The return of rheumatic fever?
Rheumatic fever, a childhood scourge during the first half of this century, may be on the upswing again. In the past 18 months, outbreaks have been reported in Utah, Colorado, Pittsburgh and New Haven, Conn., and researchers are scrambling to understand the nature of the occurrences.
At the recent American Society for Microbiology meeting in New Orleans, Ellen R. Wald of the University of Pittsburgh described 18 cases that have occurred in the last 18 months in the Pittsburgh area, up from a total of 36 there in the previous decade. And at a concurrent meeting on streptococcal disease, other researchers described over 100 cases in Utah, also in the last 18 months, compared with an average of six cases per year there in the previous decade.
Symptoms can include heart inflammation and damage, particularly involving the valves; arthritis; muscle spasm; and rash. An attack of body tissues by antibodies against group A Streptococcus bacteria is believed to cause rheumatic fever, though the exact mechanism has yet to be identified. The syndrome, which occasionally is preceded by a strep throat, can be prevented if the infection is treated within nine or 10 days.
While the noncardiac symptoms of rheumatic fever generally go away, the victim is usually left with heart damage ranging from unnoticeable to severe. The American Heart Association recommends long-term -- up to lifelong -- treatment with penicillin or other antibiotics to prevent subsequent infection and further damage. The association estimates that 2 million people alive today in the United States have had rheumatic fever and thus have at least some residual heart damage.
Rheumatic fever is still a major problem in the Third World, but the incidence in developed countries started to fall even before penicillin was introduced. Though the drop has been ascribed to better medical care and less poverty, resulting in an overall decrease in infectious illness, the exact reasons are not known.
The cause of the recent increase is also unknown. Says L. George Veasy of Primary Children's Medical Center in Salt Lake City, who has treated many cases, "We don't have a good explanation for the outbreak."
Researchers are investigating a number of possibilities. In the Utah cases one strain of Streptococcus seems to dominate, Veasy says, but there is no hard proof that it's the culprit.
Suzanne Laussucq of the Centers for Disease Control in Atlanta, who has been assisting in the investigation of the Utah outbreak, says that in addition to the predominance of a potent strain there may be a genetic component at work. "So far we've found that family history [of rheumatic fever] seems to be a risk factor," she says.
Clinically, the disease hasn't changed over time. "This is old-fashioned rheumatic fever like we were seeing 30, 40, 50 years ago," says Veasy. But unlike the previous cases, the Utah and Pittsburgh outbreaks are hitting primarily middle-class children rather than underprivileged children, and frequently the syndrome isn't preceded by a sore throat.
Prevention in the past has relied on early treatment of strep throat, but Wald points out that this would have stopped only a minority of the cases in Pittsburgh. "Only 23 percent had a history of sore throat," Wald says.
Because of the rarity of cases in the 1960s and 1970s, states stopped their surveillance programs, says Laussucq. Whether the outbreaks reported are truly isolated is unknown. "Whether it's throughout the United States is in question. It's a matter of concern -- potentially it could be quite serious," she says.
Says Edward Kaplan of the University of Minnesota in Minneapolis, who has been studying streptococcal infection for 20 years, "It would be a mistake to say we're being swept by an epidemic. But it's unquestionable we're having a large, significant increase over what we've known." Says Wald, "Acute rheumatic fever may be returning as a common clinical problem."
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|Title Annotation:||significant increase in cases|
|Date:||Oct 11, 1986|
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