Rheumatic Fever: A Deadly Reprise

December 30, 1988|By Betsy A. Lehman, Boston Globe.

In July a 4-year-old girl was admitted to Baystate Medical Center in Springfield, Mass., having trouble breathing. She had been sick for only four days was getting worse fast.

The girl was given a battery of tests: Was it pneumonia? Lung cancer?

There was no time for an answer; she died within hours.

What came back from the autopsy stunned the doctors and still shocks a leading Boston pediatrician called in later to discuss the case.

She died of rheumatic fever. Her heart showed damage typical of the condition, a major cause of death and disability decades ago but thought in this country to be all but vanquished now.

Her blood test results, not available until after her death, showed evidence of a recent strep infection, the precursor to rheumatic fever.

It`s happening in scattered outbreaks across the country: Rheumatic fever is back.

Doctors who hadn`t seen a case in years, maybe ever, are seeing children and young adults with its telltale signs: Severe joint pain, jerky arm and leg movements, fever and, most menacing of all, heart-valve damage.

The symptoms, thought to be byproducts of fighting off strep bacteria, all disappear-except the heart damage. When the initial heart inflammation subsides, it can leave behind scarred, damaged valves that leak or obstruct the flow of blood.

The numbers are still small, and the resurgence may be temporary, but rheumatic fever has given notice that it cannot be counted out.

Dr. Jane G. Schaller, pediatrician in chief at Boston`s New England Medical Center, says her hospital has treated about 20 children with rheumatic fever in the last two years. In the years immediately before, the number had been zero.

Schaller says she was astonished at the death of the 4-year-old. She tried to find another explanation; there was none. The case was unusually severe for rheumatic fever; the girl`s heart had suffered so much damage so fast that she couldn`t be saved.

Rheumatic fever sounds like a relic from the annals of medical history, but it remains a major problem in less-affluent countries and is the reason, at least in theory, for countless Americans` trips to the doctor.

When you or your child gets a very sore throat, you go to the doctor and get a throat culture. The doctor runs a swab around the back of your throat, you gag a little, and that`s it.

If the test comes back negative, you`ve probably got a virus, and there`s not much you can do except wait, gargle and take pain relievers. But if the test shows it`s a strep throat, you take antibiotics for 10 days or get a shot of long-acting penicillin.

Rheumatic fever is the reason. Not a disease of its own, rheumatic fever is a complication of untreated strep throat that usually strikes children aged 5 to 15 and can cause permanent, progressive, even fatal heart damage.

Once you`ve had it, you`re prone to more attacks, with more heart damage, whenever you get strep throat. So doctors prescribe long-term, even lifelong, penicillin to anyone with rheumatic fever to prevent further strep infections. Research in the early 1950s proved that treating strep throats with antibiotics prevented rheumatic fever from developing. The 10-day antibiotic treatment necessary to kill all the strep bacteria became a fixture of American medicine.

Rheumatic fever was already on the decline, presumably because of improved living conditions, before the introduction of antibiotics, and it had all but vanished in the United States by the early 1980s. Medicaid, initiated in 1965, made medical care available to many poor children and may deserve some of the credit.

Oddly, however, the new rheumatic fever is occurring mostly in middle-class children with access to doctors. The preceding strep throat typically is not very severe, not bad enough to warrant a trip to the doctor. In a few cases, children were given antibiotics but didn`t take them for all 10 days.

The resurgence first was noticed in Salt Lake City, at Primary Children`s Medical Center. In the early 1980s, the hospital saw about six cases of rheumatic fever a year, says the physician in chief, Dr. L. George Veasy. Suddenly in 1985, 59 children came in with rheumatic fever, some requiring heart surgery to survive. The numbers have abated somewhat-27 cases this year- but that`s still far higher than before.

Why this has happened, and what will happen in the future, is a mystery.

Veasy and Dr. Edward L. Kaplan, who directs the World Health Organization`s strep laboratory, speculate that a strain of strep is circulating that carries a double-whammy: causing unusually mild sore throats, sometimes no soreness at all, but triggering virulent rheumatic fever. It`s a dangerous combination.

What should doctors, parents and public health authorities do? It`s not entirely clear.