Take care of children with rheumatic heart disease

2021-01-30 12:00 AM

Not all children with group A hemolytic beta-hemolytic streptococci will have rheumatism. Out of 90-95% of children with strep throat, only 0.2-3% of children have rheumatism


Rheumatic heart disease is an infectious - toxic - immune disease that occurs after group A hemolytic streptococcal infection, manifested by inflammatory lesions in the connective organ system, in which the site is most often damaged. the heart, joints and blood vessels.

From 460 - 377 BC Hippocrates described polyarthritis rheumatica as a moving polyarthritis inflammatory disease with swelling, redness and pain in the joint, not endangering the patient's life. and is common in young people. Since then, it is considered to be a joint disease. Because of this, for hundreds of years, the name "Acute rheumatism (RAA - Rhumatisme Articulaire Aigu)" or "Rheumatic fever". In fact, the swelling, hot, red, painful lesions in the joints will go away quickly after 3 - 7 days, even without any treatment, moreover this is not an acute disease.

In 1835 - 1836, Bouillaud and Sokonsky, independent of each other, through clinical and pathological studies concluded that the main lesions of the disease were in the heart, in the capillaries and suggested classification. "Acute rheumatism" to the group of cardiovascular diseases. In addition, myocarditis and endocarditis are not only the most common damage, but also leave serious sequelae, easily fatal and make patients disabled. Therefore, in literature often called "Rhumatismus", "Rheumatic heart" or Bouillaud - Sokonsky disease.

Rheumatic heart disease is a children's disease, most commonly seen in children from 9 to 12 years old. Pulmonary, stenosis of the heart valve in adults is just a consequence, a consequence of low heart rate in childhood.


Rheumatic heart disease occurs only after children have strep throat; Tonsillitis inflammation due to group A hemolytic streptococcus.

Risk factor

Not all children with group A hemolytic streptococcal infection will have rheumatism. Out of 90-95% of children with strep throat, only 0.2-3% of children have rheumatism. Risk factors to keep in mind are:

Age: common in children from 7 to 15 years old, especially children from 9-12 years old.

Atopic: Rheumatic heart disease is often seen in children with allergic conditions such as urticaria, bronchial asthma, eczema.

Family factors: According to the authors, from 5.8% (Sampson) to 73.3% (Gold) of patients with rheumatism, in the history of having a family member (father, mother, siblings), have low heart rate. According to Cheadle, children from "low families" are five times more likely to develop low heart rate than children in healthy families.

Low living conditions: cramped housing, poor fertility, difficult economy.

Season: cold, humid climate. This is a condition for children to get sore throat more easily.

Mechanism of pathogenesis

The cause of rheumatoid heart disease is widely recognized as group A hemolytic streptococcus. However, the mechanism of pathogenesis remains controversial up to now. However, the infection-toxicity-immune mechanism is currently the most recognized. The nature of the infection-toxic-immune mechanism is that the coccyx membrane has an antigenic composition and its metabolic structure is similar to that of the heart muscle. When the body is infected with streptococci, the streptococcal antigens stimulate the body's immune response system to produce the corresponding antibodies. These antibodies will combine with streptococcal antigens, and also combine with myocardial organization. It is this reaction that causes allergic inflammation or "immune" inflammation in the heart.

On the other hand, streptococci also have a hemolytic ingredient. Therefore, children with low heart rate often show signs of pale skin - one of the manifestations of poisoning, anemia. Thus, for patients with low heart rate, after each streptococcal infection, the risk of immune inflammation occurs and the disease gets worse. This is the basis to explain why low heart rate is a recurrent disease.

Research into pathological lesions in rheumatism plays an important role in delivering treatment and care outcomes for patients. Pathological lesions are divided into 4 stages:

Stage 1: is the accumulation of mucopolysaccharide, hyaluronic acid and chondroitin sulfate in the connective organization, causing mucoid edema and degeneration of basic substances of the connective organization. These injuries can be completely reversed. This phase lasts from 10 to 12 days.

Stage 2: The stage of degeneration of the tigers of the connective organization: There is an accumulation of fibrinoids in the basic substances of the connective organization and in the vascular wall accompanied by necrosis. Therefore, recovery after treatment at this stage is not complete. This phase lasts from 30 to 45 days.

Stage 3: Is the stage of proliferation and creation of low particles in the connective organization in the heart muscle. This phase lasts 3 - 4 months. When this phase happens, it will continue to lead to stage 4.

Stage 4: The fibrosis stage organizes consolidation, forming heart valve sequelae. Thus, to form heart valve sequelae need to undergo 6 months to 1 year.

Through the study of 4 stages of pathological injury, we find that: To ensure that patients with low heart rate can be completely cured without any complications of the heart valve, the active treatment in phase 1 is of the most important factors. Delayed treatment for patients with low heart rate for any reason can leave heart valve sequelae - the most severe consequences leading to disability, reduced life expectancy or death.

Clinical symptoms and clinical weight

Clinical manifestations of rheumatism usually occur 2 - 4 weeks or more after the child has streptococcal infection in the oropharynx. These manifestations can appear independently or in combination.


Be typical:

Symptoms of arthritis: swelling, heat, redness, pain, limited movement.

Polyarthritis (also called polyarthritis) and inflammation of large joints such as ankle joints, wrists, knee joints, elbows ...

Arthritis is a moving nature: When one joint is better, the skin in another joint appears.

Quick cure (do not use any medicine): Inflammation time of each joint is usually from 3 to 7 days, never lasting more than 1 month.

After recovery, there are no sequelae (such as stiffness, muscle atrophy).

Atypical form:

Arthritis is manifested only by symptoms of pain, joint fatigue; no red, hot, or swollen appearance. Furthermore, up to 25-60% of patients with rheumatism do not show symptoms of arthritis. Therefore, it is difficult to diagnose rheumatoid disease early.

There may be inflammation of the small joints such as knuckles, toes ...

Heart inflammation

Myocarditis is the most common lesion in rheumatism (100%). However, in the clinical setting, it is very difficult to determine myocarditis, especially in the case of mild heart inflammation. Symptoms of myocarditis are: pre-cardiac chest pain, fangs of heart, arrhythmia, faint T sound, systolic murmur at the tip of the heart, cloudy area of ​​the heart. Fatigue patient, blue skin. Severe myocarditis will lead to acute heart failure (difficulty breathing, cyanosis, edema, low urination ...) and death.

Endocarditis (endocarditis): Usually occurs several weeks after myocarditis due to late or inactive treatment. Endocarditis is the cause of heart valve sequelae. The most common sequelae are mitral regurgitation, followed by mitral stenosis and aortic valve regurgitation. These sequelae are heart valve disease in children and adults, are the causes of chronic heart failure, reduced working capacity, reduced life expectancy and death. The clinical diagnosis of valvular heart disease is mainly based on cardiogenic signs: murmur and heart sound. The systolic murmur at the apex and the T2 sound in the strong pulmonary valve drive is seen in the case of mitral regurgitation. Chronic fibrillation at the apex of the heart and the sound of T2 in the strong pulmonary valve drive, splitting together in case of mitral stenosis. In the case of an aortic valve open, we can hear the central ventricular murmur in the left third intercostal space, the minimum BP is low, the pulse rate increases, and the T2 sound in the aortic valve drive is fuzzy. In heart valve disease, when there are manifestations of heart failure, there will be symptoms of shortness of breath, edema, and low urination.

Pericarditis: less common, less fluid is usually present, fluid decreases rapidly with corticosteroids and leaves no sequelae after recovery. Diagnosis of pericarditis is based on signs of chest pain, shortness of breath, congested BP, small tachycardia, hearing a faint heartbeat, possibly pericardial rubbing, enlarged heart area, X-ray imaging big, weak heart.

Total heart inflammation: is an inflammatory damage to the heart muscle, in the endocardium and pericardium. The disease is very serious and common in children under 7 years old, not treated early and actively. The course of the disease often leads to severe heart failure and rapid death.

Damage to the skin

Currently very few skin lesions are encountered that the previous authors stated:

Meinet seeds: A hard seed the size of a corn seed or a bean that is painless to touch, usually around the joint or along the spine. They last from 1-2 weeks to 1-2 months and then go away without leaving any trace.

Lendoch - Leyner ring rash and Besnier rash: erythematous ring with average diameter of 1-3 cm or pale erythema in the middle, seen on chest, neck, back, inner thigh, painless, no itching, change color according to the temperature of the body and the environment, disappear quickly without leaving any sequelae.

Neurological manifestations (choreé Sydenham)

Is the dance expression Sydenham, often appears in girls? These are rapid movements of no autonomy, lack of direction, purpose, increase with emotion, loss of sleep. Dance can appear full body, half body or in limbs.

Clinical manifestations are that the child has abnormal movements, fidgeting, when eating or spilling, writing scribbles, sometimes unable to write, sometimes unable to walk.

Before dancing, there are often mental disorders such as irritability, or emotion.

Dance has benign developments: children are still awake, from leaving no sequelae.

Expression elsewhere

Streptococcus can be found in rheumatic heart disease: edema, low urination, protein and red blood cells. These symptoms go away quickly.

Pneumonia is usually concentrated in the lower lobe, progressing rapidly.

Acute hepatitis can be a symptom of a rheumatic illness.

Injury to blood vessels: manifested by spots, petechiae, or nosebleeds.

Clinical weight symptoms

Examination of blood count often has increased leukocytes, increased neutrophils.

Blood sedimentation increased.

C-reactive protein (+).

Change in the number of mucoproteins in the blood:

DPA increases (normal: <220 units).

AC increased (normal <200 units).

Anti-streptococcal antibodies increased:

Increased ASLO (Anti Streptolysin-O) increased> 250 Todd / ml serum.

ASK (Ant streptokinase) increased.

AH (Ant hyaluronidase) increased.

X-ray: Seeing enlarged heart, weak squeezing force of heart muscle, pericardial effusion, lung congestion.

Insane pouring: PQ spans over 0.18 ''.

Echocardiography: Can identify myocarditis, myocardial thickening, pericarditis, damage to the heart valves.

Throat viscous culture shows growth of group A hemolytic streptococcus.


Kill coccidiosis with antibiotics

Penicillin G 1,000,000 VND / day, intramuscularly divided into 2 times 12 hours apart (test reaction before injection) or Penicillin on an empty stomach 1 hour before meals for 10 days. Then immediately switch to the backup dose.

If a Penicillin allergy can be replaced with another antibiotic that works to kill streptococcus such as Erythromycin, Rovamycin ...


Prednisolone 2 mg / kg / 24h orally at full, divided into 3 times:

1/2 dose in the morning.

In the middle of the morning, take 1/4 dose.

Take 1/4 dose at noon.

Prednisolone dose 2mg / kg / day used in 1-2 weeks or 3 weeks, then gradually reduce the dose: Every 3 - 5 - 7 days to reduce 1 tablet so that the time of using corticoid can last 45 days.


100 mg / kg / day orally in 2 divided doses after eating for 4 weeks. Then reduce the dose.

60mg / kg body, orally 2 times after eating, continuously for 2 months.

Anti- shock heart

Tachycardia: Digoxin 0.01mg / kg / 24h, taken as prescribed by physician and must be monitored for the duration of use. If the pulse or quickening is a sign of poisoning, the physician must be reported. If using intravenous Digoxin, you must check the vein before and during injection.

Diuretics are used when patients have edema: Furosemide 2mg / kg / 24h, or hypothalamic 4mg / kg / day. Mercury diuretics such as Novurite can sometimes be used (if the body function is normal).


Use Valium, Dimedone and B vitamins like B 1, B6.


Primary prevention

Apply to children who have not had rheumatism:

Limit all possibilities of strep throat: such as daily oral hygiene, tooth decay, keep warm for children, eat protein, especially.

In case of pharyngitis: must be detected in time and immediately treated with Penicillin for 10 days or Penicillin Benzathine for 1 time, 1,200,000 VND for children> 6 years old 600,000 VND for children <6 years old. tonsils removal: Children over 12 years old have large tonsil, recurrent inflammation.

Recurrence room

Apply to children with low heart rate:

Use antibiotics to kill streptococcus for at least 5 years and until patient turns 23 to prevent relapse:

Deep intramuscular injection (butt injection) 21 days / 1 injection Penicillin to eliminate acupuncture: Penicillin Benzathine (Retapen, Extencilin).

Or you can take Penicillin on an empty stomach, 2 00,000 units a day.

Instructions for patients to consciously prevent rhinitis such as oral hygiene, avoid cold infections, and eat a full range of substances.

Take care of

Human determination

Exploit carefully the history of low heart rate:

History of pharyngitis, tonsillitis.

History of arthritis, moving joint pain.

The first is a dancer.

Family history of someone with rheumatic heart disease or valvular heart disease.

Examination for symptoms of low heart rate

Arthritis: properties, location.

Heart inflammation: chest pain in the pre-heart area, shortness of breath, edema, enlarged liver, enlarged neck, cyanosis, arrhythmia, blurred heart sound, blowing, pericardial brushing, plastic sounds, enlarged heart, electrocardiogram results, ultrasound ...


Other manifestations of the skin (low grain, ring rash, rash, petechiae), nosebleeds, strep inflammation, pneumonia, fever, fatigue, blue skin ...

Care plan

Based on patient stereotypes, nurses can make specific care diagnoses, thereby setting out goals and necessary nursing interventions. For patients with low heart rate, common nursing diagnoses and essential nursing interventions are:

Shortness of breath, purple (edema) due to heart failure:

Heart failure symptoms such as dyspnea, cyanosis may appear frequently or after exertion (going up stairs, doing handwork, etc.) depending on the severity of the heart failure. There are also other symptoms of heart failure such as edema, low urination, fatigue ... Clinically usually divided into 3 levels of heart failure: Grade I, Grade II, Grade IIIA and Grade IIIB. Therefore, the plan of care also depends on the patient's degree of heart failure:

Reducing the burden on the heart:

Let the patient lie to rest completely in bed to reduce the body's need for oxygen and nutrition. Travel restriction for patients with difficulty breathing during exertion.

Eat snacks and foods that are easy to digest such as milk and fish.

Limit salt and water intake by advising the patient to eat relatively bland and limit water intake.

Regularly motivating and explaining so that the patient does not worry, can be assured of treatment, which means that the patient can rest, feel comfortable both physically and mentally, and avoid nervous stress.

Children can be placed in the Foller position for shortness of breath, cyanosis a lot and often, to reduce blood stasis in the lungs.

The patient's sleeping room must be quiet, cool, and have full living amenities.

Instruct patients and monitor the implementation of dietary and dietary instructions.

Take medicine according to the instructions (Digoxin, Digitoxin, diuretics, potassium salts ...). Instruct patients to eat fruits high in potassium during the period of diuretics and digoxin.

Every day to monitor the progress of heart failure symptoms, effectiveness and side effects of drugs to be able to give accurate and timely intervention.

Chest pain caused by heart inflammation:

The diagnosis of "angina due to heart inflammation" is made when the patient complains of pre-cardiac chest pain, tachycardia, irregular rhythm or noises, faint T 1, systolic murmur at the tip, enlargement of the heart, there is a brushing sound of the pericardium ... depending on the patient has myocarditis associated with endocarditis, pericarditis or total heart inflammation.

The necessary remedies in this case are:

Let the patient lie in bed to rest perfectly in order to reduce the body's need for oxygen and nutrition. Limiting the patient's movement to prevent heart failure.

The patient's sleeping room must be quiet, cool, and have full living amenities.

Regular encouragement and explanation for patients not to worry, to be assured of treatment, means for patients to rest, to be comfortable both physically and mentally.

Guide patients to eat foods that are easy to digest, full of nutrients and vitamins.

Follow the instructions on taking anti-inflammatory drugs (Prednisolon, Aspirin), instruct and encourage the patient to take the correct medication, keep the dosage and have enough time as directed.

Painful joints, difficult motility (swelling, heat, redness) due to arthritis:

In order to identify rheumatoid arthritis, in addition to painful red and hot signs, other properties such as migratory arthritis and the duration of inflammation per occlusion (3 - 7 days) are extremely important. However, the significance of this diagnosis is not that the joint is inflamed or not, but that due to the symptoms of arthritis, the diagnosis of rheumatism is more easily determined.

The necessary nursing procedures are:

Follow the instructions on the use of anti-inflammatory drugs (Prednisolone, Aspirin): How to drink, when to drink, dosage, number of times / days, time to take medicine ... prevent drug side effects and monitor for occurrence of these side effects.

Instruct patients to lie down to rest in a sagging position, reduce joint tension, minimize joint movement, movement, and movement to reduce pain for patients and let them feel secure and confident. into treatment (no need to massage or other treatment such as hot, cold or joint immobilization).

press complaining about abnormal vein, lack of direction due to inflammatory lesions in the nervous system:

This diagnosis is based on difficulty walking, writing difficult, scribbling letters, spilled meals ...

The necessary nursing interventions are:

Encouraging and explaining so that patients are not afraid to believe in treatment. The above symptoms will completely go away, but can last up to 1-3 months.

Consistently use drugs as ordered, in addition to anti-inflammatory drugs, you must also use B vitamins such as Bx, B6, B12 and sedatives, antihistamines such as Valium, Dimedone.

There must be someone on duty to take care of the patient in order to help the patient walk, clean, eat ...

Fever, sore throat caused by inflammation in the throat or tonsils:

This diagnosis is based on the patient's temperature rise above 37 o5, accompanied by symptoms such as sore throat, headache, and cough. Examination of a red western throat, sometimes with white pus or red seeds in the back of the throat, tonsil is swollen painful swallowing.

The necessary nursing interventions are:

Follow the instructions on using penicillin.

Use antipyretics when the temperature rises above 38.5 degrees Celsius.

Instruct patients to regularly clean their teeth, avoid cold infections, and eat enough substances to improve the body's resistance.

Family and patient complaining about long term hospital stay due to insufficient understanding of the importance of the disease:

Explain to the patient and family member the patient's current condition to take an active part in treatment.

Describe possible valvular complications and their consequences if the treatment is not timely, inactive, or in insufficient time.

Explain the need to rest, limit movement in order to reduce myocardial exertion, avoid acute heart failure and help patients recover quickly.

Explain that patients can reduce anxiety, confidence, and feel more secure in treatment.

Explain that the patient and family understand the cause of the relapse and the development of valve heart complications and the worsening of the disease after each relapse. Patient and family will actively participate in relapse prevention once the cause is understood.

Guidelines for families and patients to actively participate in the prevention of rheumatic heart disease recurrence:

Strictly follow the low-disease vaccination schedule:

Penicillin Benzathine injection was started immediately after the end of 10 days of taking Benzylpenicillin.

The shots are given 21 days apart.

The vaccination period must be 5 years or more and until the patient turns 23 years old.

Regularly clean teeth, mouth, nose, throat to prevent infections caused by streptococcus.

Avoid cold infection, eat enough to constantly improve the body's resistance.

A guide for families to prevent rheumatism for other children in their family (primary room).