bubble_chart Overview

It is a recurrent non-suppurative inflammation caused by group A beta-hemolytic streptococci, which can occur in collagen tissues throughout the body, particularly characteristic in the heart and joints. After an acute episode, if the heart is involved, it can lead to significant damage to the heart valves, resulting in rheumatic heart valve disease. This disease is more common in winter and spring, in cold, damp, and crowded environments, with the initial onset typically occurring between the ages of 5 and 15, and relapses often occurring within 3 to 5 years after the initial episode.

bubble_chart Diagnosis

1. Medical History and Symptoms:

Typical manifestations include: carditis, migratory polyarthritis, erythema marginatum, subcutaneous nodules, and chorea. One to three weeks before the onset, half of the patients may have a history of acute tonsillitis, pharyngitis, or other upper respiratory infections, or scarlet fever . Inquiry should include questions about the presence of "upper respiratory infection", fever, lack of strength, rash, family living environment, etc.; presence of palpitation, chest tightness, chest pain; presence of large joint pain, and whether it is migratory.

2. Physical Examination Findings:

① Generalized cardiac enlargement, tachycardia disproportionate to body temperature, diminished first heart sound at the apex, and diastolic gallop rhythm. High-pitched, holosystolic murmur at the apex above grade II, and possibly a soft, short, low-pitched diastolic intermediate stage [second stage] murmur (Carey-Coombs murmur); ② Fine moist rales may appear at the base of both lungs, indicating heart failure signs; ③ Some may have pericardial friction rub, possibly accompanied by pleural friction rub; ④ Joint redness, swelling, and limited movement; ⑤ A few patients may show light red annular erythema with central pallor on the trunk or inner sides of the limbs; subcutaneous nodules 2-5mm in size may be seen on the extensor sides of large joints, especially the elbows, knees, and wrists, occipital bone area, or spinous processes of the thoracic and lumbar vertebrae, which are non-tender, not adherent to the skin, and movable; ⑥ Children may show involuntary, uncoordinated movements of the hands and feet, grimacing, and other chorea manifestations; ⑦ Extracardiac wind-dampness manifestations: may include pleuritis, pneumonia, peritonitis, nephritis, vasculitis, and encephalopathy. In recent years, erythema marginatum, subcutaneous nodules, and chorea have become less common.

3. Auxiliary Examinations:

① Positive throat swab culture for streptococcus; ② Anti-streptolysin O (ASO) ≧500u or anti-DNAse >200,000 u/L, increased erythrocyte sedimentation rate (ESR), positive C-reactive protein (CRP); blood routine may show grade I anemia, increased total white blood cell count and neutrophil ratio; ③ Electrocardiogram (ECG): atrioventricular block, premature beats, atrial fibrillation, sinus tachycardia, prolonged P-R interval, ST-T changes: ST segment depression in myocardial injury, and upwardly concave ST segment elevation in acute pericarditis; ④ X-ray: enlarged cardiac silhouette, flask-shaped heart in pericardial effusion; ⑤ B-ultrasound (UCG): may show enlarged cardiac chambers, reduced myocardial pulsation amplitude, and fluid-filled dark areas in the pericardial cavity; ⑥ Isotope myocardial scan (ECT): mottled myocardial changes, enlarged cardiac chambers.

4. Diagnostic Criteria:

Presence of two or one of the above typical (major) manifestations, plus a history of wind-dampness fever or rheumatic heart disease, arthritis, fever, increased ESR, positive CRP, leukocytosis, prolonged P-R interval, ST-T changes, prolonged Q-T interval, or two of the arrhythmias, highly suggests acute wind-dampness fever. If accompanied by elevated ASO and anti-DNAse, recent history of scarlet fever, and positive throat swab culture for group A streptococcus, the diagnosis can be confirmed.

Regarding the three wind-dampness tests: if ASO is elevated while ESR and CRP are negative, it indicates streptococcal infection or the convalescent stage of wind-dampness fever; if ESR and CRP are elevated while ASO is normal, other infections should be considered; if all three are positive, it suggests active wind-dampness; wind-dampness fever with right heart failure may have normal ESR but still positive CRP; if all three are negative, active wind-dampness fever is mostly excluded, but not entirely.

In cases of chronic wind-dampness valvular membrane disease, the diagnosis of active wind-dampness should consider the presence of one or more of the following conditions: grade I anemia, sinus tachycardia, joint pain, elevated ASO and/or ESR, CRP. Changes in the nature of the original murmur or the appearance of a new pathological murmur. Recent onset of cardiac enlargement or heart failure without obvious cause. Intractable heart failure, susceptibility to poisoning by Rehmannia preparations. Recent onset of various severe arrhythmias. ESR is normal during heart failure, but an increase in ESR after correction of heart failure or surgery that excludes other causes. Recurrence of significant valvular stenosis within 1 to 2 years after biological valve replacement or valvular membrane balloon angioplasty. Presence of extracardiac manifestations of wind-dampness heat. Significant improvement in condition after diagnostic anti-wind-dampness treatment.

V. Differential Diagnosis:

Attention should be paid to differentiate from infective endocarditis, viral myocarditis, rheumatoid arthritis, Poncet syndrome, acute suppurative arthritis, post-streptococcal infection state, connective tissue diseases, etc.

bubble_chart Treatment Measures

Patients with wind-dampness affecting the heart should be strictly confined to bed rest and hospitalized. Antibiotics targeting streptococci with high sensitivity, such as penicillin 4-8 million units, IV, once daily for 10-14 days, followed by 800,000 units, IM, twice daily, should be administered. When ASO levels normalize, switch to a long-acting preparation of benzathine penicillin 1.2 million units, IM, once daily, for a total of 5 years, or until the age of 16 for children. Salicylate preparations: choose enteric-coated aspirin, 4-6 g/day for adults, 100-150 mg/kg body weight for children, divided into 3-4 doses taken immediately after meals to reduce gastrointestinal symptoms, and take aluminum hydroxide gel if necessary. Continue for 3-6 months, then reduce the dose to 2 g/day, and maintain for up to 1 year. Adrenocortical hormones: in cases of high fever, administer hydrocortisone 100 mg + 100 ml fluid, IV, once daily, and switch to prednisone 30-40 mg, once in the morning, orally, after temperature control. Reduce the dose after 2 weeks, decreasing by 2.5 mg every 3 days until reaching 5 mg, once in the morning, and discontinue after 8 weeks. After complete control of wind-dampness activity, patients with myocarditis should still rest for 2 weeks before gradually increasing activity levels.