The Return of Rheumatic Fever

In recent years it seemed that rheumatic fever, the pediatric scourge of the Thirties and Forties, had gone the way of smallpox and polio. Throughout Texas, rheumatic fever became so scarce that the legislature dropped it from the list of communicable diseases physicians are required to report to the state.

But three years ago, Charles Ginsburg, professor and chairman of pediatrics at the Univer-sity of Texas Southwestern Medical School and chief of staff at Children’s Medical Center, had a hunch he was seeing more cases of rheumatic fever. His chief resident at that time, Dr. Debra Bums, went to work researching that hunch.

Reviewing patient charts at Children’s Medical and Parkland Memorial Hospital, Burns counted sixty cases of rheumatic fever diagnosed from 1976 through 1986. She was surprised to find that slightly less than half of the cases occurred during the last three years of her study. And similar studies, Burns learned, were going on in other cities. Serious increases were found from Utah to Pittsburgh.

Rheumatic fever is an inflammatory disease that may occur after a pharyngeal infection with a group A streptococci-strep throat, in other words. Diagnosis must be based on the combination of several signs, such as clinical proof of a recent strep infection, carditis (inflammation of the heart muscle and valves), flu-like achiness, stiffness in the joints, or a skin rash.

In the past, only about40 percent of rheumatic fever patients contracted carditis, the most serious complication of rheumatic fever, but Bums says that 86 percent of the patients at Children’s Medical and Parkland have had some heart involvement due to the disease. While there have been two deaths among those children because of cardiac complications, nearly half of the patients with car-ditis were discharged with that problem resolved or improved.

As for prevention, that may be impossible. Ginsburg says there is no identified high-risk group and that the bacteria is no respecter of economic lines. Treatment is strict bed rest until all symptoms are gone; often, aspirin is given for treatment of carditis. For children with the most acute heart involvement, steroids are occasionally prescribed. Some of the children with heart valve involvement may require surgery later on.

With only sixty cases reported in these two major hospitals, it’s obvious that rheumatic fever remains rare. Burns, who is now in private practice, says the last thing she wants to do is panic parents into rushing their children to the doctor for every minor symptom. But there are lessons to be learned from the disease’s increased incidence.

“We need a high index of suspicion for unusual looking sore throats, ” she says, Several years ago, pediatricians were wondering if they should be less concerned about sore throats. Less penicillin was prescribed because the chances of complications seemed almost nil. “Now, ” says the doctor, “we know we can’t slacken our watchfulness. “