'Over-diagnosis' problem in rheumatic fever in children
Joint pain in children is a very common problem in our country. It can be due to a number of causes. Some causes are benign and require only assurance. Some serious pathological correlations must be excluded, of course. The term 'Rheumatic fever' (RF) is somehow common in society. Very often parents get confused with joint pain of their children. Some misconceptions among various level of health care provider (and also non-medical person) could result in 'over' and 'wrong' diagnosis and obviously irrational medication to such so-called 'Rheumatic fever'.
Well, some basic facts regarding RF should be cleared first. It has a correlation with infection with a certain type of bacteria, called Group A Streptococcus (GAS). Patients usually have a upper respiratory tract infection few weeks back. The incidence of both initial attacks and recurrences of acute RF peaks in children 5-15 yr of age, the age of greatest risk for GAS pharyngitis. Patients who have had an attack of acute RF tend to have recurrences, and the clinical features of the recurrences tend to mimic those of the initial attack.
To diagnose a case of RF clinician depends on revised (2015) Jones criteria. According to this, some 'major', and 'minor' criteria as well as evidence of GAS infection must be defined.
* Erythema marginatum
* Subcutaneous nodules
* Sydenham Chorea
* Blood: Elevated ESR/CRP
* ECG: Prolonger P-R interval
Evidence of GAS infection
* + throat culture or RSA test
* Elevated/increasing ASO titre
Acute initial attack of RF is only diagnosed if the patient has either:
* 2 major manifestations, plus evidence of recent GAS infection or
* 1 major and 2 minor manifestations, plus evidence of recent GAS infection.
Treatment: The treatment of RF is also complex and sometimes lengthy. Clinician aims to eliminate current infection, relieve symptoms and prevent complication. It needs clear evaluation of disease extent. Prevention is very crucial. Primary prevention is aimed to disease occurrence in a patient with only respiratory infection. Secondary prevention is directed at preventing acute GAS pharyngitis in patients at substantial risk of recurrent acute RF. Currently the idea of tertiary prevention is discussed to reduce symptoms to minimize disability and to prevent premature death in rheumatic heart disease patient.