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Cardiac Complications in Scarlet Fever

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Cardiac Complications in Scarlet Fever Arch Dis Child: first published as 10.1136/adc.20.102.81 on 1 June 1945. Downloaded from CARDIAC COMPLICATIONS IN SCARLET FEVER BY C. NEUBAUER (From the City Hospital for Infectious Diseases, Newcastle upon Tyne) Involvement of the heart is not an uncommon Harries and Mitman (1944) regard the carditis in complication in scarlet fever. A large amount of scarlet fever as identical with that of acute rheumatic clinical material has encouraged this review of the fever: in their opinion it is an endocarditis which problem of cardiac complications in scarlet fever leaves permanent valvular lesions. Cardiac en- largement was observed by Toomey (1942) in five and in related haemolytic streptococcal infections. per cent. of his cases and heart block has been seen Stegemann (1914) described pathological changes in one case during life. in the myocardium and nervous system of the heart. Siegmund (1931) found inflammation chiefly in the In the present study clinical examination, cardio- thebesian vessels. Brody and Smith (1936) found gram, x-ray photograph and blood sedimentation pathological changes in the heart of 90 per cent. of rate were taken into consideration in arriving at the the fatal cases. They described three types of conclusion whether a heart complication was present myocarditis: 1. Focal or diffuse interstitial myocar- or not. The children with a cardiac complication ditis. 2. Arteritis or periarteritis of the smaller were kept under observation for a period of at least coronary arteries. 3. An infiltration ofthe coronary one year after the onset of the acute disease to veins or of the endocardium of the ventricles. ascertain the occurrence or non-occurrence of Albert (1938) found myocarditis in four cases among eight children who died of scarlet fever. Toomey permanent cardiac damage. An attempt was made (1942) found haemorrhages in the bundle of His to differentiate cases of myocarditis from those with in a case of auriculo-ventricular block. Five cases endocarditis and from others in which both of double infection of scarlet fever and diphtheria conditions were present. were examined by the same author: myocarditis was found in two cases. Incidence http://adc.bmj.com/ Among the clinical reports Nobecourt's paper (1918) must be mentioned; he found two out of There are 602 cases of scarlet fever in the present seven soldiers who had clinical signs of endocarditis series observed from August, 1943, till August, 1944. and developed signs of permanent damage in the In the majority of the cases the disease was generally heart. Thursfield (1929) found carditis especially of a mild character. On the average cases were in cases of scarlet rheumatism and he noticed per- discharged during the fourth week of disease. The manent damage in some of the cases. The cardiac mild character of the disease can be judged by the complications due to scarlet fever without scarlatinal incidence of complications occurring. Apart from on September 30, 2021 by guest. Protected copyright. rheumatism are regarded by him as temporary and he did not see permanent damage in these cases. cardiac complications these were: Rolleston (1912) noticed a fall in blood pressure in Otitis media .. 18 cases 3 per cent. 25 per cent. of the cases after an initial rise in the Mastoiditis . 5 cases 08 , .. beginning of the disease. He found (1929) the Purulent rhinitis 68 cases 112 9.. incidence of endocarditis below one per cent.; Adenitis 57 cases 8 1 , .. myocarditis was more common and this was Scarlatinal rheumatism 4 cases 0-6 ,, .. manifested by rapid and small pulse, feeble heart Nephritis 3 cases 05 ,, .. sounds and gallop rhythm, but no data of its incidence could be given. Stoeber (1935) described There were in addition 36 cases of cardiac com- his main clinical findings in myocarditis in scarlet plication recorded in the present series, that is an fever as: cardiac enlargement, soft systolic apical incidence of 5-9 per cent. murmur and arrhythmia. He attributed sudden The ages of the patients with carditis were: death in scarlet fever to an acute myocarditis. Wyborn (1934) out of a series of 2,300 cases at the 0-10 years 25 cases South Eastern Hospital discovered only four cases Over 10 years 11 cases of arrhythmia, one being a case of auricular fibril- lation and the other three just simple arrhythmia. The history: None of the patients with a cardiac Out of 600 cases of scarlet fever Faulkner (1935) had complication had a history of a previous attack of seven that developed signs of chronic valvular acute rheumatic fever. This is of some importance, disease. In two of his cases the signs of endo- because an infection with S. haemolyticus could carditis developed in hospital before discharge. easily elicit a flare-up of a latent rheumatic carditis. G 81 82 ARCHIVES OF DISEASE IN CHILDHOOD Arch Dis Child: first published as 10.1136/adc.20.102.81 on 1 June 1945. Downloaded from Ten of the children, however, had had one acute Mitral systolic murmur, which dis- infectious disease previously, twelve had had two appeared .. 16 cases infectious diseases, nine had had three, whilst one Mitral systolic murmur which became child had had four and another five infectious permanent .. 2 cases the last two or three years. Three Mitral presystolic murmur which be- diseases within came permanent 2 cases patients had had no disease before. Cases admitted with systolic murmur, The diseases concerned were: which was permanent 6 cases Measles . 30 cases A murmur may disappear and become manifest Pertussis 13 cases again. Findlay (1931) in his comprehensive paper Chickenpox 12 cases on rheumatic infection in childhood found that in a Rubella .. 6 cases murmur a of Mumps .. 4 cases proportion the returned after period Repeated tonsillitis .. .. 4 cases years. It would be equally wrong to attribute some Bronchopneumonia 5 cases importance to each murmur as it would be, for example, to disregard all systolic murmurs at the Clinical findings apex. The difficulty lies in the fact that it is not The heart on admission: Ten cases amongst those possible to differentiate an organic from a functional who developed carditis in the course of the disease murmur on clinical grounds alone; experience has exhibited a marked tachycardia on admission; a shown that there are good reasons to suspect a soft systolic murmur was audible at the apex in carditis if the murmur at the apex is loud and if it five cases and over the heart base in one case. has a wide transmission or if a diastolic or presystolic Onset of carditis: In more than half of the cases of murmur manifests itself. the present series, the cardiac complications were CARDIAC ENLARGEMENT. A definite enlargement discovered in the second or third week of the disease. of the cardiac dullness is an important sign of acute The child was often almost ready for discharge when carditis. Owing to the enlargement the apex beat the first clinical signs were observed. is displaced either outward, or outward and down- The onset was observed: ward. This is not a common finding, however, especially in an early case, and it was found in only 5 cases Within the first 10 days of disease three cases in the present series. The cardiac From 1 lth-20th day of disease 16 cases is only a little increased in most cases. It From 21st-30th day of disease 12 cases dullness will be shown that the cardiac disease occurring in Faulkner (1935) examined 171 cases of scarlet fever scarlet fever is due as a rule to myocarditis rather cardiographically and he could not find any abnor- than to a valvular disease. Persistent tachycardia, mality before the thirteenth day of disease. Such diminished intensity of the first apical sounds are has not been my experience for, in five instances, I signs of a myocarditis in the early stages of the found the onset of carditis within the first ten days. disease, whereas changes in the rhythm like gallop http://adc.bmj.com/ As has been reported on another occasion, a myocar- rhythm or embryocardia occur more frequentiy in ditis re-occurs readily in a child who has had a advanced stages. In the present series the first myocarditis previously, especially in a child with a apical sound became markedly diminished in history of several infectious diseases within the last intensity in seven cases; the first apical sound became one or two years. In children, however, who had equal in intensity to the second in two cases; frequent no previous infectious disease or who had one a long premature beats were found in another case. manifests itself towards a or time ago, the myocarditis The clinical signs subsided after shorter on September 30, 2021 by guest. Protected copyright. the end of the second, more often in the third or longer period: fourth week of the disease. Within 3-4 weeks in 8 cases This is of some importance: 5-6 weeks,, 6 cases 1. The carditis follows the tonsillitis after a 7-8 weeks,, 8 cases certain interval as in acute rheumatic fever. 9-10 weeks in 8 cases After 3 months in 2 cases 2. The carditis occurs at a time when the ,, 6 months ,, 1 case is commonly regarded as being fit patient ,, 7 months ,, 1 case to get out of bed. General signs. Pallor, listlessness, slight cyanosis In some instances, however, a presystolic murmur may persist, it may become an early diastolic murmur may be the first signs to indicate a cardiac involve- later on and a late diastolic murmur after several ment. The eyes are shadowed. The slightest effort months. Two cases of this kind have been observed may cause fatigue.
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