Rheumatism today is recognized as one of those diseases that are extremely difficult to treat. A specificity of the pathology is its development at an early age and a protracted perennial course. Acute rheumatism is called rheumatic fever. In children, this disease is often found at the age of 7 to 15 years and is accompanied by severe violations in the work of the heart.
Is this ailment dangerous
This pathology belongs to the category of infectious and allergic diseases, which are characterized by damage to the connective tissue and the inclusion of kidneys, liver, lungs, skin, eyes, joints and serous membranes of the central nervous system. Based on the symptoms and clinical recommendations, rheumatic fever in children has a similar course with other systemic collagen diseases. This is a complex immune disorder that most often develops after infection of the body with streptococci.
The mechanism of development of rheumatic fever in children in pediatrics is practically not described. Most experts in this industry consider the cause of the disease to be individual hypersensitivity to toxins produced by streptococci. In fact, damage to the heart and joints, cerebral cortex, skin is the result of a powerful allergic reaction.
Morbidity risk factors
If we take into account the clinical recommendations for rheumatic fever in children, it becomes clear that the disease is induced by infection, but its development can be avoided by timely diagnosis and antibacterial treatment. As a rule, this pathology arises soon after nasopharyngeal ailments - tonsillitis, pharyngitis, scarlet fever, caused by β-hemolytic streptococcus group A. The autoimmune reaction of the body develops due to the massive influx of pathogenic superantigens into the body.
A favorable condition for the occurrence of the disease is the following circumstances:
- weakened immunity;
- stay in a large team;
- frequent hypothermia;
- stressful situations;
- poor social conditions;
- hereditary predisposition.
Pathophysiology of the disease
After β-hemolytic streptococcus is introduced into the body, the immune system begins to actively produce anti-streptococcal antibodies, which, when combined with the antigens of the pathogenic bacteria and components of the complementary system, form the so-called immune complexes. Within a few days, they spread throughout the body and settle on the internal organs, penetrate the tissues, but mainly accumulate in the cardiovascular system. An aseptic autoimmune reaction in the form of inflammation of the connective tissue occurs in the foci of localization of the complexes.
Streptococcal infection antigens have a strong cardiotoxic property, which provokes the formation of autoantibodies, contributing to the aggravation of the situation. Myocardial inflammation increases with repeated infection, hypothermia, stress. When fixing the pathological reaction, a relapse of rheumatic fever in children is observed. The protocol of therapeutic measures and medical history must indicate the recurrence of the disease.
The processes of damage to collagen fibers go through several stages. First, the connective tissue swells, then the smallest fibromas and granulomas form in it. The last stage of rheumatism is sclerosis. In the early stage of mucoid swelling, all ongoing processes are reversible. But if you miss the time and do not start treatment, tissue damage will not be eliminated in the future. As the disease progresses, fibrinoid necrotic changes will begin to appear, irreversibly affecting collagen fibers and cellular elements. At the stage of granulomatosis, numerous rheumatic granulomas form around dead zones. The last phase of rheumatic fever in children (a presentation would make it possible to demonstrate the sequence of pathological changes more clearly) is sclerosis, which inevitably leads to granulomatous inflammation.
Each stage of the disease lasts about 1-2 months, while the entire cycle of rheumatic fever does not exceed six months. Due to relapse of the disease, the tissues are affected repeatedly and, as a rule, in the area of already formed scars. Acquired heart defects are the most dangerous complications of acute rheumatic fever in children. Clinical recommendations come down to the need for a comprehensive diagnosis with the aim of a detailed study of heart valve tissue and the early detection of destructive changes.
Symptoms of the disease
The development of acute rheumatic fever in children (the recommendation of doctors in this case is simple: the child needs to be urgently shown to specialists) are indicated by specific symptoms. In addition to general malaise, fever, headache, characteristic of the common cold, the child has other signs of the disease that cannot be confused with the manifestations of acute respiratory infections:
- abdominal pains;
- pallor of the skin;
- decreased motor activity;
- joint pain and swelling;
- hyperemia and skin sensitivity at the lesion sites.
In children with rheumatic fever, ring-shaped dark red rashes and small nodular formations under the skin in the immediate vicinity of the tendons occur much less frequently. Damage to the membranes of the brain occurs in isolated cases. A more common complication is a change in the tissues of the heart muscle, which leads to a deterioration in the well-being of the child and the development of irreversible processes.
The first symptoms of rheumatic fever in children usually occur between the first and fifth weeks after infection with a streptococcal infection. Each patient may experience manifestations of the disease in different ways, but the most common clinical picture includes:
- Point inflammation in several joints simultaneously, associated with swelling, pain on palpation and redness. Most often, the knees and ankles are affected, much less often - elbows, hands, fingers.
- The appearance of atypical neuromuscular movements in a child, a change in gait, handwriting, sudden distortion.
- Skin rashes. The rash, as a rule, occurs on the back or abdomen, limited to a specific border.
With a prolonged or repeated course of the disease, weight loss, irritability, a feeling of constant fatigue and weakness are not excluded.
Who and when can get sick
The recommendations of doctors are mainly aimed at preventing the disease among children aged 5 to 15 years. At risk, as already noted, there are patients infected with streptococcal angina. Such patients are at a maximum likelihood of developing rheumatic fever. In children, in a family history of which this disease occurs, the chances of its development increase several times.
The peak of exacerbation of rheumatic fever occurs in winter and spring - it is at this time of the year that doctors more often turn to complaints that are characteristic of the disease. In addition, this period is the most favorable for the reproduction of representatives of streptococcal.
Epidemiology of Rheumatism
Rheumatic fever itself is not an infectious contagious disease. Streptococcus itself, the causative agent of tonsillitis, can be transmitted by airborne droplets and by domestic means. This bacterium is common throughout the planet. And if earlier it was believed that the microbe cannot exist in tropical and subtropical countries, today scientists have refuted this version. Rheumatic fever in children is diagnosed in all corners of the globe, but the largest outbreaks occur in countries with low levels of economic development. So, for comparison, we give an example of the average indicators of European regions, where the frequency of detection of the acute form of the disease is on average 0.06 cases per 1000 patients, and African - more than 19 cases per 1000 inhabitants.
In our country in the 90s of the last century, an increase in the incidence of rheumatic heart disease was first detected. The statistical increase concerned the diagnoses established for the first time. Currently, heart defects caused by rheumatic disease cause disability in half the cases of diseases of the cardiovascular system.
Diagnostic Methods
In order to recognize acute rheumatic fever in children, according to the clinical recommendations of leading specialists, in addition to studying the medical history and making an anamnesis, it is important to conduct a comprehensive examination. In practice, most doctors make a diagnosis only if there are criteria included in the content of the Kisel-Jones-Nesterov diagnostic technique. A specialist can suspect a child of rheumatic disease in the presence of one or more indicators, the main of which are:
- carditis (inflammation of the heart);
- polyarthritis (inflammation of several joints);
- chorea (uncoordinated physical activity affecting the hands and face);
- the appearance of subcutaneous nodules on the ribs, shoulder blades, collarbones, knees;
- red inconsistent rash, localized mainly on the trunk.
Secondary diagnostic criteria, according to this technique, are the patient's complaints about:
- persistent increase in body temperature;
- pain in one or more joints;
- soreness in the sternum, arrhythmia.
If you change the electrocardiogram scheme, confirm the abnormal sedimentation rate or the presence of C-reactive protein, the doctor concludes that the body is rheumatic. This will require laboratory blood tests.
This diagnosis is made for patients whose examination confirms at least two main criteria. The combination of two secondary indicators and one basic one is of similar significance. Other signs of streptococcal infection must be taken into account.
In this case, the most accurate diagnostic test to detect rheumatism does not exist. Research methods, the results of which may indicate the course of rheumatic processes, are resorted to in all cases if this pathology is suspected. In addition to blood tests, ECT is mandatory. Thanks to the obtained electrocardiogram or ECG scheme, a specialist evaluates the electrical activity of the heart muscle, reveals abnormal rhythms (angina pectoris or tachycardia). If such violations occur, the patient is referred for an ultrasound scan, during which myocardial damage can be detected.
A less effective way to diagnose rheumatic fever is through a nasopharyngeal swab. When confirming the presence of streptococcal bacteria, the likelihood of rheumatism increases, but it should be borne in mind that at the initial stages of the disease, the result of this test may be false negative.
Treatment of rheumatic fever in children
Therapy of the disease should begin with measures to eliminate foci of chronic infection: treatment or removal of adenoids, removal of inflammation of the nasal sinuses, middle ear and root canal of the tooth. Prescribing drugs for rheumatic fever is the responsibility of the attending physician. The choice of funds for the treatment of the disease depends on several conditions:
- general well-being of the child;
- the presence of concomitant serious illnesses in the medical history;
- the severity of the reaction;
- child tolerance to certain drugs.
In most cases, this disease is the basis for hospitalization. Full medical supervision and nursing care for rheumatic fever in children guarantee the relief of pathology in the early stages and the prevention of complications.
As for drugs, it is impossible to take them on their own without the appointment of a specialist. Treatment of acute rheumatic fever in children involves the use of anti-inflammatory and antibacterial agents.
Antibiotics
Such medications must be taken even if the result of a nasopharyngeal swab is negative against the background of typical indicators of the disease. The antibacterial components of the penicillin series are used, and in case of intolerance - macrolides:
- "Benzatin penicillin."
- "Phenoxymethylpenicillin."
- Amoxicillin.
- "Azithromycin."
- Spiramycin.
- Clamithromycin.
- "Erythromycin."
The optimal duration of a course of antibiotic treatment for rheumatism provoked by streptococcal bacteria is 10-14 days.
Anti-inflammatory drugs
To relieve inflammation, the patient is prescribed non-steroidal, and in complicated cases, hormonal therapy. The maximum effectiveness and safety for children have such NSAIDs, such as:
- "Acelofenac."
- "Mefenamic acid."
- Ibuprofen.
- Diclofenac.
The low therapeutic efficacy of Sodium Salicylate, Analgin and Paracetamol has been proven. These drugs usually produce antipyretic and analgesic effects. Children under seven years of age are not recommended to prescribe "Indomethacin", since this remedy activates sclerotic processes in the lesion, thereby contributing to the rapid formation of heart disease.
If drugs from the non-steroidal group are ineffective in case of a progressive disease, the child is prescribed “Prednisolone” or “Dexamethasone”. At the same time, the dosage of non-hormonal anti-inflammatory drugs is gradually halved, but the drugs do not stop giving for the next 4-6 weeks. The course of treatment with steroid hormones averages 7-10 days.
In the case of periodically recurring and sluggish rheumatism, the child is prescribed "Delagil" or "Plaquenil." Such drugs require long months of use. With their appointment, the dosage of corticoids and NSAIDs is reduced, and after a while they are completely canceled.
How to prevent complications
Prevention of rheumatic fever in children carrying out a range of measures involving the fight against streptococcal infection. By timely preventing infection and passing treatment, including sanitizing the foci of infection, you can create all the conditions for increasing the body's resistance.
Children who have undergone diseases without pronounced signs of damage to the heart valves and do not have foci of chronic infection are prescribed periodic administration of penicillin-type drugs with a prolonged effect. These include "Bicillin-5", "Benzatinbenzylpenicillin-retarpen", "Extentsillin." Drugs are used once every few months for 3 years.
If the child suffered rheumatic heart disease for the first time, has diagnosed lesions of the heart valves and foci of chronic infection, penicillins are used longer - for 5-6 years with the same interval. For children suffering from rheumatic disease, spa treatment is beneficial. Of great importance in the prevention of secondary rheumatic fever is a balanced diet and moderate physical activity.