#35 - Acute Rheumatic Fever

#35 - ARF...the child killer.

Almost completely eliminated in metropolitan Australia, is a disease process known as Acute Rheumatic Fever.  It is a immune antibody reaction to a recent infection with common old Strep bacteria.   Streptococcus Pyogenes causes Strep Throat, Scarlet fever and skin infections seen in poverty areas where over crowding and poor hygiene and substandard nutrition is evident.

We have all heard of these infections.  They are tonsillitis, infected Scabies and Impetigo or school sores.  in 10 days or so the body's immune system can set up a reaction which can ultimately cause valve damage in the persons heart of those who develop Acute Rheumatic Fever.

This condition is the biggest killer of aboriginal and Torres Strait Islander children in Australia.  It is almost never seen in white kids, or the first world.!   Read that last sentence out loud.  It is a 3rd world disease, yet still the biggest killer of indigenous children.  Across the Torres, health centres are on keen look out for ARF in kids 5-16 years of age.   And today, I had personal experience with this disease that by definition , we shouldn't have in our 1st world country.

Two days ago, a 6 year old girl walked into the clinic with a fever of 40.  She complained of a vague leg pain in her thigh.  Despite her fever she had no other symptoms that were red flags.  Urine clear, Chest- clear, ENT - clear. No rash, no lymph nodes, slight belly runs and a dry scab on her knee, otherwise nothing tangible.
  She was a bit dehydrated , so I sent her home with her Aka (grand mother), for rehydration.

Yesterday , she returned for follow up so I could reassess her.  This time she limped into the clinic, was still running a fever, had lost 200grams, was complaining of pain in her knee, and the small dry scab on her knee had become weepy with a golden exudate.  This was a Red flag.  Fever and Joint pain in a TSI child is a reportable condition.  With a phone consult to our amazing nurse practitioner to see I was on the right track, I commenced the ARF protocol which included analgesia, and a nasty injection of penicillin in the backside.  This little pickle was so brave, and I really didn't understand just how sick she really was.  It was decided that she should be sent to Thursday Island for further investigations and treatment.  Flights were organised for today, so she was able to go home to grandmothers and sleep.  I would see her in the morning.

This morning comes, this poor child is beside her self in pain.  The knee has blown up to 2/3 larger than it was, she cant walk and is carried into the clinic, still has fever despite maximum panadol and Nurofen.  I am worried.  Kids crash so fast, and 200 km from the nearest doctor or hospital makes me a little edgy.

When that plane came and took her and her dad to TI, I was very relieved.  I have spent the rest of the afternoon reading up on and learning about a condition unique to indigenous Australia, and one that when I head south, I will probably go another 25 nursing years and still not see.

These kids need there sores to be managed better.  Clean clothes daily, good hand washing and body hygiene, and for goodness sake...1 kid in a bed!!!  This little germ is a nasty bugger.

When this child comes home, she can look forward to a painful penicillin injection in her bum every month till her 21st birthday.  If tests in TI reveal any heart damage, then she could need monthly injections for up to 40 years!!!   This disease attacks heart tissue causing a Congestive Cardiac Failure, and treatment aims to minimise heart disease.  It is cruel and barbaric, and I hate giving these kids penicillin injections, but when you look ad 6 year old children as cardiac cripples the likes of an 80 year old man who has survived heart attacks, then one understands the necessity.

I wont bore you with the physiology, (you know I want to) that is what Dr Google is for, but it never ceases to amaze me how fast kids get sick, and what the Torres can throw at my steep learning curve.
Perhaps one day I will need these skills and knowledge again ;)

I will follow up this little girl.  The possibility is that she may have to be medivac to Cairns for a heart specialist, but when I listened to her chest, and took her ECG, all was normal at that stage.  That said, this disease can be unpredictible.  The sad thing for children with ARF is that the treatment of the inflammation of joints and the heart tissue, is a drug called Aspirin.  Kids cant have aspirin, so it is a classic Catch 22 situation.
Do I risk killing the kid from aspirin complication called Reyes Syndrome, or do I withhold it and risk fatal heart failure?!!!

The questions are so hard to answer, but perhaps the most difficult issue is that this condition is completely preventable......Cover your sores kids, and STOP picking your scabs!!!!!