The blood sedimentation rate is a very useful guide to progress. Relapse may follow if the patient is allowed up before the rate is normal, but on occasion this rule may have to be ignored when a slightly raised rate persists for an undue length of time. Should symptoms not rapidly subside it is improbable that they are due to rheumatic fever and some other cause should be sought. However, other somewhat similar illnesses may be benefited to some degree and occasionally rheumatic fever is slow to respond so that too much reliance should not be placed on this test. Salicylate may be given every two hours for the first day or two, and thereafter four-hourly with a double dose at night to save waking the patient from sleep. Salicylates are best given in the form of aspirin 6-10g. This is well tolerated in children and has a greater analgesic effect. Calcium aspirin has the advantage over aspirin (acetyl salicylic acid) in that it is more soluble and hence larger doses are less likely to cause gastric irritation. The total daily requirement of sodium silicate for adults varies from 8-13g according to body weight. Children will need a proportionately smaller dose.
This dosage should be continued until fever and symptoms have been controlled for at least 10 days and then gradually reduced. Should rheumatic manifestations return, treatment will have to be resumed? If toxic symptoms develop the dose must be reduced and then maintained at the highest level which can be tolerated. Nausea, headache, dizziness, tinnitus and deafness are the early toxic symptoms, followed by vomiting, hyperventilation and mental symptoms, followed by vomiting, hyperventilation mental symptoms. Clinical trials have shown that the combination of prednisolone with salicylates in high dosages is the most effective treatment for severe cases but that has no effect on long term results. Other drugs may be needed for complications, e.g. cardiac failure. There is no evidence that antibiotics and chemotherapy are of the slightest value in treatment except in so far as elimination of streptococci from the throat results and thus prevents further antibody-antigen reaction. A brief initial course of penicillin is therefore advisable.
The precise cause of rheumatic fever is unknown. However, there is much evidence that rheumatic fever is endocardium with group a hemolytic streptococci, probably on the basis of tissue allergy. There is no diagnostic laboratory test which is specific for the disease. Other factors include. Rheumatic fever is essentially a disease of temperate climates. It is much less common in the tropics. Rheumatic fever tends to occur in families, but this may be due to environment rather than heredity. Rheumatic fever commonly affects the lower income groups and town dwellers. Poor housing and overcrowding are important factors. The disease is often preceded by tonsillitis or pharyngitis one to three weeks before. The fibrous tissues of the body are involved. Joints, muscles, tendons, heart valves, subcutaneous tissues and blood vessels are all affected. In the educative stage there is hyperaemia, oedema of the collagen tissue and infiltration with leucocytes. The hallmark of rheumatic fever is the Aschoff nodule, which may be found in the interstitial tissues of any part of the heart, most frequently under the endocardium and in close relation to small blood vessels. Its microscopic appearance is that of a central area of necrosis surrounded by small round cells, histiocytes and giant cells. The lesions of rheumatic fever never suppurate.
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