Rheumatic fever is an allergic disease which occurs as a delayed sequel to group A hemolytic streptococcal infection. It involves in connective tissues of the heart, joints, skin and vessels. It appears most commonly in school-age children, and between the ages of 20¡ª30. Repeated recurrences of rheumatic fever may cause valvular damage and eventually a chronic rheumatic valvular disease. In TCM, this disease belongs to the categories of "bi zheng" (arthralgia-syndrome) and "xin bi" (obstruction of the heart qi).  

Main Points of Diagnosis

According to the revised Jones criteria for the diagnosis of rheumatic fever, if there is an evidence of group A streptococcal infection 1¡ª4 weeks previous to the rheumatic attack and if cases manifest 2 major criteria or one major criterion and 2 minor criteria listed below, the diagnosis of rheumatic fever can be established.

1. Major criteria

(1) Carditis: This includes endocarditis, myocarditis and pericarditis, manifested as tachycardia, cardiac enlargement, attenuation of the first heart sound and the presence of a systolic and diastolic murmurs (Coomb's murmur) at the apex area of heart. Pericardial friction rub may be present. Electrocardiogram may show various kinds of arrhythmia, among which various degrees of conduction block are of the greatest significance.

(2) Migratory polyarthritis: The large joints of the extremities are most frequently affected. The affected joints are red, swollen, hot and tender. The acute arthritis subsides without sequel.

(3) Erythema annulare.

(4) Subcutaneous nodules.

(5) Chorea.

2. Minor criteria

(1) Fever: Fever is mild or moderate accompanied with hidrosis, weakness and weight loss.

(2) Elevated erythrocyte sedimentation rate, positive C-reactive protein or increased white cell count.

3. The evidence of recent streptococcal infection

(1) There was angina, acute tonsillitis and others 1¡ª4 weeks prior to the onset of rheumatic fever. Or the throat swab culture is positive for group A hemolytic streptococci.

(2) Elevation of antistreptolysin (ASO) titer > 500 units, elevation of antistreptokinase (ASK) > 80 units or elevation of antihyaluronidase titer (AHT) > 128 units. Other nonspecific serum components may also have changes.  

Differentiation and Treatment of Common Syndromes     

1. Wind-Dampness-Heat Syndrome

Main Symptoms and Signs: Redness, swelling, heat sensation and pain of the joints which is too painful to be touched but relieved by cold, inability to move, restlessness and discomfort in the chest, sometimes accompanied with fever and thirst, red tongue with dry and yellow fur, slippery and rapid pulse.

Therapeutic Principle: Dispelling pathogenic heat, removing obstruction in the channels and dispelling pathogenic wind and dampness.

Recipe: Modified White Tiger Decoction Added with Cinnamon Twig.

gypsum

anemarrhena rhizome

polished round-grained non-glutinous rice

licorice root

cinnamon twig

coix seed

honeysuckle stem

mulberry twigs

phellodendron bark

red peony root

All the above herbs are to be decocted in water for oral administration.

When the case is accompanied with erythema annulare and subcutaneous nodule, the above recipe should include the following ingredients: red sage root 15g, safflower 10g and arnebia root 10.

2. Wind-Cold-Dampness Syndrome

Main Symptoms and Signs: Persistent arthralgia of the extremities aggravated by cold and relieved by warmth, pale tongue with whitish thin and greasy fur, floating and slow pulse. If the pain is migratory, involving more joints, it its mainly due to pathogenic wind. If the pain is comparatively aggravated and localized accompanied with a feeling of cold in the affected region, it is chiefly due to pathogenic cold; if the involved joints is marked by heavy sensation, numbness or swelling ,it is mainly due to pathogenic dampness.

Therapeutic Principle: Dispersing pathogenic wind, cold and dampness.

Recipe: Modified Decoction for Treating Rheumatic or Rheumatoid Arthritis.

notopterygium root

pubescent angelica root

cinnamon twig

large-leaf gentian root

Chinese angelica

ligusticum rhizome

futokadsura stem

spatholobus stem

mulberry twigs

All the above herbs are to be decocted in water for oral administration.

In cases mainly due to pathogenic wind, 12 grams of clematis root and 10 grams of ledebouriella root should be added; In cases chiefly due to pathogenic cold, 3 grams of prepared Sichuan aconite root, 3 grams of prepared wild aconite root and 6 grams of licorice root may be employed. as for cased mainly due to pathogenic dampness, 30 grams of coix seed and 12 grams of atractylodes rhizome are to be added. When the disorder is accompanied with chorea, 12 grams of white peony root, 12 grams of achyranthes root, 10 grams of gastrodia tuber and 20 grams of uncaria stem with hooks are to be included. When the case becomes chronic marked by repeated attacks and aggravated arthralgia, it is advisable to overcome it with the addition of 10 grams of frankincense, 10 grams of myrrh, 12 grams of earthworm and 6 grams of scorpion. When there are symptoms of deficiency and weakness of both qi and blood as well as deficiency of the liver and kidney caused by delayed recovery, the above recipe should also include 15 grams of astragalus root, 12 grams of codonopsis root, 12 grams of eucommia bark and 15 grams of loranthus mulberry mistletoe.

3. Deficiency of Qi and Yin

Main Symptoms and Signs: Palpitation, shortness of breath, chest stuffiness or chest pain, insomnia, arthralgia with slight swelling, red tongue with whitish thin fur, thready and rapid pulse.

Therapeutic Principle: Tonifying qi and nourishing yin, removing pathogenic dampness and obstruction in the channels.

Recipe: Pulse-Activation Powder with additional ingredients.

codonopsis root 

ophiopogon tuber

schisandra berry

Chinese angelica

red sage root

coix seed

arborvitae seed

tetrandra root

chaenomeles fruit

All the above herbs are to be decocted in water for oral administration.  

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