Rheumatic fever

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Rheumatic fever
Other namesAcute rheumatic fever (ARF)
Rheumatic heart disease, gross pathology 20G0013 lores.jpg
Rheumatic heart disease at autopsy with characteristic findings (thickened mitral valve, thickened chordae tendineae, hypertrophied left ventricular myocardium)
Specialty Cardiology
Symptoms Fever, multiple painful joints, involuntary muscle movements, erythema marginatum [1]
Complications Rheumatic heart disease, heart failure, atrial fibrillation, infection of the valves [1]
Usual onset2–4 weeks after a streptococcal throat infection, age 5–14 years [2]
Causes Autoimmune disease triggered by Streptococcus pyogenes [1]
Risk factors Genetics, malnutrition, poverty [1]
Diagnostic method Based on symptoms and infection history [3]
Prevention Antibiotics for strep throat, improved sanitation [1] [4]
TreatmentProlonged periods of antibiotics, valve replacement surgery, valve repair [1]
Frequency325,000 children a year [1]
Deaths319,400 (2015) [5]

Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. [1] The disease typically develops two to four weeks after a streptococcal throat infection. [2] Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum. [1] The heart is involved in about half of the cases. [1] Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. [1] The damaged valves may result in heart failure, atrial fibrillation and infection of the valves. [1]

Contents

Rheumatic fever may occur following an infection of the throat by the bacterium Streptococcus pyogenes . [1] If the infection is left untreated, rheumatic fever occurs in up to three percent of people. [6] The underlying mechanism is believed to involve the production of antibodies against a person's own tissues. [1] Due to their genetics, some people are more likely to get the disease when exposed to the bacteria than others. [1] Other risk factors include malnutrition and poverty. [1] Diagnosis of RF is often based on the presence of signs and symptoms in combination with evidence of a recent streptococcal infection. [3]

Treating people who have strep throat with antibiotics, such as penicillin, decreases the risk of developing rheumatic fever. [4] In order to avoid antibiotic misuse this often involves testing people with sore throats for the infection; however, testing might not be available in the developing world. [1] Other preventive measures include improved sanitation. [1] In those with rheumatic fever and rheumatic heart disease, prolonged periods of antibiotics are sometimes recommended. [1] Gradual return to normal activities may occur following an attack. [1] Once RHD develops, treatment is more difficult. [1] Occasionally valve replacement surgery or valve repair is required. [1] Otherwise complications are treated as usual. [1]

Rheumatic fever occurs in about 325,000 children each year and about 33.4 million people currently have rheumatic heart disease. [1] [7] Those who develop RF are most often between the ages of 5 and 14, [1] with 20% of first-time attacks occurring in adults. [8] The disease is most common in the developing world and among indigenous peoples in the developed world. [1] In 2015 it resulted in 319,400 deaths down from 374,000 deaths in 1990. [5] [9] Most deaths occur in the developing world where as many as 12.5% of people affected may die each year. [1] Descriptions of the condition are believed to date back to at least the 5th century BCE in the writings of Hippocrates. [10] The disease is so named because its symptoms are similar to those of some rheumatic disorders. [11]

Signs and symptoms

A culture-positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old Pos strep.JPG
A culture-positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old

The disease typically develops two to four weeks after a throat infection. [2] Symptoms include: fever, painful joints with those joints affected changing with time, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum. The heart is involved in about half of the cases. Damage to the heart valves usually occurs only after several attacks but may occasionally occur after a single case of RF. The damaged valves may result in heart failure and also increase the risk of atrial fibrillation and infection of the valves. [1]

Pathophysiology

Rheumatic fever is a systemic disease affecting the connective tissue around arterioles, and can occur after an untreated strep throat infection, specifically due to group A streptococcus (GAS), Streptococcus pyogenes . The similarity between antigens of Streptococcus pyogenes and multiple cardiac proteins can cause a life-threatening type II hypersensitivity reaction. [12] Usually, self reactive B cells remain anergic in the periphery without T cell co-stimulation. During a streptococcal infection, mature antigen-presenting cells such as B cells present the bacterial antigen to CD4+T cells which differentiate into helper T2 cells. Helper T2 cells subsequently activate the B cells to become plasma cells and induce the production of antibodies against the cell wall of Streptococcus. However the antibodies may also react against the myocardium and joints, [13] producing the symptoms of rheumatic fever. S. pyogenes is a species of aerobic, cocci, gram-positive bacteria that are non-motile, non-spore forming, and forms chains and large colonies. [14]

S. pyogenes has a cell wall composed of branched polymers which sometimes contain M protein, a virulence factor that is highly antigenic. The antibodies which the immune system generates against the M protein may cross-react with heart muscle cell protein myosin, [15] heart muscle glycogen and smooth muscle cells of arteries, inducing cytokine release and tissue destruction. However, the only proven cross-reaction is with perivascular connective tissue.[ citation needed ] This inflammation occurs through direct attachment of complement and Fc receptor-mediated recruitment of neutrophils and macrophages. Characteristic Aschoff bodies, composed of swollen eosinophilic collagen surrounded by lymphocytes and macrophages can be seen on light microscopy. The larger macrophages may become Anitschkow cells or Aschoff giant cells. Rheumatic valvular lesions may also involve a cell-mediated immunity reaction as these lesions predominantly contain T-helper cells and macrophages. [16]

In rheumatic fever, these lesions can be found in any layer of the heart causing different types of carditis. The inflammation may cause a serofibrinous pericardial exudate described as "bread-and-butter" pericarditis, which usually resolves without sequelae. Involvement of the endocardium typically results in fibrinoid necrosis and wart formation along the lines of closure of the left-sided heart valves. Warty projections arise from the deposition, while subendocardial lesions may induce irregular thickenings called MacCallum plaques.[ citation needed ]

Rheumatic heart disease

Pathophysiology of rheumatic heart disease Rheum.heart.disease.jpeg
Pathophysiology of rheumatic heart disease
Micrograph showing an Aschoff body (right of image), as seen in rheumatic heart disease. H&E stain Rheumatic heart disease - 3a - very high mag.jpg
Micrograph showing an Aschoff body (right of image), as seen in rheumatic heart disease. H&E stain

Chronic rheumatic heart disease (RHD) is characterized by repeated inflammation with fibrinous repair. The cardinal anatomic changes of the valve include leaflet thickening, commissural fusion, and shortening and thickening of the tendinous cords. [16] It is caused by an autoimmune reaction to Group A β-hemolytic streptococci (GAS) that results in valvular damage. [17] Fibrosis and scarring of valve leaflets, commissures and cusps leads to abnormalities that can result in valve stenosis or regurgitation. [18] The inflammation caused by rheumatic fever, usually during childhood, is referred to as rheumatic valvulitis. About half of patients with rheumatic fever develop inflammation involving valvular endothelium. [19] The majority of morbidity and mortality associated with rheumatic fever is caused by its destructive effects on cardiac valve tissue. [18] The complicated pathogenesis of RHD is not fully understood, though it has been observed to use molecular mimicry via group A streptococci carbohydrates and genetic predisposition involving HLA Class II genes that trigger autoimmune reactions. [20]

Molecular mimicry occurs when epitopes are shared between host antigens and Streptococcus antigens. [21] This causes an autoimmune reaction against native tissues in the heart that are incorrectly recognized as "foreign" due to the cross-reactivity of antibodies generated as a result of epitope sharing. The valvular endothelium is a prominent site of lymphocyte-induced damage. CD4+ T cells are the major effectors of heart tissue autoimmune reactions in RHD. [22] Normally, T cell activation is triggered by the presentation of bacterial antigens. In RHD, molecular mimicry results in incorrect T cell activation, and these T lymphocytes can go on to activate B cells, which will begin to produce self-antigen-specific antibodies. This leads to an immune response attack mounted against tissues in the heart that have been misidentified as pathogens. Rheumatic valves display increased expression of VCAM-1, a protein that mediates the adhesion of lymphocytes. [23] Self-antigen-specific antibodies generated via molecular mimicry between human proteins and streptococcal antigens up-regulate VCAM-1 after binding to the valvular endothelium. This leads to the inflammation and valve scarring observed in rheumatic valvulitis, mainly due to CD4+ T cell infiltration. [23]

While the mechanisms of genetic predisposition remain unclear, a few genetic factors have been found to increase susceptibility to autoimmune reactions in RHD. The dominant contributors are a component of MHC class II molecules, found on lymphocytes and antigen-presenting cells, specifically the DR and DQ alleles on human chromosome 6. [24] Certain allele combinations appear to increase RHD autoimmune susceptibility. Human leukocyte antigen (HLA) class II allele DR7 (HLA-DR7) is most often associated with RHD, and its combination with certain DQ alleles is seemingly associated with the development of valvular lesions. [24] The mechanism by which MHC class II molecules increase a host's susceptibility to autoimmune reactions in RHD is unknown, but it is likely related to the role HLA molecules play in presenting antigens to T cell receptors, thus triggering an immune response. Also found on human chromosome 6 is the cytokine TNF-α which is also associated with RHD. [24] High expression levels of TNF-α may exacerbate valvular tissue inflammation, because as this cytokine circulates in the bloodstream, it triggers the activation of multiple pathways that stimulate further pro-inflammatory cytokine secretion. [25] Mannose-binding lectin (MBL) is an inflammatory protein involved in pathogen recognition. Different variants of MBL2 gene regions are associated with RHD. RHD-induced mitral valve stenosis has been associated with MBL2 alleles encoding for high production of MBL. [26] Aortic valve regurgitation in RHD patients has been associated with different MBL2 alleles that encode for low production of MBL. [27] In addition, the allele IGHV4-61, located on chromosome 14, which helps code for the immunoglobulin heavy chain (IgH) is linked to greater susceptibility to RHD because it may affect protein structure of the IgH. [28] Other genes are also being investigated to better understand the complexity of autoimmune reactions that occur in RHD.[ citation needed ]

Diagnosis

Synovial fluid examination [29] [30]
TypeWBC (per mm3) % neutrophilsViscosityAppearance
Normal<2000HighTransparent
Osteoarthritis <5000<25HighClear yellow
Trauma <10,000<50VariableBloody
Inflammatory2,000–50,00050–80LowCloudy yellow
Septic arthritis >50,000>75LowCloudy yellow
Gonorrhea ~10,00060LowCloudy yellow
Tuberculosis ~20,00070LowCloudy yellow
Inflammatory: Arthritis, gout, rheumatoid arthritis, rheumatic fever
Streptococcus pyogenes bacteria (Pappenheim's stain), the trigger for rheumatic fever Streptococcus pyogenes 01.jpg
Streptococcus pyogenes bacteria (Pappenheim's stain), the trigger for rheumatic fever

The original method of diagnosing rheumatic heart disease was through heart auscultation, specifically listening for the sound of blood regurgitation from possibly dysfunctional valves. However, studies have shown that echocardiography is much more efficient in detecting RHD due to its high sensitivity. An echocardiogram has the ability to detect signs of RHD before the development of more obvious symptoms such as tissue scarring and stenosis. [31] Modified Jones criteria were first published in 1944 by T. Duckett Jones, MD. [32] They have been periodically revised by the American Heart Association in collaboration with other groups. [33] [34] According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre [35] or anti-DNase B. [8] [36] A recurrent episode can be diagnosed when three minor criteria are present. [34] Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever. [37] [38] [39] An April 2013 review article in the Indian Journal of Medical Research stated that echocardiographic and Doppler (E & D) studies, despite some reservations about their utility, have identified a massive burden of rheumatic heart disease, which suggests the inadequacy of the 1992 Jones' criteria. E & D studies have identified subclinical carditis in patients with rheumatic fever, as well as in follow-ups of rheumatic heart disease patients who initially presented as having isolated cases of Sydenham's chorea. [40] Signs of a preceding streptococcal infection include: recent scarlet fever, raised antistreptolysin O or other streptococcal antibody titre, or positive throat culture. [41] The last revision of 2015 suggested variable diagnostic criteria in low-risk and high-risk populations to avoid overdiagnosis in the first category and underdiagnosis in the last one. [34] Low-risk populations were defined as those with acute rheumatic fever annual incidence ≤2 per 100 000 school-aged children or all-age rheumatic heart disease prevalence of ≤1 per 1000. [34] All other populations were categorised as having a moderate or high risk. [34]

Major criteria

  1. Joint manifestations are the unique clinical signs that have different implications for different population-risk categories : Only polyarthritis [42] (a temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards) is considered as a major criterion in low-risk populations, whereas monoarthritis, polyarthritis and polyarthralgia (joint pain without swelling) are all included as major criteria in high-risk populations. [34]
  2. Carditis : Carditis can involve the pericardium (pericarditis which resolves without sequelae), some regions of the myocardium (which might not provoke systolic dysfunction), and more consistently the endocardium in the form of valvulitis. [43] Carditis is diagnosed clinically (palpitations, shortness of breath, heart failure, or a new heart murmur) or by echocardiography/Doppler studies revealing mitral or aortic valvulitis. Both of clinical and subclinical carditis are now considered a major criterion. [34] [43]
  3. Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.[ citation needed ]
  4. Erythema marginatum : A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.[ citation needed ]
  5. Sydenham's chorea (St. Vitus' dance): A characteristic series of involuntary rapid movements of the face and arms. This can occur very late in the disease for at least three months from onset of infection.[ citation needed ]

Minor criteria

  1. Arthralgia : Polyarthralgia in low-risk populations and monoarthralgia in others. [34] However, joint manifestations cannot be considered in both major and minor categories in the same patient. [34]
  2. Fever : ≥ 38.5 °C (101.3 °F) in low-incidence populations and ≥ 38 °C (100.4 °F) in high-risk populations. [34]
  3. Raised erythrocyte sedimentation rate (≥60 mm in the first hour in lox-risk populations and ≥30 mm/h in others) or C reactive protein (>3.0 mg/dL). [34]
  4. ECG showing a prolonged PR interval [34] [41] [44] after accounting for age variability (Cannot be included if carditis is present as a major symptom)

Prevention

Rheumatic fever can be prevented by effectively and promptly treating strep throat with antibiotics. [45] Globally, rheumatic fever is seen in populations that are socioeconomically disadvantaged and with limited access to health care. [46] Overcrowding [46] [47] and exposure to domestic air pollution [47] have been cited as associated risk factors.

In those who have previously had rheumatic fever, antibiotics may be used in a preventative manner as secondary prophylaxis. [45] Antibiotic prophylaxis after an episode of acute rheumatic fever is recommended owing to the high likelihood of recurrence. [48] Streptococcal pharyngitis may occur asymptomatically and rheumatic fever may recur even after a treated infection. [49] The American Heart Association recommends, based on low quality evidence but with high predicted efficacy, that people with mitral stenosis due to rheumatic heart disease receive prophylactic antibiotics for 10 years or until age 40, whichever would be longer. [49] The AHA also supports good dental hygiene in people with RHD, and antibiotics for the prevention of infective endocarditis during dental procedures are recommended in high-risk patients. [49]

Vaccine

No vaccines are currently available to protect against S. pyogenes infection, although research is underway to develop one. [50] Difficulties in developing a vaccine include the wide variety of strains of S. pyogenes present in the environment and the large amount of time and number of people that will be needed for appropriate trials for safety and efficacy of the vaccine. [51]

Treatment

The management of rheumatic fever is directed toward the reduction of inflammation with anti-inflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for strep throat should also be treated with antibiotics. [42]

Infection

People with positive cultures for Streptococcus pyogenes should be treated with penicillin as long as allergy is not present. The use of antibiotics will not alter cardiac involvement in the development of rheumatic fever. [42] Some suggest the use of benzathine benzylpenicillin.[ citation needed ]

Monthly injections of long-acting penicillin must be given for a period of five years in patients having one attack of rheumatic fever. If there is evidence of carditis, the length of therapy may be up to 40 years. Another important cornerstone in treating rheumatic fever includes the continual use of low-dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence.[ citation needed ]

Inflammation

Aspirin at high doses has historically been used for treatment of rheumatic fever. [52] However, due to side effects like gastritis and salicylate poisoning, necessitating serum monitoring of salicylate levels, and the risk of Reye syndrome, a serious and potentially deadly condition that may arise in children treated with aspirin or aspirin-containing products, alternatives to aspirin have been sought, especially in children. [48] While evidence suggests that treatment of rheumatic fever–associated arthritis with naproxen may be equally effective as with aspirin, [48] [53] its role in managing carditis has not been established. [54] Management of carditis in acute rheumatic fever is controversial and based on dated literature. [55] Corticosteroids may be considered, especially in people with allergies to NSAIDs or severe disease, [48] although use of steroids may cause tissue atrophy, which could present challenges during future cardiac surgery for valve repair. [55]

Heart failure

Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure: ACE inhibitors, diuretics, beta blockers, and digoxin.[ citation needed ] Unlike typical heart failure, rheumatic heart failure responds well to corticosteroids.[ citation needed ]

Epidemiology

Deaths from rheumatic heart disease per million persons in 2012 .mw-parser-output .div-col{margin-top:0.3em;column-width:30em}.mw-parser-output .div-col-small{font-size:90%}.mw-parser-output .div-col-rules{column-rule:1px solid #aaa}.mw-parser-output .div-col dl,.mw-parser-output .div-col ol,.mw-parser-output .div-col ul{margin-top:0}.mw-parser-output .div-col li,.mw-parser-output .div-col dd{page-break-inside:avoid;break-inside:avoid-column} .mw-parser-output .legend{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .legend-color{display:inline-block;min-width:1.25em;height:1.25em;line-height:1.25;margin:1px 0;text-align:center;border:1px solid black;background-color:transparent;color:black}.mw-parser-output .legend-text{} 0-7 8-14 15-20 21-25 26-32 33-38 39-45 46-52 53-63 64-250 Rheumatic heart disease world map-Deaths per million persons-WHO2012.svg
Deaths from rheumatic heart disease per million persons in 2012
  0–7
  8–14
  15–20
  21–25
  26–32
  33–38
  39–45
  46–52
  53–63
  64–250
Disability-adjusted life year for rheumatic heart disease per 100,000 inhabitants in 2004. no data less than 20 20-40 40-60 60-80 80-100 100-120 120-140 140-160 160-180 180-200 200-330 more than 330 Rheumatic heart disease world map - DALY - WHO2004.svg
Disability-adjusted life year for rheumatic heart disease per 100,000 inhabitants in 2004.
  no data
  less than 20
  20–40
  40–60
  60–80
  80–100
  100–120
  120–140
  140–160
  160–180
  180–200
  200–330
  more than 330

About 33 million people are affected by rheumatic heart disease with an additional 47 million having asymptomatic damage to their heart valves. [46] As of 2010 globally it resulted in 345,000 deaths, down from 463,000 in 1990. [57]

In Western countries, rheumatic fever has become fairly rare since the 1960s, probably due to the widespread use of antibiotics to treat streptococcus infections. While it has been far less common in the United States since the beginning of the 20th century, there have been a few outbreaks since the 1980s. [58] The disease is most common among Indigenous Australians (particularly in central and northern Australia), Māori, and Pacific Islanders, and is also common in Sub-Saharan Africa, Latin America, the Indian subcontinent, and North Africa. [59]

Rheumatic fever primarily affects children between ages 5 and 17 years and occurs approximately 20 days after strep throat. In up to a third of cases, the underlying strep infection may not have caused any symptoms.[ citation needed ]

The rate of development of rheumatic fever in individuals with untreated strep infection is estimated to be 3%. The incidence of recurrence with a subsequent untreated infection is substantially greater (about 50%). [60] The rate of development is far lower in individuals who have received antibiotic treatment. Persons who have had a case of rheumatic fever have a tendency to develop flare-ups with repeated strep infections.[ citation needed ]

The recurrence of rheumatic fever is relatively common in the absence of maintenance of low dose antibiotics, especially during the first three to five years after the first episode. Recurrent bouts of rheumatic fever can lead to valvular heart disease. Heart complications may be long-term and severe, particularly if valves are involved. In countries in Southeast-Asia, sub-Saharan Africa, and Oceania, the percentage of people with rheumatic heart disease detected by listening to the heart was 2.9 per 1000 children and by echocardiography it was 12.9 per 1000 children. [61] [62] [63] [64] To assist in the identification of RHD in low resource settings and where prevalence of GAS infections is high, the World Heart Federation has developed criteria for RHD diagnosis using echocardiography, supported by clinical history if available. [65] The WHF additionally defines criteria for use in people younger than age 20 to diagnose "borderline" RHD, as identification of cases of RHD among children is a priority to prevent complications and progression. [46] However, spontaneous regression is more likely in borderline RHD than in definite cases, and its natural history may vary between populations. [46]

Echocardiographic screening among children and timely initiation of secondary antibiotic prophylaxis in children with evidence of early stages of rheumatic heart disease may be effective to reduce the burden of rheumatic heart disease in endemic regions. [66] [67] The efficacy of treating latent RHD in populations with high prevalence is balanced by the potential development of antibiotic resistance, which might be offset through use of narrow-spectrum antibiotics like benzathine benzapenicillin. [67] Public health research is ongoing to determine if screening is beneficial and cost effective.

See also

Related Research Articles

<i>Streptococcus</i> Genus of bacteria

Streptococcus is a genus of gram-positive coccus or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales, in the phylum Bacillota. Cell division in streptococci occurs along a single axis, so as they grow, they tend to form pairs or chains that may appear bent or twisted. This differs from staphylococci, which divide along multiple axes, thereby generating irregular, grape-like clusters of cells. Most streptococci are oxidase-negative and catalase-negative, and many are facultative anaerobes.

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enter the bloodstream an infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<i>Streptococcus pyogenes</i> Species of bacterium

Streptococcus pyogenes is a species of Gram-positive, aerotolerant bacteria in the genus Streptococcus. These bacteria are extracellular, and made up of non-motile and non-sporing cocci that tend to link in chains. They are clinically important for humans, as they are an infrequent, but usually pathogenic, part of the skin microbiota that can cause Group A streptococcal infection. S. pyogenes is the predominant species harboring the Lancefield group A antigen, and is often called group A Streptococcus (GAS). However, both Streptococcus dysgalactiae and the Streptococcus anginosus group can possess group A antigen as well. Group A streptococci, when grown on blood agar, typically produce small (2–3 mm) zones of beta-hemolysis, a complete destruction of red blood cells. The name group A (beta-hemolytic) Streptococcus is thus also used.

<span class="mw-page-title-main">Scarlet fever</span> Infectious disease caused by Streptococcus pyogenes

Scarlet fever, also known as scarlatina, is an infectious disease caused by Streptococcus pyogenes, a Group A streptococcus (GAS). It most commonly affects children between five and 15 years of age. The signs and symptoms include a sore throat, fever, headache, swollen lymph nodes, and a characteristic rash. The face is flushed and the rash is red and blanching. It typically feels like sandpaper and the tongue may be red and bumpy. The rash occurs as a result of capillary damage by exotoxins produced by S.pyogenes. On darker-pigmented skin the rash may be hard to discern.

<span class="mw-page-title-main">Streptococcal pharyngitis</span> Medical condition

Streptococcal pharyngitis, also known as streptococcal sore throat, is pharyngitis caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.

<span class="mw-page-title-main">Pharyngitis</span> Inflammation of the back of the throat

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

<span class="mw-page-title-main">Sore throat</span> Medical condition

Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include:

<span class="mw-page-title-main">Infective endocarditis</span> Medical condition

Infective endocarditis is an infection of the inner surface of the heart, usually the valves. Signs and symptoms may include fever, small areas of bleeding into the skin, heart murmur, feeling tired, and low red blood cell count. Complications may include backward blood flow in the heart, heart failure – the heart struggling to pump a sufficient amount of blood to meet the body's needs, abnormal electrical conduction in the heart, stroke, and kidney failure.

<span class="mw-page-title-main">Tonsillitis</span> Inflammation of the tonsils

Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. Complications include peritonsillar abscess (Quinsy).

Sydenham's chorea, also known as rheumatic chorea, is a disorder characterized by rapid, uncoordinated jerking movements primarily affecting the face, hands and feet. Sydenham's chorea is an autoimmune disease that results from childhood infection with Group A beta-haemolytic Streptococcus. It is reported to occur in 20–30% of people with acute rheumatic fever and is one of the major criteria for it, although it sometimes occurs in isolation. The disease occurs typically a few weeks, but up to 6 months, after the acute infection, which may have been a simple sore throat (pharyngitis).

<span class="mw-page-title-main">Erythema marginatum</span> Medical condition

Erythema marginatum is an acquired skin condition which primarily affects the arms, trunk, and legs. It is a type of erythema characterised by bright pink or red circular lesions which have sharply-defined borders and faint central clearing. The lesions typically range from 3 to 10 cm in size, and are distributed symmetrically over the torso and inner surfaces of the limbs and extensor surfaces. The lesions last between one and four weeks but have been known to be present on patients for as long as several months.

A complication in medicine, or medical complication, is an unfavorable result of a disease, health condition, or treatment. Complications may adversely affect the prognosis, or outcome, of a disease. Complications generally involve a worsening in the severity of the disease or the development of new signs, symptoms, or pathological changes that may become widespread throughout the body and affect other organ systems. Thus, complications may lead to the development of new diseases resulting from previously existing diseases. Complications may also arise as a result of various treatments.

<span class="mw-page-title-main">Valvular heart disease</span> Disease in the valves of the heart

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

<span class="mw-page-title-main">PANDAS</span> Hypothesis in pediatric medicine

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a controversial hypothetical diagnosis for a subset of children with rapid onset of obsessive-compulsive disorder (OCD) or tic disorders. Symptoms are proposed to be caused by group A streptococcal (GAS), and more specifically, group A beta-hemolytic streptococcal (GABHS) infections. OCD and tic disorders are hypothesized to arise in a subset of children as a result of a post-streptococcal autoimmune process. The proposed link between infection and these disorders is that an autoimmune reaction to infection produces antibodies that interfere with basal ganglia function, causing symptom exacerbations, and this autoimmune response results in a broad range of neuropsychiatric symptoms.

<span class="mw-page-title-main">Rapid strep test</span> Test for strep throat

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<span class="mw-page-title-main">Centor criteria</span> Tool for medical diagnosis of the throat

The Centor criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in patients complaining of a sore throat. They were developed as a method to quickly diagnose the presence of Group A streptococcal infection or diagnosis of streptococcal pharyngitis in "adult patients who presented to an urban emergency room complaining of a sore throat." The Centor criteria are named after Robert M. Centor, an internist at the University of Alabama at Birmingham School of Medicine.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Bacteriophage T12 is a bacteriophage that infects Streptococcus pyogenes bacteria. It is a proposed species of the family Siphoviridae in the order Caudovirales also known as tailed viruses. It converts a harmless strain of bacteria into a virulent strain. It carries the speA gene which codes for erythrogenic toxin A. speA is also known as streptococcal pyogenic exotoxin A, scarlet fever toxin A, or even scarlatinal toxin. Note that the name of the gene "speA" is italicized; the name of the toxin "speA" is not italicized. Erythrogenic toxin A converts a harmless, non-virulent strain of Streptococcus pyogenes to a virulent strain through lysogeny, a life cycle which is characterized by the ability of the genome to become a part of the host cell and be stably maintained there for generations. Phages with a lysogenic life cycle are also called temperate phages. Bacteriophage T12, proposed member of family Siphoviridae including related speA-carrying bacteriophages, is also a prototypic phage for all the speA-carrying phages of Streptococcus pyogenes, meaning that its genome is the prototype for the genomes of all such phages of S. pyogenes. It is the main suspect as the cause of scarlet fever, an infectious disease that affects small children.

Anti-Deoxyribonuclease B titres are a quantitative measure of the presence of serologic antibodies obtained from patients suspected of having a recent group A (Beta-hemolytic) streptococcus bacteria infection, from Streptococcus pyogenes.

Shiranee Sriskandan is a British academic who is Professor of Infectious Diseases at Imperial College London and Honorary Consultant at Hammersmith Hospital. Her research considers how Gram-positive bacteria cause disease, with a particular focus on the bacteria Streptococcus pyogenes.

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