The reasons for the cause rheumatic fever

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Group A streptococcus rheumatic fever and wind on the etiology of heart disease between the epidemiological and clinical immunology in some indirect evidence has supported a number of clinical and epidemiological studies in group A streptococcus infection and rheumatic fever closely related to immunization study Also confirmed that before the onset of acute rheumatic fever there are early history of the streptococcus infection; forward-looking long-term follow-up of the anti-bacterial treatment and prevention of Streptococcus suis infection may be the primary prevention of rheumatic fever and relapse; means of infection is crucial Streptococcus Throat infection is the incidence of rheumatic fever must be conditions

Nevertheless Group A streptococcus cause rheumatic fever incidence has not yet understand the mechanism of Streptococcus rheumatic fever is not caused by direct infection because the incidence of rheumatic fever is not the streptococcus infection at the time but in the weeks after infection to the onset of rheumatic fever patients Culture and the blood in the heart tissue has never been found in the group A streptococcus after suffering from streptococcus pharyngitis only% ~% of patients in rheumatic fever

In recent years found that group A streptococcus cell wall containing protein for the MT-R and protein components of the M protein which can impede the most important role is swallowed up by type of bacteria, also known as the basis of “cross-antigen reaction” in the cell walls of Streptococcus Polysaccharide components of the species-specific antigen, also known as the “C substances” by the human Streptococcus suis infection may be some people not only to produce antibodies can be their own role in Streptococcus role in heart valve disease and valvular heart valve caused the mucopolysaccharide Composition with age and thus can explain variations in young people and adults of different heart valve disease incidence of immunology research suggested that the immune regulation of acute rheumatic fever there are shortcomings in their identity as B cells and helper T cells and inhibit the increased T-cell Led to relative decline in humoral and cellular immune enhancement is no chronic rheumatic heart disease rheumatoid activities but continued to exist prompted increased number of B-cell immune inflammatory process is still underway whether Streptococcus suis infection in rheumatic fever and also the response of the human body in this The level of response with the streptococcus antigen antibodies in the parallel relationship between allergy antibodies in a long time in the big opportunities; other hand, and the function of the nervous system related to the change

Rheumatic fever

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(rheumatic fever) is the kind of common recurrent acute or chronic inflammation of connective tissue main body of the joint central nervous system involving the heart and subcutaneous tissue of the skin to performance-based heart inflammation and arthritis can be accompanied by fever toxaemia Chorea, such as skin rash Summary of acute arthritis, usually more obvious but at this stage rheumatic heart inflammation may result in the death of patients with acute attack often left behind after the severity of damage from the heart valve disease especially in the most significant form of chronic rheumatic heart Disease (rheumaticheart disease) or rheumatic valve disease (rheumatic valvular disease)

The cause of rheumatic fever pathology

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Rheumatic fever is streptococcus infection with the autoimmune disease systemic plant characterized by the inflammation of connective tissue body, mainly involving the heart rent joints, followed by skin, serosa, blood vessels and brain tissue. The clinical performance of arthritis, heart inflammation, skin annular erythema, skin nodules, such as fever and Chorea. Have the tendency to repeatedly attack, heart valve disease can be left behind. For the cause of rheumatic heart disease in children and adults the main reason. Therefore, prevention of rheumatic fever in children to ensure that children’s health and prevent the occurrence of rheumatic heart valve disease is extremely important.
In recent years the incidence of rheumatic fever gradually declining, it is widely carried out prevention and control of Streptococcus and the correct application of anti-drug results.
The age of 5 to 15 years more (especially 7 to 8 years old the most common), 3-year-old following rare. The disease occurs in the cold and humid regions. May be the year the incidence, but in winter and spring.
Cause of rheumatic fever and blood group A streptococcus B infection is closely related to the fact that reasoning:
First, rheumatic fever and streptococcal infection in the distribution of seasonal and climatic characteristics in line.
Second, 1-5 weeks prior to the onset of hot and humid often hemolytic streptococcus infection, such as the pharynx Gap Yan, tonsillitis, scarlet fever, and so on. Children often develop throat bacteria, Streptococcus anti-blood antibody titers increased.
Third, take control of Streptococcus suis infection and remove chronic lesions (such as tonsils removed), and other measures, significantly decreased the incidence of rheumatic fever, after the initial onset of penicillin or sulfa drugs used to prevent duplication of Streptococcus infection can reduce the recurrence of the disease.
While rheumatic fever B and Group A hemolytic streptococcus infection are closely related, but this is not a direct result of the partial lesions on the grounds that:
(A) of Streptococcus suis infection after 1-5 weeks before the disease is the direct spread of infection and inconsistent, and generally have immunity and in line with the law.
(B) From the patient’s blood, serous effusion and disease has never been found in hemolytic streptococcus.
Now that the disease is a autoimmune disease, Streptococcus suis infection may be due, some patients have a high degree of antigen of Streptococcus and its metabolites to produce antibodies, antibody combining deposited in connective tissue, such damage Organization also has antigen, allowing the body produce antibodies against the organization, from their own immune response. Also that the glycoprotein heart valve with Streptococcus polysaccharide component is similar to the antigen, human Streptococcus suis infection may have a heart valve damage to the cross-antibody.
Pathological pathological process is divided into the following three, several changes often coexist.
1. Exudation of collagen fibers swelling and splitting, degeneration and necrosis, with non-specific inflammatory cell infiltration and serous leakage. Exudation of clinical symptoms. And the joint pericardial effusion mainly to pathological changes.
2. Connective tissue proliferation of local cell proliferation, a rheumatic or rheumatoid body granuloma (Aschoff body), in Aschoff bodies are still around a small number of lymphocytes and plasma cell infiltration, this disease is common in endocardium, Cardiac and skin. This is a characteristic of rheumatic fever disease, is considered pathological diagnosis on the basis of rheumatic fever, rheumatic and be seen as the indicator.
3. Sclerosis period of reduced infiltration, fibrous tissue proliferation, the formation of scar in the granuloma, the valve caused the deformation.

Laboratory examination of rheumatic fever

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1, blood can have mild anemia, IL moderate increase in the total number of the left and the phenomenon.
Second, the ESR activities in the fast growing period, but in congestive heart failure, liver impede manufacturing fibrinogen, ESR may increase soon. Salicylic acid used in the preparation, adrenal hormone treatment period may also not obvious ESR by fast.
Third, the antibody of Streptococcus
(A) Antistreptolysin-”O” (ASO) Group A hemolytic streptococcus infection can produce hemolysin “O” to dissolve red blood cells. The disease serum Antistreptolysin-”O” titration of the increase in 1:500 more positive; Antistreptolysin-”O” increased only show that the recent Streptococcus suis infection, is not that the activities of rheumatism. Such as continuous inspection is still more than 500 units can be combined with clinical considered likely to rheumatic fever.
(B) if the other conditions of streptococcus antibodies for anti-Streptococcus kinase (ASK), anti-Streptococcus hyaluronidase (ASH), and anti-nuclear Streptococcus diphosphate pyridine Effect of acid (ADPN enzyme), such as Titration of the increase will help the diagnosis.
40, a special protein in
(1) C-reactive protein (CRP) Where organizations with the acute phase of devastating diseases, blood may appear in a special protein (C-reactive protein), and Streptococcus pneumoniae polysaccharide in a body with the participation of calcium From the reaction sediments. Rheumatoid activities of C-reactive protein may appear, their quantity and seriousness of the disease is directly proportional, when the static disappeared, re-emergence of a recurrence of omen, but in low activity of the often negative. Ring’s disease or simple red blood when there is no C-reactive protein. C-reactive protein than the ESR by a fast early, but also fast disappearing, the general from the impact of heart failure.
(B) of protein (MPT) connective tissue matrix for the chemical composition of mucin, a glycoproteins, when rheumatoid activities, connective tissue damage, blood-cadherin increased. Therefore, blood viscosity in the amount exceeds the normal protein (in the normal 4 mg / min or less), compared with rheumatoid activities of the indicators.
5, the activities of serum protein serum albumin protein electrophoresis analysis presented to reduce, α2 globulin and the γ globulin increase.
6, immunoglobulin in the early stages of IgG, IgM and IgA increased, then dropped to the normal recovery period.

The differential diagnosis of rheumatic fever

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First, fever and disease identification and should pay attention to tuberculosis or chronic Gan Ranzao and Streptococcus infection status of identification.
Streptococcus suis infection in the state of Streptococcus suis infection (as flu, tonsillitis or scarlet fever, etc.) after the fever, fatigue weakness, joint Suanteng symptoms. In addition to inspections by rapid heart rate, no significant change in heart, there is no rash. ESR by fast and Antistreptolysin-”O” increased. Using low-dose penicillin and adrenal hormone therapy, quickly returned to normal, no recurrence. However, these performance may also be for the early rheumatic fever, should continue to closely watch. If the heart or heart murmur increased significantly, should be considered rheumatic fever.
Second, the heart
(1) functional cacophony first should pay attention to rule out the murmur of the heart. Such noise more common in school-age children, in the sternum left intercostal margin of 3 to 4 medial apex, generally Ⅱ, Ⅲ up to the individual level. Characterized by a higher pitch, a small number of music can be a ring, only to shrink as early as the mid-conduction is not extensive and no other symptoms of rheumatoid activities.
(B) of congenital heart diseases such as congenital mitral regurgitation, some AV access, in infants and young children are generally found that during the noise.
(C) of viral myocarditis is an increasing trend in recent years. The disease often marked the history of viral respiratory infection, quickly discovered that the abnormal heart, but no significant noise, and more arrhythmia. - Can quickly cause congestive heart failure and serious arrhythmias. No arthritis and multiple skin nodules and other performance Antistreptolysin-”O” does not generally higher.
Third, in respect of joint disease and the identification of the following:
(A) category rheumatism Changcheng flip-heat, the general situation is good, many involving small joints, for symmetry, very few of the performance of migration, can even influence joints, can cause joint deformities. With cardiac damage minimal. Salicylic acid used in the treatment of rheumatoid arthritis as easy to bear fruit.
(B) TB arthritis according to a history of exposure to tuberculosis, tuberculin tests positive, single joint involvement, X-ray checks to the main bone destruction, no change heart, lung lesions, such as tuberculosis often can find a diagnosis.
(C) Septic Arthritis often the primary pyogenic lesions, sepsis symptoms are general. Arthritis can start with multiple performance, but soon confined to a joint, red, swollen, hot, the pain obvious. Nongye puncture a joint cavity, Nongye and blood culture can be positive, Antistreptolysin-”O” does not generally high. X-ray the latter part of a bone destruction. Salicylic acid preparations invalid.
(D) of acute leukemia in early sometimes to the joint symptoms, often misdiagnosed as rheumatoid arthritis. However, leukemia has obvious bleeding and anemia, blood found around the naive cells, bone marrow, as are, leukemia change.
(5) TB allergic arthritis (Poncet syndrome) for TB infection caused by allergic arthritis, tuberculosis symptoms of poisoning, acute attack may have flip-heat, and erythema nodosum and rheumatism Arthritis-like symptoms, rheumatoid arthritis and similar. However, the involvement of non-cardiac symptoms, often accompanied herpes keratitis, the body active TB lesions, Duocheng positive tuberculin tests. With salicylic acid preparations for the treatment of rheumatoid no significant effect, and effective anti-tuberculosis treatment, this is an important diagnosis based on, but generally the fastest disappearance of fever, and joint symptoms of erythema nodosum and dissipated slowly.
4.’s Disease with the identification of customary spasm distinction, the latter is a single action duplication. Children with scattered attention, the spasm can disappear.

The treatment of rheumatic fever

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1, in accordance with bed rest and control of disease activity in the acute phase to bed rest, to the general clinical symptoms disappeared, ESR near normal, can gradually get up activities. But recovery should also be restricted activity, the general had no cardiac symptoms about a month, cardiac involvement but does not extend to February to March, expanding the heart or those with heart failure about 5 to 6 months before gradually returning to normal Activities.
Second, restaurants should be easy to digest, full of protein, carbohydrate and vitamin C diet. Severe cases can be an additional supply of vitamin B: and vitamin C. Have congestive heart failure may be appropriate to limit the intake of salt and water. To prevent the expansion of oppression heart and stomach to increase the heart load, can take Shaoliangduocan. Application of the adrenal cortex hormones in children with appropriate restrictions should be salt.
Third, the original Gan Ranzao infection control inflammation have not yet been fully dissipated, the application of penicillin 40 to 80 million units / day, intramuscular injection, conducted a thorough treatment. General application two weeks, also under the condition and continued to cultivate positive throat swab appropriate extension, some people advocate available to six weeks. Such as penicillin can not be applied, can also consider the use of erythromycin and the general dose of 30 mg / kg / day, three to four times oral.
4, anti-rheumatoid drugs are commonly used by the application of salicylic acid preparations for the general control of acute symptoms are obvious effect.
Obviously heart inflammation may choose adrenal cortex hormones drugs, especially in more serious cases should be considered. In view of the general activity of rheumatic fever is often continued for three months, the application of these drugs the best of not less than 12 weeks. Can be flexible in individual cases, or an appropriate extension.
(A) of salicylic acid preparations mainly to arthritis had no heart inflammation performance of salicylic acid, may begin preparations such as aspirin dose of 80 to 100 mg / kg / day, four times every six hours of oral one. Stable condition (referring to the normal body temperature, joint symptoms disappeared, C-reactive protein negative, normally take two to three weeks), reduced to 40 to 50 mg / kg / day. Starting dose of sodium salicylate to be 100 to 150 mg / kg / day in a stable condition can be reduced to half of the maintenance.
All the above drug treatment is generally three months, if necessary, could be extended to six months or longer. Application of salicylic acid preparations can cause nausea, vomiting, stomach pain, even gastrorrhagia, or medication after a meal in addition to oral aluminum hydroxide, can reduce side effects. The original bleeding tendencies or who do not have anti-and addition of vitamin K, 4 to 6 mg daily oral; experience toxic symptoms such as dizziness, tinnitus, vomiting, nasal bleeding and acid poisoning, or abnormal liver function, should be timely Withdrawal, if necessary, to give appropriate treatment. In addition, the clinical application of sometimes-than-lam 0.1 g / age / day, the tablets of the drug can cause cells to reduce disease, not long-term application.
(B) adrenal cortex hormones have significant heart inflammation may be optional. General use of prednisone prednisolone, starting dose of 1.5 to 2.0 mg / kg / day, at 2 to 3 times oral, three to four weeks after the gradual reduction to 12 weeks completely disabled. Serious heart inflammation are also dexamethasone 0.15 to 0.3 mg / kg / day, three to four times oral or intramuscular injection or intravenous infusion, the symptoms improved after switching to oral prednisolone, the symptoms gradually reduced control Volume. To prevent the rebound phenomenon (that is, withdrawal symptoms occur again after rheumatic fever) can be stopped two weeks before the start hormone plus salicylic acid formulations, stopping hormone 2 to 3 weeks after stopping acid formulations, can also continue to maintain a small amount of 2 to 3 months to withdrawal.
5, the treatment of congestive heart failure if they develop heart failure in children with rheumatic diseases are often accompanied rheumatoid activities, treatment should take into account the existence of heart inflammation, it should tie in with the use of hormones, added Mao Dihuang and potash.
6, the children should have the patient’s disease care, children with lifting the spirit of burden and enhance the confidence to overcome the disease.
Rest in a quiet environment, to take serious security measures to prevent injury. In order to reduce involuntary movement, the heavier the case may be appropriate given tranquilizers. Such as phenobarbital, and so on. In addition, if accompanied by other symptoms of rheumatoid, and the treatment of rheumatism.

Children rheumatoid Profile

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Period of juvenile rheumatoid arthritis in children is a common connective tissue disease, chronic arthritis to its main feature, and with the general multi-system involvement, including the joints, skin, muscle, liver, spleen, lymph nodes

Children and the cause of rheumatoid pathology

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Children like rheumatism is a relatively common systemic connective tissue disease, and its main long-term clinical performance for the more irregular fever, and the large, medium and small joint swelling and pain (especially the small joints Zhizhi), falling into a can Joint deformities, often accompanied with Gan, general swollen lymph nodes and spleen, anemia and self-cells increased, and so on. Children aged less, the clinical manifestations Pianyu more systemic symptoms, older children or adult patients more limited joint symptoms. Therefore, in the category often called Pediatric Rheumatology, compared with the previous “rheumatoid arthritis, the name of a more comprehensive.
Children and adults with chronic rheumatic diseases like rheumatoid arthritis and there are still more differences. If I have more general performance (flip-fever, rash, swollen lymph nodes liver and spleen, WBC number increased significantly, and so on), and joint disease lighter, sometimes with iridocyclitis, pericarditis, cervical involvement Dengzheng; On the other hand relatively rare in children subcutaneous nodules, rheumatoid factor positive rate low.
Cause has not entirely clear, and is generally believed that allergic and autoimmune related. May be due to viruses, mycoplasma or other pathogenic infections continued to make its degeneration into a lgG antigen to stimulate the body produce antibodies called rheumatoid factor, which is IgM antibodies category. One of the elements of serum rheumatoid factor and the five self-antigen IgG with the formation of a complex, this complex antibody response with all the characteristics of precipitation in the body tissue, in particular joint, synovial, after the activation of complement To attract neutrophil and the release of its lysosomal enzyme (protein decomposition enzymes), caused vascular basement membrane and the nearby organizations, including the synovial damage.
Pathological changes in the pathogenesis of the disease mainly occurred in the joints, but can also involve other parts of the connective tissue. Articular synovial first invasion, early congestion, edema and lymphocyte infiltration, then synovial thickening was villous, the final formation of granulation tissue. also swollen joints. Continue to develop inflammation, granulation tissue from the edge of the articular cartilage of the synovial began gradually extended to the cartilage, cartilage covering the end, interdictions of the cartilage from Huanang intake of nutrition, therefore, the surface of cartilage ulcer. At the same time under the cartilage in the bone marrow also lymphocyte infiltration and granulation tissue formation, cartilage stripping. Finally cartilage surface of granulation tissue fibrosis and even ossification, from top to bottom integration and joint stiffness. Joint was near the demineralized bone and osteoporosis, muscle atrophy, joint capsule and ligaments may also be granulation tissue invasion, caused dislocation.
In addition can also see the skin nodules, myocarditis and pericarditis, iridocyclitis Yandeng.

Children of the clinical manifestations of rheumatoid

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Can occur at any age, but 2 to 4 years and 8 to 10-year-old incidence maximum. Women more than men.
Disease can be divided into three types:
A body type more common in children, men and women can get sick. Mainly fever, rash, arthritis and other symptoms of organ involvement.
A flip-fever-hot, one day there may be one or two peaks, high fever up to 40 ℃ above, the daily fluctuations up to 3 ~ 4 ℃, shivering with fever before can. Febrile illness during the heavy, hot Forward to children with general good. Sustainable fever a few weeks or months, often natural ease, but easy to relapse.
During the rash accompanied fever, rash was polymorphous, scattered in the size of erythema, can be integrated into dual-chip, or a ring erythema, rash in a short time, easy to relapse to the trunk Most of can also be seen at Limbs, and even palm and foot.
Arthritis symptoms generally lighter, more performance for the multi-joint involvement, have no joint symptoms. There are many children with different degrees of liver, spleen, lymph nodes. A small number of cases may have pleurisy, myocarditis or pericarditis.
Second, multiple joints of this type of performance similar to adult rheumatoid arthritis, started only one to two joint involvement, early for the migration of fixed gradually become more symmetrical arthritis. Major facet of the characteristics of this type, the most proximal interphalangeal joint disease, followed by metacarpal, the toe joint, the joint can be involved if the knee, ankle, wrist, elbow, hip, spine, particularly the joints, such as cervical . The more slow-onset, a small number of incidence Jizhou. Local soreness in the beginning, Chen Jiang, after joint swelling, heat, pain, becoming spindle, activities restricted, knee, elbow, means that a fixed flexion of the wrist. Only a small number of cases is not swollen pain without swelling or pain. Joint near the muscle cramps, then in decline, eventually to joint diseases and deformities in deformation and tonic, joint deformation more common in six months to one year after the onset, that is, reduce the pain at this time. If other parts of the body such as cervical joint involvement can cause neck pain and stiffness, TMJ often suffer from chewing obstacles.
Systemic minor symptoms, only low heat, fatigue, loss of appetite, mild anemia and mild liver, spleen, lymph nodes.
A small number of children in the vicinity of a joint subcutaneous nodules. Rheumatoid factor for the positive.
Third, single joint involvement of only a few joints (often one), mainly involving large joints like the knee, ankle, elbow, etc..
Joints can be a chronic inflammatory process or repeated attack, but rarely cause serious joint activities restricted. This type of joint involvement in a few cases at the same time or later will have iridocyclitis, and sometimes become the first symptom of this type. Minor symptoms of systemic, have low heat, weakness, mild anemia and liver and spleen swollen lymph nodes.

The treatment of children with rheumatoid

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First, the general treatment of acute joint pain, fever and bed rest, but should be encouraged to get up at the appropriate daily activities. Especially in the general situation improves, the more muscle to carry out joint training activities, night splints will be available in the joint fixed physical location, in order to avoid deformities.
Second, the first cases of salicylic acid preparations general use of aspirin, at the beginning dose of 80 to 100 mg / kg / day, four to six oral dose. 1 to 2 weeks after the condition improved, that is gradually reducing, and to maintain the smallest effective dose for at least six months.
If symptoms of relapse after treatment, can maintain the low-dose, treatment for 1 to 2 years. Should avoid large number of long-term medication.
Third, adrenal cortex hormones on the body or with more serious symptoms of myocarditis, pericarditis, iridocyclitis children should be the early application of adrenal cortex hormones. Starting dose of prednisone 1-2 mg / kg / day, three to four times oral application l ~ 2 weeks, to get better after an illness and the restoration of ESR, to assist in the preparation of salicylic acid under the gradual reduction to The smallest effective dose (after reduction may be the next day or intermittent medication), the 3 to 6 months or even longer. If a stable condition, can gradually reducing until withdrawal. Withdrawal, there should be closely observed adverse reactions. Early use of adrenal cortex hormones, it can prevent or delay the occurrence of joint deformities, had observed biopsy pathology, also showed that synovitis in hormone therapy have dissipated during the period.
Fourth, anti-inflammatory pain is a non-steroid anti-inflammatory corticosteroid, antipyretic and analgesics. Combined with the hormone, the hormone might reduce the dosage. Amount of 0.5 to 1.0 mg / kg / times on the 1st, 2-3, taken after a meal.
5, eliminate acid drugs
(A) of chlorine eliminate acid (anti-rheumatoid Ling) 4 to 8 mg / kg / times on the 1st three times, side effects are dizziness, headache.
(2) A chlorine eliminate acid (anti-inflammatory acid) 5 mg / kg / times on the 1st 3 to 4 times, side effects are loss of appetite, nausea.
6, the soluble salt with salicylic acid preparations invalid, the application could be considered. Dosage: Apple sodium thiosulfate gold (Gold sodium thiomalate) l mg / kg / week, intramuscular, if effective, the administration interval may be extended to three to one in April. Such as 20 weeks after the disabled should be invalid. Note toxicity such as skin rash, mucosal ulcers, neutropenia, thrombocytopenia and proteinuria, and so on.
7, immunosuppressive agents such as cyclophosphamide or azathioprine.
Eight other suspected infections such as the treatment of lesions exist, should select the appropriate antibiotic therapy. For iridocyclitis local application should adrenal cortex hormones and mydriasis medicine. Contracture of bone and joint deformities should be adopted or medical sports, training activities, plywood and other fixed method for treatment, or orthopaedic surgery.