Rheumatic fever is now extremely uncommon in developed countries, but remains common in developing areas. Diagnosis is based on the presence of two or more major manifestations – endocarditis (see under HEART, DISEASES OF), POLYARTHRITIS, chorea, ERYTHEMA marginatum, subcutaneous nodules – or one major and two or more minor ones – fever, arthralgia, previous attacks, raised ESR, raised white blood cell count, and ELECTROCARDIOGRAM (ECG) changes. Evidence of previous infection with streptococcus is also a criterion.
Clinical features Fever is high, with attacks of shivering or rigor. Joint pain and swelling (arthralgia) may affect the knee, ankle, wrist or shoulder and may migrate from one joint to another. TACHYCARDIA may indicate cardiac involvement. Subcutaneous nodules may occur, particularly over the back of the wrist or over the elbow or knee. Erythema marginatum is a red rash, looking like the outline of a map, characteristic of the condition.
Cardiac involvement includes PERICARDITIS, ENDOCARDITIS, and MYOCARDITIS. The main long-term complication is damage to the mitral and aortic valves (see HEART).
The chief neurological problem is chorea (St Vitus’s dance) which may develop after the acute symptoms have subsided.
Chronic rheumatic heart disease occurs subsequently in at least half of those who have had rheumatic fever with carditis. The heart valve usually involved is the mitral; less commonly the aortic, tricuspid and pulmonary. The lesions may take 10–20 years to develop in developed countries but sooner elsewhere. The heart valves progressively ?brose and ?brosis may also develop in the myocardium and pericardium. The outcome is either mitral stenosis or mitral regurgitation and the subsequent malfunction of this or other heart valves affected is chronic failure in the functioning of the heart. (see HEART, DISEASES OF).
Treatment Eradication of streptococcal infection is essential. Other features are treated symptomatically. PARACETAMOL may be preferred to ASPIRIN as an antipyretic in young children. One of the NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS) may bene?t the joint symptoms. CORTICOSTEROIDS may be indicated for more serious complications.
Patients who have developed cardiac-valve abnormalities require antibiotic prophylaxis during dental treatment and other procedures where bacteria may enter the bloodstream. Secondary cardiac problems may occur several decades later and require replacement of affected heart valves.... rheumatic fever
Causes There is a major immunogenetic predisposition to rheumatoid arthritis in people carrying the HLA-DR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also been implicated. In addition, there is a degree of familial clustering which suggests other unidenti?ed genetic factors. Genetic factors cannot alone explain aetiology, and environmental and chance factors must be important, but these have yet to be identi?ed.
Epidemiology Rheumatoid arthritis more commonly occurs in women from the age of 30 onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may occur in adolescence, but in childhood chronic SYNOVITIS usually takes one of a number of di?erent patterns, classi?ed under juvenile chronic arthritis.
Pathology The primary lesion is an in?ammation of the synovial membrane of joints. The synovial ?uid becomes diluted with in?ammatory exudate: if this persists for months it leads to progressive destruction of articular CARTILAGE and BONE. Cartilage is replaced by in?ammatory tissue known as pannus; a similar tissue invades bone to form erosions. Synovitis also affects tendon sheaths, and may lead to adhesion ?brosis or attrition and rupture of tendons. Subcutaneous and other bursae may be involved. Necrobiotic nodules also occur at sites outside synovium, including the subcutaneous tissues, the lungs, the pericardium and the pleura.
Clinical features Rheumatoid arthritis varies from the very mild to the severely disabling. Many mild cases probably go undiagnosed. At least 50 per cent of patients continue to lead a reasonably normal life; around 25 per cent are signi?cantly disabled in terms of work and leisure activities; and a minority become markedly disabled and are limited in their independence. There is often an early acute phase, followed by substantial remission, but in other patients gradual step-wise deterioration may occur, with progressive involvement of an increasing number of joints.
The diagnosis of rheumatoid arthritis is largely based on clinical symptoms and signs. Approximately 70 per cent of patients have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number of false positives and false negatives, this test has very little value in clinical practice. It may be a useful pointer to a worse prognosis in early cases if the level is high. X-RAYS may help in diagnosing early cases and are particularly helpful when considering surgery or possible complications such as pathological fracture. Patients commonly develop ANAEMIA, which may be partly due to gastrointestinal blood loss from antiin?ammatory drug treatment (see below).
Treatment involves physical, pharmacological, and surgical measures, together with psychological and social support tailored to the individual patient’s needs. Regular activity should be maintained. Resting of certain joints such as the wrist with splints may be helpful at night or to assist prolonged manual activities. Sound footwear is important. Early use of antirheumatic drugs reduces long-term disability. Drug treatment includes simple ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), and slow-acting drugs including GOLD SALTS (in the form of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHIOPRINE.
The non-steroidal agents are largely e?ective in reducing pain and early-morning sti?ness, and have no e?ect on the chronic in?ammatory process. It is important, especially in the elderly, to explain to patients the adverse effects of NSAIDs, the dosage of which can be cut by prescribing paracetamol at the same time. Combinations of anti-rheumatic drugs seem better than single agents. The slow-acting drugs take approximately three months to act but have a more global e?ect on chronic in?ammation, with a greater reduction in swelling and an associated fall in erythrocyte sedimentation rate (ESR) and rise in the level of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints. Systemic corticosteroids carry serious problems if continued long term, but may be useful under special circumstances. Much research is currently going on into the use of tumour necrosis factor antagonists such as INFLIXIMAB and etanercept, but their precise role remains uncertain.... rheumatoid arthritis
Habitat: Sub-alpine Himalayas, from Kashmir to Sikkim at altitudes of 3,300-5,200 m.; also cultivated in Assam.
English: Indian Rhubarb, Himalayan Rhubarb.Ayurvedic: Amlaparni, Pitamuuli, Gandhini Revatikaa. Revandachini (roots).Unani: Revandchini.Siddha/Tamil: Revalchinikattai, Nattirevaichini.Action: Purgative, astringent, aperient. Used for constipation and atonic dyspepsia. Not advised for patients suffering from gout, rheumatism, epilepsy. (When given internally, the root imparts a deep tinge to the urine.)
The root gave emodin, emodin- 3-monomethyl ether, chrysophanol, aloe-emodin, rhein. These occur free and as quinone, anthrone or dianthrone glycosides. The astringent principle consists of gallic acid together with small amounts of tannin. The drug also contain cinnamic and rhe- inolic acids, volatile oil, starch and calcium oxalate. Two major glyco- sidic active principles, sennoside A and B, are present along with free an- thraquinones.At low doses, the tannin exerts astringent effect and relieves diarrhoea; at higher doses anthraquinones stimulate laxative effect and relieve constipation. (Natural Medicines Comprehensive Database, 2007.)There are three main types of rhubarbs—Chinese, Indian or Himalayan, and Rhapontic.The Chinese rhubarb consists of the rhizomes and roots of Rheum palma- tum and R. officinale.The Indian rhubarb consists of dried rhizomes of R. emodi and R. web- bianum; rhizomes and roots of R. moorcroftianum and R. spiciforme are also reported to be mixed with the drug. R. rhaponticum is the Rhapontic rhubarb.Rheum moorcroftianum Royle (the Himalayas at altitudes of 3,0005,200 m., chiefly in Garhwal and Ku- maon) possesses properties similar to those of R. emodi and the roots are mixed with the latter.Rheum spiciforme Royle (drier ranges of Kumaon and Sikkim at altitudes of 2,700-4,800 m.) also possesses purgative properties. The rhizomes and roots are mixed up with Himalayan rhubarb.Rheum webbianum Royle (the western and central Himalayas at altitudes of 3,000-5,000 m.) is the source of Himalayan rhubarb.Rheum palmatum is esteemed as the best type of (Chinese) rhubarb. Two new stilbene glycosides, 4'-O- methylpiceid and rhapontin, isolated from the roots, exhibited moderate alpha-glucosidase inhibitory activity. Anthraquinone glucoside, pul- matin, isolated from the roots, along with its congeners, chrysophanein and physcionin, showed cytotoxic activity against several types of carcinoma cells. Polysaccharides, isolated from the roots and rhizomes, contained lyx- ose, glucose, galactose, xylose, rham- nose, mannose and ribose.Dosage: Root—0.2-1.0 g powder. (CCRAS.)... rheum emodiHabitat: The Himalayas from Nepal to Bhutan at 3,900-4,800 m.
Folk: Tehuka (Sikkim).Action: The roots resemble those of Rheum emodi, but are spongy and inert. Stems are acidic, used as salad. Dried leaves are sometimes used as a substitute for tobacco.... rheum nobile
Habitat: Western Himalayas. Folk: Archa.
Action: Antispasmodic, muscle relaxant, antiseptic.
The rhizomes contain desoxyrha- pontigenin. The compound, like papaverine, exhibited smooth muscle relaxant activity in a wide variety of in vitro and in vivo tests. Aqueous alcoholic extract showed papaverine-like non-specific spasmolytic activity.The paste of fresh rhizomes is applied on burns, blisters and boils to prevent scar formation.... rheum webbianumHabitat: Southeast Tibet, West and Northwest China.
English: Rhubarb.Unani: Usaare Rewand.Action: Astringent and cathartic (anthraquinones are laxative and tannins astringent), stomachic, aperient, cholinergic, gastric stimulant, antispasmodic, anti-inflammatory, antiseptic. Used for indigestion, diarrhoea, dysentery and disorders of liver and gallbladder.
Key application: In constipation. Contraindicated in acute intestinal inflammation and obstruction. (German Commission E, ESCOP, The British Herbal Pharmacopoeia, WHO.)Rhubarb contains 1,8-dihydroxy- anthracene derivatives. The laxative effect of the herb is primarily due to its influence on the motility of the colon, inhibiting stationary and stimulating propulsive contractions. Stimulation of the chloride secretion increases the water and electrolyte content of stool. (German Commission E.)The plant extract of R. officinale is found to be strong and effective scavenger of oxygen radicals in xan- thine/xanthine oxidase and other systems in vitro.Rheum rhaponticum, known as Rha- pontic or English rhubarb, is extensively cultivated all over Europe and America; also cultivated to a small extent in India in the Khasi Hills, the Nilgiris and West Bengal.Rhubarbs contain anthraquinones but English rhubarb contains only chrysophanic acid and some of its glycosides. Stilbene glycosides, present in other types, are also found in English rhubarb. The roots contain rhapontin. (1.42%), reported to restore oestrus cycle in castrated female rats.... rheum officinaleTeas: Nettles, Borage, Mate, Figwort, Gotu Kola, Motherwort.
Decoctions: Blach Cohosh, Cramp bark, Hawthorn, Lily of the Valley, White Willow, Sarsaparilla. Any one.
Formula. Combine Black Cohosh root half; White Willow bark 2; Gotu Kola 1; Hawthorn berries 1. 1oz to 1 pint water; bring to boil; simmer gently 15 minutes; strain when cold. Dose: half-1 cup thrice daily, and when necessary.
Ligvites. Guaiacum resin BHP (1983) 40mg; Black Cohosh BHP (1983) 35mg; White Willow bark BHP (1983) 100mg; Extract Sarsaparilla 4:1 25mg; Extract Poplar bark 7:1 17mg. (Gerard House)
Powders. Combine, Hawthorn 1; Cactus 2; Black Cohosh half; White Willow bark 1; with pinch Cayenne. 750mg (three 00 capsules or half a teaspoon) 2-3 times daily.
White Bryony. Liquid Extract: 15-60 drops, thrice daily. Good results reported.
Colchicum, Tincture. Indicated in presence of gout: Dose: 0.5-2ml in water. (Practitioner use only) Vitamin E. Should not be taken in rheumatic heart disorders.
Diet. See: DIET – HEART AND CIRCULATION. ... heart - rheumatic heart
Symptoms. Morning stiffness and pain wearing off later. Easy fatigue and decline in health. Nodules on surface of bones (elbows, wrists, fingers). Joint fluids (synovia) appear to be the object of attack for which abundant Vitamin C is preventative. Anaemia and muscle wasting call attention to inadequate nutrition, possibly from faulty food habits for which liver and intestine herbs are indicated.
Treatment. Varies in accord with individual needs. May have to be changed many times before progress is made. Whatever treatment is prescribed, agents should have a beneficial effect upon the stomach and intestines to ensure proper absorption of active ingredients. (Meadowsweet)
It is a widely held opinion that the first cause of this condition is a bacterial pathogen. An anti- inflammatory herb should be included in each combination of agents at the onset of the disease. See: ANTI-INFLAMMATORY HERBS. Guaiacum (Lignum vitae) and Turmeric (Curcuma longa) have a powerful anti-inflammatory action and have no adverse effects upon bone marrow cells or suppress the body’s immune system. Breast feeding cuts RA death rate.
Of therapeutic value according to the case. Agrimony, Angelica root, Balmony, Black Cohosh (particularly in presence of low back pain and sciatica), Bogbean, Boldo, Burdock, Celery, Cramp bark, Devil’s Claw, Echinacea (to cleanse and stimulate lymphatic system), Ginseng (Korean), Ginseng (Siberian), Liquorice, Meadowsweet, Poke root, Prickly Ash bark, White Poplar bark, White Willow bark, Wild Yam.
Tea. Formula. Equal parts. Alfalfa, Bogbean, Nettles. 1 heaped teaspoon to each cup boiling water; infuse 5-10 minutes, 1 cup thrice daily.
Decoction. Prickly Ash bark 1; Cramp bark 1; White Willow bark 2. Mix. 1oz to 1 pint water gently simmered 20 minutes. Dose: Half-1 cup thrice daily.
Tablets/capsules. Black Cohosh, Celery, Cramp bark, Devil’s Claw, Feverfew, Poke root, Prickly Ash, Wild Yam, Ligvites.
Alternative formulae:– Powders. White Willow bark 2; Devil’s Claw 1; Black Cohosh half; Ginger quarter. Mix. Dose: 750mg (three 00 capsules or half a teaspoon) thrice daily.
Liquid extracts. White Willow bark 2; Wild Yam half; Liquorice half; Guaiacum quarter. Mix. Dose: 1-2 teaspoons thrice daily.
Tinctures. Cramp bark 1; Bogbean 1; Prickly Ash half; Meadowsweet 1; Fennel half. Mix. Dose: 1-3 teaspoons thrice daily.
Ligvites. (Gerard House)
Cod Liver oil. Contains organic iodine, an important factor in softening-up fibrous tissue, to assist metabolism of uric-acid, help formation of haemoglobin, dilate blood vessels; all related to arthritics. The oil, taken internally, can reach and nourish cartilage by the process of osmosis; its constituents filter into cartilage and impart increased elasticity.
Topical. Evening Primrose oil, Wintergreen lotion, Comfrey poultice. Hydrotherapy: hot fomentations of Hops, Chamomile or Ragwort. Cold water packs: crushed ice or packet of frozen peas in a damp towel applied daily for 10 minutes for stiffness and pain. See: MASSAGE OIL.
Aromatherapy. Massage oils, any one: Cajeput, Juniper, Pine or Rosemary. 6 drops to 2 teaspoons Almond oil.
Supportives: under-water massage, brush baths, sweat packs, Rosemary baths, exposure of joints to sunlight.
Diet. Low salt, low fat, oily fish, Mate tea, Dandelion coffee. On exacerbation of the disease cut out all dairy products.
Supplements. Daily. Evening Primrose capsules: four 500mg; Vitamin C (1-3g); Bromelain 250mg between meals; Zinc 25mg.
General. Residence in a warm climate. Yoga. Disability and deformity may be avoided by a conscientious approach to the subject. ... arthritis – rheumatoid