Rheumatic fever physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Physical Examination
Rheumatic fever is highly variable, enough so that a rigid set of criteria, such as the Jones Criteria, is somewhat superficial and only meaninful in very high-grade cases of rheumatic fever. Since the majority of cases of rheumatic fever are lower-grade cases, reliance on the Jones Criteria will cause physicians to simply miss, or ignore, most of the cases, probably over ninety-five percent of cases.
Dr. Osler continues with the following most important information: "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced. The fever rarely rises above 101 deg. F.; fewer joints are involved; and the arthritis is less intense. The cases may drag on for weeks or months. It should not be forgotten that mild or subacute forms may be associated with endocarditis or pericarditis.
The influence of age on the manifestations is marked. While the usual description applies to the disease as seen in adults, in young children there may not be any pronounced arthritis or any arthritis at all, and the discovery of endocarditis often suggests the diagnosis. Endocarditis and myocarditis are the prominant features in children in whom the picture may be very variable. The onset may be so insidious that it can hardly be termed even subacute. Ill health without any evident cause, loss of weight, anorexia, fatigue, complaint of slight pains and fever with no apparent cause should suggest the possibility. Acute arthritis is the exception in the child; cardiac involvement of some kind is the rule."
It is very difficult to record the symptoms and signs of a disease with so much variation, since they depend on the age of the sick individual, on the level of prior rheumatic sensitization, on the strain of Streptococcus pyogenes involved in the acute infection, on the pattern of infection and its secondary autoimmunological response, and on prior autoimmunological damage that has taken place during prior rheumatic, autoimmunological episodes. Then there is randomness, which is statistically enhanced in complex, systemic diseases.
One type of pathology, which is omitted from the "Jones Criteria", and from Dr. Osler's description of the signs and symptoms of rheumatic fever, but not omitted from the description provided by the information on rheumatic fever in the first edition of the Encyclopedia Britannica,cited above, is the existence of lumbago, or lumbosacral pain. Lumbosacral pain is neurological in nature and its anatomical source is deep in the gluteal area, but pain radiates centrepitally into the lumbosacral area and, of course, at times, dysesthesias radiate down the leg. Neurological pain is the worst type of pain patients with severe rheumatic fever experience, and when Dr. Osler indicates, "In attacks of great severity every one of the larger joints may be involved. Perhaps no disease is more painful..." he means that larger joints such as the shoulder and hip are involved. Within those joints patients suffer from acute brachial plexitis and neuritis of the terminal nerves of the sacral plexus with the sciatic, the posterior femoral cutaneous, and the pudendal nerves, respectively, being involved. Another name for the latter condition is, sciatica. A name provided during the late 1800's and early 1900's was sciatic rheumatism or hip gout.
Not surprisingly, lesser, more chronic levels of rheumatic autoimmunity also affect the peripheral nervous system and the many cases of lumbosacral/buttock pain and shoulder/cervical pain, which are treated as surgical conditions (herniated discs of the lumbar and cervical spine)are often caused by chronic, relatively high-levels of rheumatic autoimmune mediated neuropathy secondary to Streptococcus pyogenes infections. Often pain syndromes with the above character are "familial" in nature. One might think that the frequency of sciatic pain reflects the frequency of rheumatic autoimmunity in a community. In addition, the increased incidence of fibromyalgia, that was termed in prior eras, muscular rheuamtism, is also an indication of the increase in rheumatic autoimmunity of the American population.