Dr. Jones Nghaamwa
The spotlight has finally been shown on an act that has long been ongoing, albeit in the “dark” away from the world’s wealthy nations. This old act is Rheumatic Heart Disease, a disease that strongly linked to poverty stricken environments common in the developing nations of the world.
On May 25, 2018, the 71st World Health Assembly in Geneva adopted a resolution on rheumatic heart disease. This resolution acknowledges rheumatic heart disease as a major public health concern and the need for strategies for prevention and control of the disease in endemic countries.
Explaining Acute Rheumatic Fever and Rheumatic Heart Disease:
At the back of the mouth, before the swallowing and breathing pipes is the pharynx. Glands of lymphoid tissue, the tonsils are located here. Viral and bacterial organisms commonly cause infection of the pharynx (pharyngitis or sore throat).
Acute Rheumatic fever is a disease or phenomenon that occurs as follows:
1. A person develops a sore throat caused by a specific bacteria namely group A Streptococcus (gas).
2. The immune systems fights the infection by making antibodies (“soldiers”) that attack and destroy the bacteria (“the enemy”). Programs to make these antibodies are “stored” within the immune system to be activated should the same bacteria attack again. These “soldiers” will attack anything that looks like the enemy
3. In a phenomenon referred to as molecular mimicry (autoimmune phenomenon), once the antibodies or “soldiers” are activated again by a sore throat infection in the future, they attack tissues that resemble the bacterial antigens. That person’s heart, brain, joints and skin are attacked by the same “soldiers” or antibodies that are supposed to protect the body.
4. When the same person gets another sore throat, the above phenomenon occurs, Acute Rheumatic Fever manifests. With each new bout of acute rheumatic fever, the organs like the heart, which are attacked by these “soldiers”, are progressively damaged.
Acute rheumatic fever is strongly linked to conditions prevalent amongst poor nations. These include overcrowding, poor housing, poor general hygiene levels, poor nutrition, low education and ignorance. Importantly, access to health in poor nations is also limited. There is a genetic susceptibility in certain people and families. Children between the ages of 5 and 14 years are most affected.
Manifestations of acute rheumatic fever include fever, heart failure, joint pains, abnormal movements and skin lesions. A current or past sore throat may not be remembered. Joint pains or arthritis usually involved multiple joints (swelling and pain) and may move from joint to joint. Heart failure results from lesions caused by damages to the heart valve resulting in “leaky” or regurgitant valves. Abnormal body movements, referred to as Sydenham’s chorea or St. Vitus dance, involves uncontrolled jerky movements of the arms, legs, and facial muscles. Neuro-psychiatric problems such as labile emotions may also be seen with chorea. Chorea occurs when a specific area in the brain is attacked by the antibodies against gas. Skin manifestations are more rare. There are criteria that medical professionals use to help them make a diagnosis. Because the symptoms are non-specific and presentation variable, doctors need a high index suspicion to diagnose acute rheumatic fever.
Symptoms of Acute Rheumatic Fever
Rheumatic Heart Disease is the consequence of Acute Rheumatic Fever. As explained above the heart is one of the organs attacked by antibodies meant to fight the bacteria, group A Streptococcus. The heart valves are one of the structures that are attacked. Left sided valves are most affected, specifically the mitral valve. From the series on understanding how your heart works, recall there are four valves in the heart that allow an adequate volume of blood to flow past (when open) and prevent blood flowing in the opposite direction (when closed). During fresh attacks, these valves become inflamed (swollen) and their structures may weaken. Subsequently they may not close properly, allowing blood to be regurgitated in the opposite direction. A volume load is placed on the heart requiring the organ to work harder but in an inefficient manner as all the blood, arriving in the heart is not pumped forwards. Heart failure may ensue. Attacks of Acute Rheumatic Fever may re-occur with subsequent throat infection even if such sore throats are not sever enough for the person to seek medical help. As time progresses the inflamed valves heal by a process of fibrosis. This hardens the valve tissues and may narrow (stenosis) the opening of the valve resulting in inadequate volume of blood passing the valve to meet bodily needs. This process takes place over time. Because acute rheumatic fever occurs in children, Rheumatic Heart Disease, the sequelae, may only manifest and be detected later in life (adolescence or adulthood).
*Dr. Jones Nghaamwa is a cardiothoracic, heart and lung surgeon at Windhoek Central Hospital and Lady Pohamba Hospital.