Etiology and Treatment

The disease is caused by infection, most often of the throat, with type A beta-hemolytic strains of streptococcus. Fever, migratory joint pains and tachycardia, the most frequent symptoms, typically begin 1 to 3 weeks after the onset of untreated streptococcal pharyngitis. However, only 0.1 to 3.0 percent of untreated bouts of this infection result in a first attack of rheumatic fever. Consequently, various largely unidentified permissive factors must participate in initiating the immunologic pathogenesis of the disease.

First attacks of acute rheumatic fever can be prevented by timely treatment of the streptococcal infection with penicillin or another appropriate antibiotic, but such treatment does not influence the course of the disease once it has begun. Rheumatic fever recurs only as a result of a new infection with a pathogenic strain of streptococcus. Prophylactic antibiotic treatment diminishes, but does not eradicate recurrences (Taranta et al. 1964). The shorter the interval since the previous bout of rheumatic fever, the greater is the likelihood that a new attack will be elicited. An infection that occurs within 2 years of an attack has a 20 to 25 percent chance of inducing a recurrence. If the first attack does not affect the heart, a recurrence usually spares it as well, but if the heart has been involved, a second bout it likely to result in greater damage (Spagnuolo, Pasternack, and Taranta 1971). An attack of rheumatic fever usually lasts several weeks, but is rarely fatal. Death most often is a consequence of chronic heart failure, which is the end result of damage to heart valves (predominantly the mitral and aortic valve). Rheumatic heart disease in about one-half the cases develops in the absence of any history of acute rheumatic fever, the infection having slightly initiated the pathogenic immunologic mechanism in the heart (Vendsborg, Hansen, and Olesen 1968).

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