Rheumatic fever in children

The clinical picture of rheumatism varied and depends on the age and the reactivity of the organism of the child.
In recent years there has been more than a mild case of rheumatic fever in children; affected mainly the cardiovascular system. The disease occurs in the form of acute attacks or is sluggish and latent (more children of preschool age).
Severe circulatory insufficiency is rare and mostly in repeated attacks and constantly recurrent course.
Myocardial damage in rheumatoid arthritis in children is observed in most cases. When developing myocarditis increased body temperature, worsens the General condition, fatigue, headaches, disturbed sleep or appetite, discomfort or pain in the heart area. Weakened apical impulse, and the expansion of the heart, muted tones heart, systolic murmur at the apex of the heart. Sometimes before changes in heart may be volatile joint pain, blurred expressed swelling, redness, quickly disappearing in the treatment. In children of preschool age are marked non-permanent joint pain, often without their visible changes. Sometimes rheumatic fever begins with abdominal pain. In the blood, leukocytosis, and neutrophilia, accelerated ROHE. On ECG typical changes characteristic of myocarditis.
The endocardium most often affected by repeated attacks (attacks), less often - in primary rheumatism. Endocarditis is the main reason of education of heart defects in children; usually develops on the background of acute rheumatic process, as a rule, occurs in 2-3 weeks after infection. Body temperature increases up to 39-40°, deteriorating overall health, growing pale skin. Characterized by increased systolic noise after the disappearance of the main symptoms of myocarditis, resistance it by changing the position, and the expansion of the heart and persistent increase in left ventricular on the radiograph; often appears, see diastolic murmur in the II and III intercostal space to the left of the sternum; liver increased damage valves, the aorta. In the blood, leukocytosis, and neutrophilia, accelerated ROHE. ECG without deviation from the norm.
Persistent expansion of the left border of the heart, acceptance II tone pulmonary artery, strengthening of left ventricular hypertrophy indicate mitral valve insufficiency.
Defeat all of the membranes of the heart is rare and is a severe manifestation of rheumatism; there is a combination of symptoms myo-, endo -, and pericarditis. The development of pancarditis accompanied by a deterioration of the General condition of the child.
Relapses often occur early after the first attack and have a slow, prolonged course. Sometimes temperature rises, there has been a General malaise, small changes in the blood. Relapse lead to the formation of the heart diseases.

The peculiarity of rheumatic fever in children are denominated exudative manifestations contributing to the severity of the disease and the tendency to frequent recurrence of the process. The smaller the child's age at the time of the first attack, the more often relapse of the disease, the harder the heart of defeat.
The expression of the major and minor characters rheumatism A. I. Nesterov distinguishes three levels of activity of rheumatic process (see above).
The clinical picture and diagnosis. Clinical manifestations of the active phase of rheumatoid arthritis is very diverse. But the defeat of the heart determines the severity and prognosis of the disease. Most typically combined involvement in the process of m & e-, endo -, and pericardium (milindaraja, pancarditis). However, there are cases and isolated or preferential myocarditis or endocarditis. This usually occurs at a moderate severity of the disease.
The clinical picture of myocarditis varies depending on the extent of damage to the heart muscle. Myocarditis in most cases is developing along with other manifestations of active rheumatoid arthritis. Attack of rheumatism often occurs after 1.5-2 weeks after sore throat, respiratory catarrh, scarlet fever. The patient complains of weakness, headache. The temperature may be elevated for several days, then gradually returning to normal. Broken General condition of the patient. See the weakness, paleness of skin often with cyanotic tint the lips and nails. May be discomfort and pain in the heart area. Pulse frequent, reduced filling. Blood pressure is slightly lowered. Shortness of breath. Border cardiac dullness usually in varying degrees expanded. Muffled heart sounds. At the top is often bugged trinomial rhythm [Gallop rhythm (see)] at the expense of a third heart sound, which is enhanced by reducing the tone of the myocardium. Systolic murmur soft, short, not held outside the heart region, not worse after exercise.
In the first days of the disease is often observed tachycardia. On the 2nd week she often followed bradycardia (vagus-phase of arthritis).
The defeat of the heart muscle is reflected on the ECG. Most typical: violation AV and vnutrijeludockova conductivity (increase the interval P - Q, and the widening of the QRS complex); violations heart rhythm (tachycardia, aetiology, arrythmia, nodal rhythm); decrease of voltage peaks; the offset segment S-T; increase of systolic and systolic indicator.
On FCG patients with myocarditis is determined by decreasing the amplitude and the broadening of the first tone, the emergence of III and IV tones, systolic murmur of small amplitude (N. M. Kogan, M. K. Oskolkov).
Acute lesion of the heart muscle is confirmed by the dynamics of these indicators FCG and ECG (Fig. 9). In severe diffuse myocarditis expressed signs of circulatory failure.

Fig. 9. Electrocardiogram of the child 13 years. Acute rheumatic endomyocardial: 1 - 4th day of illness, the P - Q=0,35"; 2 - to 6-day sickness P - Q= 0,24"; 3 - to 8-day sickness P - Q=0,18".

Systolic murmur of myocarditis in nature similar to the "functional" muscle noises. But at last the border hearts remain within the normal range, usually no violations of heart rhythm, ECG changes other than myocarditis, laboratory studies do not indicate the activity of rheumatism.
It is necessary to differentiate myocarditis rheumatism from allergic postirochnaja myocarditis. In most cases it develops soon polovinoi infection occurs hard, causing circulatory failure. Severe rheumatic myocarditis almost never isolated, accompanied, as a rule, endocarditis and extracardiac manifestations of the disease.
Rheumatic endocarditis in children is most often affects the mitral valve. Common manifestations of the disease are not different from those in patients with myocarditis, but when endomyocarditis they are generally heavier. Cases of rheumatic heart disease with predominant: the defeat of the endocardium can sometimes occur when a satisfactory General condition of the child. Decisive in the diagnosis of endocarditis are auscultation of the heart and phonocardiogram. In a patient with endomyocarditis in the first days of the disease on the background of muted colors of the heart and often three-member of the pace at the top and in the fifth point is listening short mild systolic murmur. However, in the 2nd week of illness noise becomes longer, coarser, takes blowing nature, increases after exercise, launched the left from the top (Fig. 10). On pulmonary artery appears the focus of the second tone. Thus, systolic murmur gradually acquires the features of organic noise of mitral valve insufficiency, caused not yet by hardening, and acute rheumatic valvulitis which can be exposed to the opposite development.
Some children in the acute period of the active phase of rheumatoid arthritis, along with systolic noise at the apex of the heart appears, and mediastrategy noise that no symptoms of the infection of the endocardium is not observed. As a result of swelling and infiltration of valve cusps, its fibrous ring and chords, there is a certain narrowing of the mitral orifice, with the consequence is mediastrategy noise (Og, Solomatina). Such children is endocarditis with a defeat of the mitral valve, causing not only the symptoms of mitral regurgitation, but the symptoms narrowing of the left atrioventricular holes (Fig. 11).
The first manifestation of defeat valve of aorta is prettiesiski noise in the fifth point. First, the noise is very soft, not conducted from the projection of the aortic valves. In the future, as more deformation of valves from valvulitis or sclerosing noise becomes longer and listening in II intercostal space to the right and to the left of the sternum, but the voice of noise remains soft. To reveal the "peripheral arterial symptoms": pulsus celer et altus, capillary and articulation pulse, reinforced ripple carotid arteries, the colours on the hip and elbow arteries without overlap cuff, low minimum blood pressure. With the defeat of valvular aortic more often than another localization process, there are aortic and coronaria. Clinically they are a pain in the chest, and rapid changes in the ECG of teeth, G, Q and offset segment 5,
Early detection mediatormessage and protohistorical noise is extremely important as it indicates heavy endomyocardial and requires active treatment, which in some cases may decrease the processes of scarring and prevent the formation of heart diseases.
The clinical picture of endocarditis on the background of heart defects is defined as the localization of acute valvulitis and existing disease (Fig. 12 and 13).

Fig. 10. Phonocardiogram with the apex of the heart of a child 5 years. Active endomyocardial with the defeat of the mitral valve: 1 to 3-day sickness; 2 - 15-th day of illness (top ECG in the second lead).
Fig. 11. Phonocardiogram with the apex of the heart of a child of 9 years. Acute rheumatic endomyocarditis with the defeat of the mitral valve: the first tone broadened, systolic murmur-the second and third tones, mediastrategy noise (at the top of the ECG second lead)
Fig. 12. Radiograph heart rheumatic endomyocarditis on the background of the combined mitral valve.
Fig. 13. Radiograph heart rheumatic endomyocarditis amid metrolina-aortic insufficiency.
Fig. 14. Radiograph heart rheumatic polyserositis. Pancarditis on the background of the combined mitral valve and bilateral pleural effusion.

The defeat of the endocardium of the heart valves and the subsequent development of vices is a cardinal symptom of rheumatoid arthritis. Among other diseases affecting the endocardium, it should be noted septic endocarditis (see) and systemic lupus erythematosus (see), in which endocarditis is usually near-wall character and leaves no valvular.
Pericarditis is more likely to occur with repeated attacks of rheumatic fever. The child's condition is severe. Often children polusidya, leaning his chest on the pillow. Pain
and a feeling of heaviness in the heart. Shortness of breath, tachycardia, increased liver, often vomiting. Borders of heart in varying degrees expanded. Pericarditis with limited effusion is often not accompanied by the usual symptoms and may not be diagnosed. The main feature is a noise pericardial friction. In patients with massive effusion heart sounds sharply muted, expressed circulatory failure. The radiological examination border heart expanded his shadow can be spherical or triangular shape (Fig. 14). Characteristic ECG: a decrease in the total voltage, sharp deformation of the T wave, offset segment S - So
Pericarditis may be terminated by resolution of exudates or obliteration pericardium cavity. Rheumatic pericarditis should be distinguished from pericarditis in systemic lupus erythematosus, rheumatoid Wissler - Fanconi's syndrome, tuberculosis. The main difference is that pericarditis rheumatism, usually combined with damage to other shells heart (pancarditis) and extracardiac manifestations of rheumatism, as these diseases have their characteristic features.
Among extracardiac manifestations of rheumatism arthritis is more common. As adults, usually affects the middle joints of the knee, elbow, wrist, and ankle. Arthritis small and large (TASO-femoral, shoulder joint is rare. Arthritis currently have children is netzero, lasts 2-3 days and is characterized by volatility and the lack of subsequent deformation.
Rheumatic fever should be differentiated with infestation. The last commonly affects the small joints, causing deformation. Less rheumatic arthritis have to differentiate with hemorrhagic vasculitis, brucellosis, osteomyelitis, tuberculosis, leukemia. None of these conditions does not proceed with the typical for rheumatic heart damage.
In the first days of the attack of rheumatic fever in children sometimes there is abdominal syndrome (see), which consists in appearance of abdominal pain, and sometimes vomiting. Unlike appendicitis pain in abdominal syndrome rheumatism often fickle, without clear localization. During sleep, the child does not respond to palpation of the abdomen, muscle tension of the abdominal wall disappears. When appendicitis pain is constant during sleep, muscle tension persists, the child wakes up in pain on palpation. Rheumatism with severe exudative component, the manifestation of which is the abdominal syndrome, there are headaches, temperature up to 38 - 39C, ROE 40-50 mm Appendicitis not accompanied by headache, fever early in the disease does not reach such high numbers, ROE in the range of 20-30 mm (C. D. Ternovskii).
Pleurisy and pneumonia developing on the background of the typical picture of a severe attack of rheumatism. At present these symptoms of rheumatic fever are rare, and in children with the presence of polyserositis and polivitaminov required differential diagnosis with other collagen diseases.
Kidney damage in rheumatoid arthritis in children can be of different nature. 1. In the first days of the disease during expressed toxicosis urine may cause a small amount of protein (0,033-of 0.066%0), single red blood cells and hyaline cylinders. Changes are kept for several days and disappear together with the elimination of toxic (toxic kidney). Special treatment is not required. 2. Rheumatic jade (one of visceral manifestations of rheumatism) usually detected at the height of the active phase. Most often occurs in the form gematrical form with a favorable course. Jade requires persistent Antirheumatic therapy, as well as activities necessary for jade.
3. Patients with rheumatism with circulatory insufficiency II and III extent in the urine may be changes associated with congestive phenomena and disturbance of trophism body - congestive kidney. When layering on rheumatism septic phenomena in urine often pathological changes.
Anularea (ring) rash in children is observed more often than in adults. The lesions are kind of pale pink rings, located more often on the chest, back, shoulders. Usually they are not rich, not accompanied by itching and saved from several hours to several days, leaving pigmentation. May recur. In the active phase of rheumatoid arthritis sometimes there urticarnae skin rashes.
Rheumatic nodules are observed in severe course of the disease and testify about the activity of rheumatism. However, in recent years they are comparatively rare. Nodules are often in the joints, is at hand. They are not soldered with the skin, but are connected with the subject ' tendon, ligament. At offset skin nodule remains stationary. The sizes of the knots from millet grain to large hazel, the skin above them is not changed, they are painless and can be singular and plural.
Chorea (see) is a form of nervous system at rheumatism and refers to the basic signs of the disease. The first manifestation horei is changing the behavior of the child: irritability, deterioration of handwriting, gramatycznie. Then there hyperkinesia, incoordination, muscular hypotonia. Often the hyperkinesia apply to the muscles of the face, neck, and extremities. To identify impaired coordination apply knee-heel and paltsenosovaja samples. Light hyperkinesia you can see, applying the method Filatov (the doctor takes the child's hand in his and feels twitching). Can be a symptom of mobiles (indrawing of the anterior abdominal wall, with breath instead of its protrusion), symptom "flabby arms", a symptom of "eyes and language". Severe disease is manifested in the form of "koreizskoe storm" - hyperkinesia so strong that the child is in continuous motion, could not sit up or hold objects there. When the attacks of rheumatic fever occurring in the form of horei, heart damage often not severe. However, some patients, especially when late and inadequate treatment can be detected and significant heart changes. Blood tests with trochaic not give typical for rheumatism shifts. When combined horei with carditis in the analysis there are characteristic changes. Horey must be differentiated from nahoriansky hyperkinesia when ticks and stereotypical obsessive movements, which often observed in children. When these conditions are observed motion only the election of muscle groups, no hypotension and other symptoms horei.