Article 1: How Rheumatic Heart Disease Affects the Functions of the Body

Sore throat caused by some strains of Streptococcus bacteria may turn into rheumatic fever or rheumatic heart disease. This article explains the pathophysiology of the disease and some treatment interventions. Rheumatic heart disease (RHD) is a severe complication occurring after a rheumatic fever (RF) episode. Rheumatic fever is an inflammatory disease that develops after being infected by the group A beta-hemolytic Streptococci bacteria. It is commonly seen in children 5 to 15 year old, although RF can also develop in adults. Rheumatic fever usually starts as a simple sore throat, but its complications can be life-threatening. A number of acute RF patients may develop various degrees of carditis, an inflammation of the tissues of the heart, with accompanying valve insufficiency, pericarditis, heart failure and sometimes, even death. Patients with chronic RHD may also have valve stenosis or narrowing of the heart valves with various degrees of valve regurgitation, ventricular dysfunction and arrhythmias or irregular heart rhythms. The cause of acute RF and RHD is still not clear, but it is thought to be an autoimmune disease.

Pathophysiology of Rheumatic Heart Disease

RF generally occurs in children and adolescents after an episode of upper respiratory tract infection (URTI) caused by the group A beta-hemolytic Streptococcus bacteria. The bacteria attach themselves to the epithelial cells of the respiratory tract and produce substances or enzymes that cause destruction to the surrounding tissues. Symptoms of the inflammatory process usually manifest after two to four days of incubation period and these include high fever, sore throat, headache, body weakness, and increase in WBC count. URTI caused by these bacteria are often contagious and spreads easily through oral and respiratory secretions. Most individuals who get treatment and those with strong immune systems usually recover from the infection without complications. Some patients however, about 3% of them, may develop RF several weeks after the infection has resolved. A serious complication of RF is rheumatic heart disease. It is believed that certain proteins produced by the group A Streptococci are structurally similar to those found in the heart. The immune system reacts to the presence of bacteria by producing specific substances, called antibodies, to attack them and stop their spread inside the body. But as these antibodies attack the bacteria, some of them also attack or cross-react with the tissues in the heart, and this often results in the manifestation of many RHD symptoms, like carditis, endocarditis, pericarditis and myocarditis. When the heart muscles are affected by inflammation, the result is myocarditis. Pericarditis occurs when there is inflammation of the sac that surrounds the heart, and endocarditis happens when the inner layer of the heart is involved in the inflammatory process.

Rheumatic Heart Disease Treatment

Treatment for rheumatic heart disease intends to get rid of the streptococcal infection, give relief to symptoms and prevent recurrence of the disease. Medications often given to patients include antibiotics, anti-inflammatory drugs and other medications to treat the heart problems.

Article 2: Pathophysiology Of Rheumatic Heart Disease

Since the disease occurs primarily as a result of sore throat, through a specific group of organism i.e. group A streptococcus, therefore, prophylaxis of RF /RHD means prevention of sore throat. But the prevention of sore throat is not so simple as it may appear to be. There are a large number of cases of sore throat, and most of them are viral in nature, and out of the bacterial infection only a small number may be related to the specific organism i.e. group A streptococcus, responsible for RF /RHD. These specific organisms can only be identified if a throat swab is taken of each and every child for culture of the organisms. It may not be feasible in a disease like sore throat which is so commonly prevalent and subsides even without treatment in many of the cases, i.e., it is a self-limiting disease. Due to the above reasons, it is not possible to detect the occult/hidden cases of sore throat as a result of group A streptococcus in a mass survey/check-up of children, as for example in various schools and colonies etc., because throat culture takes 48-72 hours, and there is no kit for quick detection of cases. However, as a general prophylaxis sore throat should be immediately treated, irrespective of the causative organism, especially in children/adults for the prevention of RF /RHD. Doctors, especially pediatricians, can play a significant role in explaining to parents, especially mothers, for immediate treatment of sore throat in their children whenever it occurs. Teachers in schools also play an equally important role in this respect. A long-term drug prophylaxis should be given to all children/ adults, who once suffered an attack of RF /RHD, for the protection of the throat against streptococcal infection. The duration of prophylaxis differs from case to case, as the incidence of the disease decreases as age advances. This drug prophylaxis may be given till the child reaches the adult age, or for five years after the last attack of RF /RHD. Once the prophylaxis is withdrawn, great vigilance is required, and the child/ adult should take proper treatment for sore throat as and when it occurs. However, drug prophylaxis may be required almost forever/lifelong, especially in cases which exhibit permanent signs of valvular /rheumatic heart disease. These damaged valves need foolproof protection against infection, and due to this reason, drug prophylaxis is given continuously. Long-acting antibiotics, like penicillin, is given in such cases every month; some advocate it every three weeks. In the case of children, the concerned parents must see to it that the child is strictly administered a regular course of antibiotic, as explained/motivated by their physician. Also, all cases of RHO should take a short course of antibiotics (besides the long-acting antibiotics they are taking monthly) before undergoing any operative procedure, either minor or major, as for example dental extraction etc., as more virulent bacteria are likely to enter the blood from the area of operation leading to gross infection of the already damaged valves of the heart, called subacute bacterial endocarditic (SBE), which requires emergent measures to save the heart from damage. In that case strong antibiotics will be required to tide over the crisis. As a part of prophylaxis, it is also important that the warning signals of rheumatic fever, must be known to all, especially parents/teachers and those at the rural level. The children should be immediately treated

on the very first attack .of RF, and drug prophylaxis should be started without any delay. Above all, since the disease occurs as a result of the infection of throat, proper hygienic conditions must be maintained for the prevention of sore throat / RF /RHO. This is the reason that people living in overcrowded/highly-populated, damp colonies/slums etc. become highly prone to this disease. Good food is also necessary for the prevention of this disease. Summing up, it may be said that in order to achieve everlasting prevention, socio-economic factors as a whole, including especially the living conditions as well as the nutrition of the people, have to be improved, particularly among the lower strata of society. The people are required to be educated through various media regarding the dangerous consequences of ~ore throat, and that any sore throat must be treated promptly whenever it occurs. Of course, an early detection/treatment of cases which have already picked up the disease will be essentially required. For this all, we need a national strategy / programme, and only then we can hope to prevent this disease which is still one of the major health hazards in many developing countries. It is earnestly hoped that a streptococcal vaccine will soon be available, which may indeed prove to be a breakthrough in the prevention of this disease.