Clinical course and the diagnosis of rheumatic fever

In the evolution of the rheumatic process and the formation of the clinical symptoms of the disease can be distinguished three main periods. In the first period - the period of streptococcal infection (sore throat, exacerbation of chronic tonsillitis) and after its liquidation in the body, forming an allergic reactivity, which, however, expressed clinically apparent. II although this period can be detected with reasonable dysproteinemia and some acceleration ROHE, the doctor does not find neither General nor organ manifestations rheumatic diseases. In the second period, after 7 to 10 days to 15 days after a previous streptococcal infection, sometimes under the influence of cooling, fatigue, other infections, often against the background of apparent prosperity arise clinical manifestations giperergicakie tissue reactions in the form of rheumatic polyarthritis or carditis, or horei, i.e., the syndrome of the first attacks of rheumatic fever with a characteristic display it in the reaction temperature, changes in blood and serological parameters, if rheumatism not leak latent.
Finally, the third period rheumatic disease with a strong allergic and probably already autoimmune reactivity, with a deep and persistent violation of immunogenesis is characterized by advanced pattern of progressive relapsing suffering. From a clinical point of view of the third period of the disease is expressed in all variety of clinical symptoms of rheumatism: syndrome of recurrent rheumatic heart disease, recurrent horei, serosity, jade, etc.
Currently, there are four basic options for the start of clinical disease. Most often, the disease develops slowly and gradually, with prodromal symptoms such as discomfort, unexplained weakness, decrease in appetite, sweating, pulling pain in the extremities, headaches in children - nasal bleeding, decrease of interest in school classes. To these common symptoms of a prodromal period then join signs visceral pathology, mainly in the form of rheumatic heart disease.
The second option is the beginning of rheumatic fever is cardio-articular form. It is characterized by sudden sharp rise of temperature to 38-39° after 1-2 weeks of angina or acute exacerbation of chronic tonsillitis, sometimes after cooling, operations, personal injury. Simultaneously with increasing temperature or 1-2 days after that develops a picture of acute or subacute arthritis with alternating swelling symmetric joints, the neutrophilic leucocytosis, dysproteinemia in the form of increase of alpha-two-globulins, increased fibrinogen and acceleration ROHE. After 2-3 weeks the symptoms usually already fading arthritis join symptoms visceral pathology - of rheumatic heart disease, sometimes pericarditis, pleuritis.
Third, the presently observed quite often a clinical variant of onset, occurring mainly among school-age children or adolescents, initially characterized by almost full absence of clear symptoms of the disease. On closer questioning of children and their parents can, however, be noted some malaise, lethargy, fatigue, loss of appetite, light arthralgia, nosebleeds, unpleasant fleeting feelings in the heart area. Objectively asthenia, paleness of skin, sweating, respiratory arrhythmia, noticeable increased heart rate at a moderate physical activity. Auscultation of the heart is unclean, overextended, crushed the first tone, sometimes easy systolic murmur at the top, the focus of the second tone on the pulmonary trunk, often third tone at the top. ECG - respiratory arrhythmia, reduced voltage peaks, in the study of blood - normal or slightly accelerated ROHE. As you can see, described the syndrome is so fuzzy, often because of age-related reactions, or if it is combined with transferred angina or acute exacerbation of chronic tonsillitis, under the diagnosis of consilierilor syndrome, influenza, and so on, often described the disease onset is replaced seemingly complete well-being and ill continuing training, participates in sports, and so on; then, when the relapse of the disease or when the next medical examination as if he suddenly detected mitral heart disease, more often mitral valve insufficiency. Latent development of rheumatic process, supported histomorphologically control, has allowed to call this form of outpatient rheumatism (M. M. Kutyin, such as Talalaev). While we do not have reliable statistics on the incidence of various debuts rheumatism, however, many clinicians confirm the considerable frequency of the outpatient variant of the disease.
In connection with the change of reactivity of people, and maybe change the pathogenic properties of Streptococcus currently almost never occurs fourth option beginning of rheumatic fever, which was mentioned often by doctors of the previous generation and severe clinical picture reminded typhoid fever (typhoid form) or miliary TB, tubercular meningitis. This form with a quick sharp rise of temperature up to 40-41°, weakness and prostration during 5-7 days were followed then the picture visceral rheumatism in the form of diffuse rheumatic heart disease, rarely polyarthritis, serosity (pleurisy, peritonitis, pneumonia, and other). In today's very rare to see a light form of the debut rheumatism with the rapid rise of temperature up to 39C, satisfactory General condition and the subsequent identification of the symptoms of visceral disease.


Although rheumatoid arthritis occurs in very diverse clinical forms, revealed already in the described variants of onset, and in various course and the outcome has evolved over the last decade due to changes in the General reactivity and application of new active methods of treatment and prevention of disease,yet for the doctor has practical value picture common symptoms of the disease. With the exception of outpatient forms of rheumatism, its usually precedes tonsillar acute or sub-acute streptococcal infection (sore throat, pharyngitis, sinusitis and others) with subsequent bright interval 1-2, less than 3 weeks.
Already in this period, some patients were accelerated ROHE, subfebrile temperature (when multiple dimension), fatigue, sweating, sometimes small arthralgia. Under the influence of new infection or cooling, fatigue, sometimes regardless of increased temperature, considerable weakness, weakness, loss of appetite, headache, arise out of or are enhanced arthralgia, palpitations, shortness of breath at moderate physical stress, discomfort or mild pain in the heart, paleness of skin, reduction of arterial blood pressure, tachycardia, ECG changes indicating pathology of the heart (reduction of voltage main teeth, violation of AV conduction, extrasystoles, and others). At the heart damage may indicate a small or moderate increase of the left ventricle, the decrease in the amplitude of pulsations of the heart on roentgenogram, sometimes pleuropericardial adhesions, auscultation - the weakening of the first tone at the top and soft systolic murmur, occupying 1/3-1/2 of the first pause, sometimes the focus of the second tone on pulmonary artery, the emergence of the third tone phonocardiogram and while listening, i.e., the signs of affection of cardiac muscle.
In children with diffuse rheumatic heart disease can show the signs of circulatory disorders (congestion in the lungs, liver, on the periphery). The other cardinal signs of rheumatic fever (subcutaneous nodules, erythema annulare, polyarthritis, chorea)prior described the syndrome, as well as the positive effect Antirheumatic therapy can confirm the diagnosis.
Due to the Commonwealth in research clinicians, therapists, pediatricians and morphologists has formed an idea of rheumatism how about the system of cardiovascular disease. Constantly and significantly increased capillary permeability rheumatism in active phase, and involvement in rheumatic process heart muscle, serous of the skin, the Central nervous system and other critical systems and organs usually associated with generalized rheumatic affection of capillary-tissue structures.
Capillarity, nodular lesions and periarteriit is the most common form of vascular pathology in rheumatoid arthritis. Thrombovascular is the second most important form of rheumatic diseases of vessels at rheumatism and related heart attacks the lungs, liver, kidneys, spleen, thrombosis of cerebral vessels, less trombozov coronary arteries, which is probably caused by defeat of the smaller arteries, are well compensated collateral circulation.

Pleurisy rheumatic frequency is on the second place after tuberculosis. It is often combined with pericarditis, rarely polyarthritis and is rarely seen without these manifestations of rheumatism. In children rheumatoid pleurisy occurs more often than in adults, the clinical picture is no different from other toxico-allergic pleurisy (see).

For rheumatism characteristic greater tendency to relapse, first of all children of school age. The symptomology of the recurrence of diseases to some extent repeats the primary attack. However, if recurrences of rheumatic fever are less clearly symptoms exudative-allergies, arthritis, pleural effusion, pericarditis exudative) and more often and in more significantly, there are signs of circulatory failure, than during the initial attack. Circulatory failure at low current forms of rheumatic fever is one of the earliest and most reliable reference points for the definition of relapse. It appears the earlier and is the greater, the more relapses was preceded by its appearance, the less persistent and long-held their treatment and the less favourable environments and work in a particular patient.
Clinical experience leaves no doubts that less than circulatory insufficiency respond to therapy, the more active rheumatic process and greater degree is caused them defeat valvular heart and the heart muscle (myocarditis, myocardiosclerosis, myocardiodystrophy).
To determine the degree of activity of rheumatic process (rheumatic heart disease) according to the adopted in 1964, the classification and nomenclature of rheumatism, it is recommended to use the developed by the Institute of rheumatism (A. I. Nesterov) criteria activity.