Polymorphonuclear leukocyte functions in patients with acute rheumatic fever and rheumatic heart disease

Polymorphonuclear (PMN) cell function was assessed in 30 children with active rheumatic fever (ARF) (Group I), 30 cases with active rheumatic heart disease (RHD) (Group II), 28 cases of ARF and RHD in remission (Group III) and 34 adults with quiescent RHD along with their age matched controls. All the groups showed normal spontaneous and chemotactic movement. Phagocytosis of yeast particles was significantly reduced in groups II (P less than 0.0005), III (P less than 0.025) and IV (P less than 0.005). The opsonic activity of disease sera was low in all 4 groups (P less than 0.0005). The intracellular metabolic activity was moderately elevated in Group III. Phagocytosis and opsonic activity were thus persistently low in all the groups including the remission and quiescent group.     

Prevention of rheumatic fever and heart disease

This brief overview of current information on rheumatic fever and rheumatic heart disease focuses on the problems of diagnosis, prevention, and treatment in relatively undeveloped countries.     

Progress in M-protein-based subunit vaccines to prevent rheumatic fever and rheumatic heart disease

Infection with the human bacterial pathogen group A Streptococcus (GAS) is estimated to cause over 500,000 deaths per year, the majority of which are related to rheumatic fever (RF) and rheumatic heart disease (RHD). While GAS is an important cause of morbidity and mortality globally, the burden of GAS-associated diseases is greater in less developed countries and in indigenous populations of developed countries. The antiphagocytic bacterial surface M protein is a major candidate antigen in the development of a vaccine to prevent GAS infection and RF/RHD. A major obstacle, however, in the development of an M-protein-based vaccine is the widespread diversity of circulating GAS strains and M protein types. Added to this is the possibility of inducing autoimmunity following vaccination as a result of molecular mimicry between the M protein and host tissue proteins. Research has been aimed at the development of a safe GAS vaccine that is able to induce broad-coverage protective immunity. The development of subunit vaccine approaches targeting the M protein using various vaccine delivery technologies is the focus of this review.     

Persistence of heart reactive antibodies (HRA) in acute rheumatic fever (ARF) and rheumatic heart disease (RHD) patients

Heart Reactive Antibodies (HRA) of IgG and IgM classes were investigated in 79 patients in four clinically classified groups. Group I comprised of 16 children with Acute Rheumatic Fever (ARF) and Group II consisted of 15 cases with active Rheumatic Heart Disease (RHD). Twenty seven cases of ARF and RHD in remission and 21 adults with quiescent RHD were included in Groups III and IV respectively. Control groups comprised of 14 normal, healthy, donors and eight Post Streptococcal Acute Glomerular Nephritis (PSAGN) cases. Low levels of HRA of IgG and IgM classes were detected in control groups. The overall incidence of HRA of IgG and IgM classes was 82.28 and 39.24% respectively in the patient group. An increased frequency of HRA-IgM antibodies was observed in Groups I, III and IV (p less than 0.01, 0.001 and 0.025 respectively). All the four groups demonstrated a highly significant increase in incidence of HRA--IgG class (p less than 0.0005). Persistence of high titres of HRA-IgG class in ARF and RHD is reported in the paper.     

抗DNA酶B在风湿热诊断中的应用

目的评估Ａ组溶血性链球菌感染的血清学测定方法对诊断风湿热的临床价值。方法采用抗ＤＮＡ酶Ｂ微量法和自制试剂测定急性风湿热８７例、活动期风湿性心脏病２０２例病人血清的抗ＤＮＡ酶Ｂ抗体,与抗溶血素Ｏ抗体（ＡＳＯ）对照研究。结果在急性风湿热组,抗ＤＮＡ酶Ｂ阳性占７２４％,和ＡＳＯ测定阳性６７８％比较,差异无显著意义（Ｐ＞００５）;在活动期风湿性心脏病组,抗ＤＮＡ酶Ｂ阳性占８３７％,明显超过ＡＳＯ的４７０％阳性,其差异有非常显著意义（Ｐ＜０００１）。抗ＤＮＡ酶Ｂ试验结合ＡＳＯ测定,在急性风湿热组和活动期风湿性心脏病组的阳性例数分别占９０８％和８８６％。结论抗ＤＮＡ酶Ｂ试验对急性风湿热和风湿性心脏病活动期的诊断有重要临床价值,与ＡＳＯ结合检测可提高诊断率。     

Enzyme immunoassay (ELISA) for the detection of anticarbohydrate antibodies in rheumatic fever and rheumatic heart disease

Antibodies to group A streptococcal polysaccharide were estimated in the following groups of patients: (I) Patients with uncomplicated streptococcal pharyngitis: 10 patients, followed up for 3 months. (II) Patients with acute rheumatic fever: 8 patients with first attack followed up for one year. (III) Patients with reactivated rheumatic heart disease: 10 patients, followed up for one year. (IV) Patients with chronic rheumatic heart disease: followed up for one year. (V) normal controls without any history of sore throat/fever/vaccination/rheumatic disease: 10 patients followed up for one year. Group (I) patients did not show any significant elevation in anticarbohydrate antibodies by both ELISA and RIA. In the case of (III) and (IV), antibody levels were significantly higher as compared to group (V) and remained so till one year of follow up. In group (II) patients there was no significant rise in antibody levels. There was a good correlation between the ELISA and RIA used to detect the antibody levels. These findings suggest that the use of ELISA to detect anticarbohydrate antibody can be of help in diagnosing cases of rheumatic heart disease (both acute and chronic RHD).     

Cardiolipin antibodies in acute rheumatic fever]

The paper presented the results obtained in studying the patients with acute rheumatic fever for antibodies to cardiolipin (ACL). The study resulted in the establishment that the development of immunopathies in the presence of acute rheumatic fever combined with the acute streptococcal infection was accompanied by hyperproduction of ACL (more common IgG versus IgM isotypes). The phenomenon mentioned widened the spectrum of acute infectious diseases associated with an increase in ACL synthesis. It was also stated that increased ACL contents were closely related with the involvement of the cardiac valves. Authentic clinical and echocardiological signs of the heart disease were mainly revealed in the patients with high contents of IgG and IgM isotypes of ACL. A certain relationship between the laboratory activity of the disease and ACL hyperproduction was noted as well. The latter permitted the discussion on the impact of streptococcal infection initiating the development of acute inflammation on the hyperproduction of ACL.     

Nitric oxide metabolities in acute rheumatic fever

Acute rheumatic fever (ARF), is a systemic inflammatory disease etiologically related to infection with group A beta hemolytic streptococcus, characterized by a broad spectrum of disorders in cellular immunity. To estimate the activity of the immunopathological process in patients with ARF, plasma nitric oxide metabolities (NOx) concentrations, IL-1alpha and IL-2 levels were investigated in 22 patients with ARF at the time on admission, and after 3 months, in children with chronic rheumatic heart disease (CRHD). Plasma NOx concentrations, IL-1alpha and IL/2 levels in patients with ARF on admission were significantly higher than in the same patients 3 months later, and higher than in CRHD, or controls. Increased plasma NO may be a useful index for the quantitative assessment of the activity during immunological challenge. This information may be useful for the prognosis and monitoring of ARF.     

Further observations and characterization of monoclonal antibodies reacting with B cell alloantigens associated with rheumatic fever and rheumatic heart disease

Elevated levels of B lymphocytes with a unique surface alloantigen have been reported to be characteristic of patients with acute rheumatic fever or rheumatic heart disease. Mouse monoclonal antibodies (mAbs) to this alloantigen have been proposed as being useful in identifying individuals at risk for the development of these sequelae of group A streptococcal infection. However, previous studies have suggested that the discriminating ability of the mAbs was highest when the mAbs were made by using lymphocytes from the same ethnic population. To confirm and extend this observation, additional mouse mAbs were developed and their properties defined. These three mAbs-PG-12A, PG-13A, and PG-20A-reacted with B cells from more than 90% of North Indian patients with acute rheumatic fever or rheumatic heart disease. Each of these three new mAbs identified the highest levels of reactive B cells in patients with active acute rheumatic fever. Lower levels of positive reacting lymphocytes were found in individuals with quiescent chronic rheumatic heart disease, and markedly reduced percentages of reactive cells were observed in normal control subjects. The proportion of reactive lymphocytes in individual patients varied according to which of the three was tested, suggesting the possibility of a spectrum of "rheumatic" epitopes in susceptible individuals. The data further suggested that enhanced discriminatory ability for identifying "at-risk" susceptible patients could be obtained by testing with a combination of mAbs. If reduction in the incidence of acute rheumatic fever can be facilitated by early identification of susceptible individuals, accurate and sensitive detection of a marker antigen would result in more cost-effective public health measures. Additional population studies are required to more precisely define and confirm these detection techniques.     

Acute rheumatic fever mimicking an acute coronary syndrome

An elevated troponin measurement does not always reflect myocardial ischaemia secondary to obstructive coronary artery disease. Troponin levels can also be elevated in other disease states including pulmonary emboli, myo‐pericarditis, acute rheumatic fever, and in the critically ill. Thus, patients presenting with chest pain and electrocardiological and biochemical evidence of myocardial necrosis are not always suffering from an acute coronary syndrome.     

The serum neopterin level in acute rheumatic fever]

Acute rheumatic fever (ARF) is a systemic inflammatory disease etiologically related to infection with group A streptococcus characterized by a broad spectrum of disorders of cellular and humoral immunity. To estimate the activity of the immunopathological process and to forecast myocardial derangement in ARF patients, measurements were made of neopterin in the serum of ARF patients. Nine men with ARF serving in the armed forces were examined. The control group comprised 24 donors. The reference group included 13 patients with dilated cardiomyopathy and 14 with chronic myocarditis. The mean level of neopterin in ARF patients was equal to 14.5 +/- 12.2 nM/l and was significantly higher than in the donors (5.0 +/- 2.0 nM/l). In patients with dilated cardiomyopathy and chronic myocarditis, it was 9 +/- 6 and 16 +/- 11 nM/l, respectively. On more careful clinical analysis the highest level of neopterin was recorded in 3 patients with impairment of the valvular apparatus of the heart. That level was observable during the whole period of the follow-up of the patients. In other patients, no impairment of the valves was detected, whereas the concentration of neopterin fell to normal. Therefore, the rise of the level of neopterin was described for the first time in patients with ARF. Besides, a relationship was found between the high level of neopterin and impairment of the valvular apparatus of the heart.     

Resurgence of acute rheumatic fever in west Alabama.

This study was done to ascertain whether there was an increased incidence of acute rheumatic fever (ARF) in west Alabama, similar to that reported elsewhere within the United States. Hospital records for the previous 10 years were reviewed and 5-year intervals were compared (1980 through 1984 vs 1985 through 1989). A sevenfold increase was noted in the later period. Possible explanations for this increase are discussed. Close surveillance, appropriate testing, and adequate complete treatment must be continued to eradicate streptococcal disease leading to acute rheumatic fever.     

Lymphocytes binding C-reactive protein during acute rheumatic fever.

Lymphocytes binding C-reactive protein (CRP) were studied in 31 patients with acute rheumatic fever and 30 controls who were children. Marked elevations in both proportions and absolute numbers of CRP-binding lymphocytes were recorded in rheumatic fever (P less than 0.001). No clear correlation was noted between plasma CRP as quantitated by radioimmunoassay and proportions or numbers of CRP-binding cells. Double-labeling experiments indicated that 60-80% of CRP-binding lymphocytes also showed Fc receptors reacting with fluorescein-conjugated IgG aggregates. Passage of lymphocytes over Ig--anti-IgG columns, removed cells bearing surface Ig but not CRP-binding lymphocytes. Studies of T-cell subpopulations indicated no overlap between Tmicron- and CRP-binding cells; however about half of Tgamma-cells showed concurrent CRP binding. "Active" T-cell rosetting cells did not bind CRP. A 12-15-h incubation of lymphocytes at 37 degrees C in 5% CO2-air showed persistence of CRP binding in substantial proportions of cells particularly in acute rheumatic fever. CRP-binding lymphocytes may represent a marker for immunologically committed cells in acute rheumatic fever.     

风湿性三瓣膜病变的外科治疗

目的：总结风湿性三瓣膜病变外科治疗经验,降低手术死亡率,方法：1993年11月至2000年5月对23例风湿性二尖瓣,主动脉瓣及三尖瓣病变患施行三瓣膜联合手术,其中二尖瓣及主动脉瓣替换术（DVR）加三尖瓣成形术（TVP）16例,DVR加三尖瓣替换术（TVR）7例。结果：手术早期及晚期死亡各1例,均死于多脏器功能衰竭（MOF）,术后低心排3例,结论：预防术后低心排及MOF,注意术中处理要点并妥善处理三尖瓣病变是降低手术死亡率的主要措施。     

风湿性心脏病伴急性动脉栓塞的抢救及围术期的护理

风湿性心脏病常引起心脏瓣膜的毁损、纤维化、粘连、短缩造成瓣膜狭窄或关闭不全 ,其中以二尖瓣病变最为常见 ,患者常伴有心房颤动、左房血栓形成 ,因此易发生动脉血栓栓塞[1 ] ,患者常突然发病 ,进展迅速 ,如不早期诊治 ,将会危及生命。南京医科大学第一附属医院 1 999年 5月～2 0 0 4年 8月共有 3例患者在等待手术时发生动脉栓塞 ,现将抢救及护理体会介绍如下。1　临床资料1 1　一般资料本组 3例均为女性 ,年龄 46～ 5 1岁 ,风湿性心脏瓣膜病变病程 1 2～ 1 9年 ,加重 6～ 1 2个月。入院时心电图检查示心房颤动 ;超声心动图示风湿性心脏…