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Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever.

This review of the medical literature reveals that the incidence of rheumatic fever has been declining for at least 150 years, preceding by many decades the use of penicillin as a preventive measure. Simultaneously, the prevalence of rheumatic heart disease has diminished. Streptococcal upper respiratory tract infections remain common but with reduced severity and fewer subsequent cases of rheumatic fever. Scarlet fever has become relatively benign, with low mortality. Whether recent sporadic outbreaks of rheumatic fever due to known rheumatogenic strains of group A streptococci will have a significant effect on morbidity and mortality trends remains to be seen. Relatively high rates of rheumatic fever and rheumatic heart disease in developing countries are difficult to evaluate because of irregularities in reporting and investigative procedures.

Humans

Rocky Mountain spotted fever in Mississippi: survey for spotted fever antibodies in dogs and for spotted fever group reckettsiae in dog ticks.

During epidemiologic studies of Rocky Mountain Spotted Fever in Mississippi in 1973, dogs were surveyed for antibodies tp spotted fever group antigens and for tick parasites infected with rickettsiae of the spotted fever group. Fifty-three (46%) of 116 serum samples had complement-fixing antibody titers greater than or equal to 1:8 as compared to only one (5%) of 21 samples from a group of dogs obtained from metropolitan Chicage. Fifty-two per cent of the dogs tested from Mississippi had microagglutinating antibodies titers greater than or equal to 1:8; 9% of dogs from Chicago had similar titers. Rickettsia rickettsii was demonstrated in only one (0.8%) of 129 Dermacentor variabilis removed from Mississippi dogs. Quite unexpectedly, 167 (18.9%) of 884 Rhipicephalus sanguineus taken from these dogs contained spotted fever group rickettsiae.

Agglutination Tests

Pathogenesis of viral hemorrhagic fevers: Rift Valley fever and Lassa fever contrasted.

Although many viral infections have on occasion been associated with hemorrhagic complications, infection with any of several RNA viruses regularly results in vascular involvement and the syndrome called viral hemorrhagic fever (VHF). In spite of clinically useful similarities among various VHFs, there are significant differences in their pathogenesis and clinical evolution; these are often related to characteristics of their viral taxon. Infection with Rift Valley fever (RVF) virus, a phlebovirus, appears to be regulated by interferon and terminated by neutralizing antibody. In contrast, Lassa fever (LF) virus, an arenavirus, is resistant to interferon, and LF is terminated by cellular immune effector mechanisms. The lytic virus-cell interaction typical of RVF virus suggests its major effects occur by direct, virus-induced cellular necrosis, particularly in the liver. In the primate RVF model, disseminated intravascular coagulation (DIC) may be important. LF virus--characteristically noncytopathic--may exert its effects through induction of mediator secretion from infected macrophages. DIC does not appear to be a central pathogenetic mechanism in LF. Pichinde virus, which is not pathogenic for humans, provides an alternate model for study of LF. Infected guinea pigs do not show histologic lesions that could explain their body wasting, cardiovascular deterioration, and pulmonary edema. In the heart, for example, loss of tissue mass, protein, and contractile function proceed without direct viral involvement or myocarditis. Sulfidopeptide leukotrienes have been implicated as one relevant soluble mediator participating in the disease state.

Animals

1987 yellow fever epidemics in Oyo State, Nigeria: a survey for yellow fever virus haemagglutination inhibiting antibody in residents of two communities before and after the epidemics.

A survey for yellow fever haemagglutination inhibiting antibody was carried out before and after the 1987 yellow fever epidemics in Nigeria in two localities in Oyo State, namely: Ibadan and Ogbomosho. A total of 129 sera were collected from the two localities before the epidemic. The overall prevalence of yellow fever HI antibody was 37%. A breakdown of positive sera showed that 30/100 and 18/29 sera tested in Ibadan and Ogbomosho respectively were positive. There was a higher prevalence of HI antibody in males (43%) than in females (32%). Of the 48 yellow fever positive sera 23(47%) contained HI antibody to West Nile and 26(52%) to Potiskum viruses. Following the epidemic and the subsequent mass vaccination campaign with the 17D yellow fever vaccine, 200 sera were randomly collected from the same localities. The overall prevalence of yellow fever HI antibody was 67%. The percentage of positive sera in the individual locality was 63% in Ibadan and 73% in Ogbomosho. No statistical difference was observed in the prevalence of yellow fever antibody in both sexes following the yellow fever vaccination campaign (P greater than 0.05). Tests on yellow fever HI antibody positive sera collected after the vaccination campaign showed that 74% and 82% were positive for West Nile and Potiskum HI antibody respectively. Results of this study showed that despite the massive antiyellow fever vaccination campaign there was still a high percentage of seronegative persons in the two communities.

Age Factors

Milk fever in dairy cows. VII. Effect of continuous vitamin D feeding on incidence of milk fever.

Feeding of 20 to 30 million units of vitamin D for 3 to 8 days prepartum previously prevented about 80% of expected milk fever cases in mature Jersey cows with histories of milk fever. In this experiment vitamin D was fed continuously through the year via 32,000 units of vitamin D added to each .455 kg of concentrate fed (approximately 100,000 to 580,000 units/day). Milk fever incidence was measured after 5 yr of age (third calf) at 43 parturitions in mature Jersey cows with histories of milk fever and at 139 parturitions in mature Jersey cows with no previous milk fever. Continuous feeding of vitamin D reduced incidence of milk fever in cows with previous milk fever from 60% in the controls to 26.1% in the group fed vitamin D. In the cows with no milk fever previously, feeding vitamin D did not reduce incidence of milk fever (controls 23.7%, vitamin-D-fed 28.3%).

Animals

[No connection between scarlet fever and gouty fever. Historical analysis from Ytre Nordhordland during 1862-1884].

In 1987 there was an unexplained increase in severe streptococcal diseases in Norway and other western countries. In Norway this increase was not accompanied by a corresponding increase in acute rheumatic fever. This study investigated the occurrence of scarlet fever and acute rheumatic fever in a rural district (approximately 15,000 inhabitants) of western Norway during the years 1862-1884. Four epidemics of severe scarlet fever occurred during this period. The local doctor treated 1,155 patients (96% children), of whom 154 (13.3%) died. Acute glomerulonephritis with subsequent kidney failure seems to have been a major cause of death. During the same period 76 patients (96% adults) were treated for acute rheumatic fever. These cases were not related to the severe epidemics of scarlet fever. It is probable that different, co-circulating strains of streptococci caused the infections, which were followed by glomerulonephritis and rheumatic fever. It is possible that rheumatic fever was caused by the strain that induced the more benign "Angina tonsillaris".

Disease Outbreaks

Rheumatic fever in Minnesota. II. Evaluation of hospitalized patients and utilization of a State Rheumatic Fever Registry.

We studied the hospital records of 124 patients with a discharge diagnosis of acute rheumatic fever who were hospitalized in 21 Minneapolis-St. Paul hospitals during 1975 and 1976. After careful review of the hospital records, we found that 83 (67 per cent) of these patients did not have an acute illness. Seventeen (41 per cent) of the 41 cases with an acute illness were thought to adequately fulfill the Jones' Criteria for acute rheumatic fever. Upon review of the rheumatic fever registry of the Minnesota State Health Department, we found that less than one-half of the hospitalized patients had been reported to the registry. Cases that fulfilled and did not fulfill the Jones' Criteria were reported with equal frequency, indicating significant underreporting and overreporting of rheumatic fever. Evaluation of secondary rheumatic fever prophylaxis, both in those patients with acute rheumatic fever as well as in those with rheumatic heart disease, indicated that many patients who, in theory, should be receiving prophylaxis were not receiving it. These studies indicate a need for more thorough evaluation of the current epidemiology of rheumatic fever and the role of a rheumatic fever registry, and imply a need for reevaluation of these programs. (Am J Public Health 69:767-771, 1979).

Acute Disease

Fever and fever syndrome--current problems.

Research into the complex humoral and neurophysiological events of pyrogen-induced fever has proceeded rapidly to establish the thermal and non-thermal components of the fever syndrome. The major breakthroughs derive from the elucidation of the identity of the endogenous pyrogen interleukin 1 with the humoral factors responsible for the acute phase reaction and for the activation of lymphocytic, cellular, and immunological defence as host responses to infections. As a consequence, fever research is no longer concerned primarily with the changes in temperature regulation responsible for the febrile alteration of temperature regulation, but aims at the elucidation of the contributions that are made by both the thermal and non-thermal components of the fever syndrome to the defence of the host against the microbial intruder responsible for this syndrome. In order to account for this development in these introductory remarks to the current issues of fever research, this review has tried to pay particular attention to the following points: 1) The role of humoral factors in the generation of febrile hyperthermia, including endogenous pyrogens as well as mediators acting on the thermoregulatory center. 2) The "fever syndrome" with special consideration of its regulation and of the significance of its components from the viewpoint of fever as a host-defence reaction. 3) The assessment of the role of PG's in the generation of the fever syndrome, both as putative central mediators and as systemically released agents, with special consideration of the inhibitory action of the established antipyretic drugs on PG synthesis.

Antibody Formation

[Fever of unknown origin: re-evaluation of 67Ga scintigraphy in detecting causes of fever].

Radioactive gallium citrate has been known to accumulate not only in neoplasms but also in inflammatory foci, and thus widely used to find out pyrogenic lesions in cases of unexplainable prolonged fever. However, with developments and improvements of other imaging modalities, its diagnostic significance may have changed. To probe that issue, recent 65 scans for the patients with fever of unknown origin were reviewed retrospectively. Of these, 56 had sufficient clinical assessment and laboratory examinations to evaluate causative illnesses. Gallium images of 33 patients were interpreted as positive. Local inflammatory lesions were detected in 23 cases, with lung tuberculosis, urinary tract infection, and inflammatory joint diseases as prevalent final diagnoses. Pyogenic abscesses, though popular in the literatures on fever of unknown origin, were found in only 2 cases in our present series. This seemed to be due to earlier detection of affected sites by other imaging technics. Osteomyelitis, other major cause of fever in the past, was not found this time, probably owing to wide use of antibiotics. Besides localized diseases, seven cases of generalized disorders were found. There were 3 patients with hematological malignancies, 3 with systemic autoimmune diseases, and 1 with severe infectious mononucleosis. There were three false positive cases; intestinal gallium radioactivity in 2 cases and physiological pulmonary hilar accumulation in 1 were erroneously read as abnormal. Of 23 cases with negative gallium scan, no definite cause of fever were found in 19; twelve patients had spontaneous reduction of fever, 2 did so with antibiotics, and 5 with corticosteroids. False negative cases were; two with urinary tract infection on antibiotics, one with bacterial meningitis, and one with polyarteritis nodosa. Our results reconfirmed the excellent sensitivity and accuracy of gallium scan in the diagnosis of fever of unknown origin. In addition to the detection of focal inflammations, it may sometimes contribute to an early diagnosis of unexpected systemic diseases. From the results obtained, it is advisable that, in patients with fever of unknown origin, this test should be done early in diagnostic schedule and before administration of drugs that may mask potential sites of abnormal accumulation.

Adolescent

Fever in general practice. II. Reasons for encounter, management and duration of fever conditions.

A sample of 80 direct and 36 telephone encounters for fever was established in 1988 as part of a Norwegian study on fever as a clinical problem in general practice. Reasons for encounter (ICPC) and clinical examinations were recorded along with clinical laboratory tests, treatment, management and follow up (IC-Process-PC). The doctors assessed the diagnostic process by means of visual analogue scale. Duration of the fever conditions was estimated through a postal questionnaire. Patients with direct encounters presented a wide range of reasons for the encounters. Fever was the most frequent single presenting complaint (31%). The general practitioners put major emphasis on the clinical examinations. They prescribed drugs in 68% of the direct encounters. Seventy per cent of the prescriptions were general systemic anti-infectives. Penicillin accounted for 58% of antibiotics. Six (8%) patients were hospitalized, and three (4%) were referred to a specialist. The mean time until complete recovery was 15 days for direct and 19 days for telephone encounters. Fever may be a sign even when it is not a presenting complaint. Major emphasis is probably put on the clinical examination of febrile patients because of the complexity of symptoms and the wide range of diagnoses associated with fever.

Anti-Infective Agents

Tick-borne diseases in the United States: Rocky Mountain spotted fever and Colorado tick fever. A review.

The historical, clinical, ecological, and epidemiological features of Rocky Mountain spotted fever and Colorado tick fever, the two important tick-borne diseases in the United States, are reviewed. Rocky Mountain spotted fever, once considered a disease of the past, has again become a measurable public health problem. Its nationwide incidence has steadily increased since 1960 and has reached record proportions in 1976. The various factors responsible for this trend as well as for the mortality rates, which in spite of availability of effective antibiotics ranges from 5 to 10%, are discussed. Education of the public about ticks and their potential role as vectors of Rickettsia rickettsii and/or Colorado tick fever virus, and about the clinical manifestations of Rocky Mountain spotted fever, is considered the best means for preventing high incidence and mortality from these diseases.

Antibodies, Viral

Rat bite fever misdiagnosed as Rocky Mountain spotted fever.

A patient who had been exposed to ticks and who had also been bitten by a laboratory rat developed fever, headache, and a rash. He was treated with chloramphenicol for Rocky Mountain spotted fever, and recovered. Blood cultures, however, grew Streptobacillus moniliformis, a causative agent of rat bite fever. The case report illustrates the clinical similarities between rat bite fever and Rocky Mountain spotted fever.

Adult

Persistent fever as the only symptom of familial Mediterranean fever.

We describe a 54-year-old man who suffered from familial Mediterranean fever, but the fever has been the only symptom during a 10-year period. During this period, results of laboratory tests and roentgenographic studies were negative. On the basis of these findings we propose that familial Mediterranean fever can be included in the causes of persistent fever in patients with long periods of fever.

Familial Mediterranean Fever