, but do not prevent joint damage. They do not contain corticosteroids (steroids). There is no proof that any one NSAID is better than others. Your doctor will prescribe these prescription drugs with a higher dose of the active substance. The exact effective dose varies from patient to patient. High doses of short‐acting NSAIDs give the fastest relief of symptoms. Given in the correct dose and duration, these drugs give great relief for most patients.
If symptoms are severe or your child isn’t responding to the anti-inflammatory drugs, your doctor might prescribe a corticosteroid.
• A corticosteroid (an artificial adrenal cortex hormone) is an anti-inflammatory drug that resembles the natural hormone that the body produces in the adrenal cortex. Corticosteroids mimic the effects of hormones your body produces naturally in your adrenal glands, which sit on top of your kidneys. When prescribed in doses that exceed your body’s usual levels, corticosteroids suppress inflammation. This can reduce the signs and symptoms of inflammatory conditions, such as arthritis. Corticosteroids also suppress your immune system, which can help control conditions in which your immune system mistakenly attacks its own tissues.
Anticonvulsant medications. For severe involuntary movements caused by Sydenham chorea, your doctor might prescribe an anticonvulsant, such as valproic acid (Depakene) or carbamazepine (Carbatrol, Tegretol, others).
• If you get an operation at the dentist, have to undergo an operation in the hospital or have a viral or bacterial infection of the upper respiratory tract, then you get extra antibiotics to prevent complications.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side-effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side-effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.


Is resting important?
Yes, besides the medication it is advised to take a lot of rest until the acute symptoms have disappeared.

Can you more often get an attack of acute rheumatic fever?
Yes, because acute rheumatic fever sometimes occurs in recurrent episodes, so you can more often get a recurrent attack.

Does acute rheumatic fever also cure without treatment?
If acute rheumatic fever is not treated, it usually heals itself within about 5 months. The joint inflammation usually heals without lasting consequences. But in the worst case an attack of acute rheumatic fever can also cause complications, so that in case of severe abnormalities you may have to undergo an operation at a later time to repair it.
Fortunately, due to antibiotics, improved hygiene and healthier food, the disease of acute rheumatic fever is no longer so common.

Osmosis I Rheumatic fever & heart disease - causes, symptoms, treatment & pathology

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Osmosis I Rheumatic fever & heart disease – causes, symptoms, treatment & pathology I

Accountability text acute rheumatic fever
The information about acute rheumatic fever (ARF) is general.
Every situation is different, so if you have any questions or complaints, always consult your doctor, medical specialist or pharmacist.

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