Prospects of Homoeopathy in UAE
Dr. Abdul Gafar with Dr. Sudinkumar 

Homoeopathy in UAE is an infant, just born.  Never the less it is healthy and very much active, from our first hand experience.

UAE Government approved practice of Homoeopathy in the country in the beginning of 2001.  A separate section was established under UAE Ministry of Health (MOH) for Complementary and Alternative Medicines.  A qualifying examination is held by MOH about three times a year, and so far 92 Homoeopaths have qualified to practice in UAE.

        For practicing in UAE first one needs the license from the Ministry of Health (MOH). The procedure for the same is described below. After getting the license one should register with the respective local governments (municipalities) depending upon in which emirate of UAE you intent to practice and this registration one shall get only after getting the license from MOH. Remember that even after getting the above two documents one can do the practice only under an existing medical institution, obviously an allopathic one as there are no Homoeopathic institutions there yet. For starting a separate individual Homoeopathic clinic one should get a license for starting/running a clinic which is usually given to only UAE nationals and that also costs a hefty fee. 

         The MOH examination is of a simple structure but analyze in depth the capacity of the doctors.  It consists of two parts.  The first, a written examination for 100 marks is a mixture of MCQ and short-answer questions.  This is a common test for all the branches of complimentary and alternative medicines like Homoeopathy, Ayurveda, Unani, Acupuncture etc.  This is based on General Medicine and the questions are of good standard.  Those who clear this examination will be called for an interview, where a panel of experts (Allopathic and Homoeopathic doctors) will judge the capacity of the candidate as a physician.  The Homoeopathic knowledge is assessed in this part.  The successful doctors will be given an evaluation certificate with register numbers, which is the license to practice Homoeopathy in UAE. 

For help in preparing for the examination it is best to have a thorough knowledge in Practice of Medicine based on Davidson’s textbook. For familiarizing with the MCQ it is advisable to go to the questions from www.fleshandbones.com where a number of MCQs are given from Davidson’s as well as questions from US Medical Licensing Examination (USMLE). But remember that your practical knowledge is what counts especially in the interview. 

One has to submit the application in person at the MOH office in Abu Dhabi with all the documentary evidences (For details visit our website “www.homedpa.com/events.htm”) and the prescribed fee (presently 50 UAE Dirham).  The candidates have to bear the travel and other expenses for the trip and also make their own arrangements for their visa. Further clarification about all these can be had at the MOH website “www.moh.gov.ae”. 

Even though the system got official blessings in UAE very recently, Homoeopathy was never a stranger in the peninsula.  Many people there depend on Homoeopathy for their treatment.  While some of them bring medicines from their home countries a few go to clandestine (qualified) practitioners for this end. 

As all major cities of UAE are cosmopolitan in nature one get people of all walks and classes of life here.   So there is never a shortage of supporters to the system. It is reassuring to see that even the labor classes, who can't miss even a day of their work, come to Homoeopathy for their ailments.  One another factor is that the common illnesses met with here like UTI, RTI, infertility, Headache and alopecia are all responding wonderfully to the simple medicines.  The unique climate and life style being the main culprit, the task of the physician is made much easy. 

Another welcoming thing is the number of patrons coming up to sponsor Homoeopathic clinics.  All the major healthcare establishments have started a Homoeopathic section also along with their institutions.  The doctors already cleared by MOH and started their practice here sounded enthusiastic and hopeful about the future.  The large Indian population also sounded relieved that at last they could get quality Homoeopathic treatment nearby.

One minor obstacle yet to be overcome is the problem with dispensing medicines.  As of now no permission is given to freely dispense the medicines by the physicians.  Even if this is of vital importance to successful Homoeopathic practice the doctors here have to depend on sealed bottles of pre-medicated pills of a fixed dose, which is to be dispensed as a whole to the patient.  The trouble with this is that often there won’t be the necessity of that much doses of medicine and it will eventually lead to over dosage.  Another one being the heavy cost of these sealed bottle preparations, which jeopardises the very claim of cost effectiveness of the system. 

We hope the problems will be solved as the system grows up.  Once the results start coming up the system will sustain itself as it has done in many other countries and the obstacles will be melted away one by one.

Dr.. Abdul Gafar, the Editor-in-Chief along with Editor Dr. Sudinkumar had an extensive tour in UAE in May2003. This article is brought in for the reference of all the doctors who would like to sit for the MOH examination.

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A case of Congenital Hydrocele.

By.Dr.Sanjay Panicker BHMS.

There are many diseases which the world of contemporary medicine has classified as purely surgical conditions, and often homoeo­paths fall prey to these predictions.

In college as a student Homoeopath I was often told by many learned tutors that hydrocele is a purely surgical condition.  Somehow, I couldn’t accept this statement completely.  I often wondered... if hypersecretion & collection of fluid in the Tunica vaginalis leads to hydrocele,  then, reabsorption of this fluid by the body tissues, which are brought back to health can lead to a CURE.  I still feel that the process of surgical correction is often thought of too early in the disease.  These conditions are ‘CURABLE’, unless gross structural changes have occurred.  Not only hydrocele, but there are many, conditions which are consid­ered surgical.....about which my mind says,  “No” ! There could be a chance with homoeopathy.

Case :

A young baby, 25 days old was brought to me with complaints of abdominal distension and enlargements of the scrotum, more on the right side.  The child also had loose stool and vomiting and was crying continuously.  The parents were worried as the allopathic doctor treating the child had diagnosed “Hydrocele” and had advised surgery.

On examination, I could get above the swelling.  Also the Tran­s-illumination test was ‘+ve’ confirming the presence of a hydro­cele.  There was also abdominal distension.  The posterior aspect of the tongue was coated yellow (obviously not due to any kind of yellow coloured food or medicine intake-as some people may attribute this to be) The child had frequent hiccough & was writhing & twisting as if due to some abdominal distress.  The child had snuffles and wasn’t suckling due to blocked nose.

All the symptoms of the case including the fact that, the child had been on allopathic treatment, which did not give any relief (rather the child began crying continuously since it) made me think of Nux.vomica.

The child’s parents were very poor and couldn’t afford an opera­tion.  They wanted to know, if I could help the child with ho­moeopathy.  The desire to confirm my hope of a possible cure for hydrocele, made me to take up the case.  I convinced the parents not to go in for surgery unless they find that the remedies are not helping the child, and explained to them about the possibili­ties of a long duration of treatment, and convinced them about the general improvement of the child before the particular symp­toms improved which was an indication of “TRUE CURE”.

The following are the details of treatment

1st Prescription

17/6/99

a : Nux.Vom.30 (3-3-3)

24/6/99

loose stools (0)

vomitting (0)

child not crying.

Anterior fontanelle depressed.

Scrotal swelling

Fever since last day-It started suddenly.  The fever comes in intermittent paroxysm with periods of apyrexia.  Great heat during fever. Redness of the face

Tongue:Clear with red elevated prominent papillae on the anterior margin of the tongue.

a : 1) Bell.200 (pl.3, tds)

22/8/99 They did not report to me as the-

-fever was normal within 2 days after taking the medicine

Now loose stools-greenish

Rattling in the chest

The complaints are of sudden onset, starting last day

The child has cough.  He coughs until he gags and vomits.

a : 1) Ipecac.200 (3-3-3)

31/8/99

All complaints are relieved.Stools normal

But swelling of the scrotum is worse.

a : 1) Rhododendron 200 (3-3-3)

(As it is the only medicine mentioned in the Kent’s repertory for congenital hydrocele)

6/9/99

Scrotal swelling >++

Child is normal

Appetite is decreased.?

a : 1) Rhododendron 200 (3-3-3)

10/9/99

Scrotal swelling >++

Appetite-decreased, still

There is an offensive discharge from the ear.

Also cracks in the neck folds-which are red++

a : 1) Rhododendron 200 (3-3-3)

1/10/99

Child has developed high fever & urticaria all over the body since last evening.

Offensive discharge from the ear and cracks in the folds of neck remain the same.

[Observation:It had started raining since last evening]

a : 1) Camphor 30

2/10/99

Fever and urticaria gone, completely

Discharge from the ears with offensiveness (+++)

Cracks in the neck folds (+++)-with redness (+++)

loose greenish stools

with redness of anus

child puts fingers in the mouth

a : 1) Bell 200 (3-3-3)

2) Sulphur.200, On improvement

12/10/99

loose stools, watery

occassionally greenish with sago like

particles in it; Redness of anus +

Neck folds remain the same

puts fingers in the mouth & vomits sour fluid.

a : 1) Sulphur IM (IP)-15/10/99

2) Rs.Pills (3-3-3)

21/10/99

The child is still not better

a : 1) Calcarea carb IM (IP)-22/10/99

2) Rs.Pills (3-3-3)

27/10/99

Complaints better.

1) Calcarea carb IM (IP)-28/10/99

9/11/99

loose stools are no longer there

flexural redness of neck

scrotal swelling and

offensive ear discharge +++ remain

a :1) Calcarea carb 10M (IP)-15/11/99

2) Rs.Pills.(3-3-3)

21/11/99

Ear discharge better

offensiveness better

But since last day the ear started discharging again.  Scrotal swelling is the same.

Also is flexural redness of neck(+++)

The child’s mother asked for any ointment for the redness of the neck folds & the cracked skin in these folds.  But it was ex­plained to her that the body is trying to remove the disease through the skin & suppression may increase the hydrocele.

a : 1) Calcarea carb 10M-25/11/99

2) Rs Pills 3-3-3.

7/12/99

Ear discharge gone fully and no-

offensiveness

Scrotal swelling remain

Appetitte Good

Sleep sound

But for 2 days child has fever in intermittent paroxysms

a : 1) Bell 200 (3-3-3)

2) Calcarea carb IM (IP) every 3 days

20/12/99

Fever gone

Neck redness increased a bit more

Scrotal swelling remains

a : 1) Calcarea carb IM->(IP) every 4 days

2) Rs.pills.3-3-3.

15/11/2000

All Complaints better except for the scrotal swelling.

Now child has

fever

Slight loose stools, yellowish

Vomiting-after nursing.

Hiccough frequent.

Nose block (not able to nurse)

a : 1) Nux.vomica 30 (3-3-3)

2/3/2000

Scrotal swelling is better

Now rattling cough with

breathing difficulty

Child eats mud.

Posterior part of tongue coated yellow.

a . 1) Nux.vom 30 (3-3-3)

2) Calcarea carb IM (IP) on improvement.

7/3/2000

[rattling mucus in chest & cough relieved] Improved after taking powder only.

Diarrboea-every night & day

Undigested, (loose stools)

Occassional vomiting of milk after nursing.  Swelling of scrotum is better.

a : 1) Nux-vomica 30 (3-3-3)

2) Rs.pills (IP) on improvement.

21/3/2000

The patient could not be given medicine for 2 weeks, but is improving.

Swelling of the scrotum is better.

Ear discharge is worse.

Neck & groin folds->Cracked and discharging

a moist fluid which is excoriating causing redness of these areas+++

Abdomen distended

One leg hot, other leg cold

a : 1) Lycopodium 30 (IP)

2) Rs Pills (3-3-3)

5/4/2000

Ear discharge, Abdomen distension and excoriation of flexural aspects Scrotal swelling (>++) Urticaria on body (Bathing after.)

Extremities warm.

a : 1) Sulphur 200 (IP)

2) Rs.pills 3-3-3.

17/4/2000

Ear discharging again

Rt ear tender.  Tragus sign (+ve)

Scrotal swelling and

flexural excoriation fully relieved

child sucking thumb again for a few days.  With increased head perspiration.

a : 1) Calcarea carb IM (IP)

12/7/2000

No complaints till recently.

Now child has ‘plica polonica’ on scalp.

hair sticking & matting together with

suppuration(+)

a : 1) Vinca minor 30 (3-3-3)

2) Rs powder (IP) on improvement.

9/10/2000

No complaints till date, as on writing this except for an incident when the child accidentally consumed kerosene from a lamp and took treatment in a hospital.

(Photos on back inner cover)

Retrospective Study Of The Case

The greatest question I had in my mind was, “Why did a curable case TAKE SUCH A LONG DURATION TO BE CURED?”

The possible answers may be

1. The miasmatic influence was so strong that it couldn’t be removed easily

2. The similimum was not found early in the disease

3. There were some obstacles to cure

4. The onion peel like nature of disease leads to removal of disease only layer by layer with remedies (phase remedies) admin­istered as and when needed.

If the Aphorism in Organon says, “The HIGHEST IDEAL OF CURE IS RAPID, GENTLE & PERMANENT RESTORATION OF HEALTH IN THE SHORTEST, MOST RELIABLE AND MOST HARMLESS WAY ON EASILY COMPREHENSIBLE PRINCIPLES”.....Why did the disease take so long to be REMOVED?

The following inferences derived from the case study give the answers.

Inferences

1. 22/8/99-> when the patient who was cured with Belladonna of a fever had come up this time with a rattling respiration in the chest & loose greenish stools,  I prescribed Ipecac 200 (3-3-3) because the child also coughs gags & vomits.  Calcarea carb would have been a better remedy.  Even in this initial stage of treat­ment, Calcarea carb which helped the child for a long time in the case (in the later stages) seems to be indicated.  Ipecac was only a PARTIAL SIMILIMUM.

2. 31/8/99-> The fact that Ipecac is only a partial similium can be seen in this follow up The cough, rattling respiration & green stools under the domain of Ipecac has improved.  But these secretions which were not “properly cured” has caused the SCROTAL SWELLING to become worse [The WRONG DIRECTION OF CURE!]-This is also a form of suppression, with homoeopathic remedies (not with HOMOEOPATHY!)-WITH TRUE HOMOEOPATHY there can be no SUPPRESSION; but partial Similimum lead to suppression.

3. 31/8/99-> Rhododendron was prescribed despite knowing that there are no specifics in homoeopathy, as all our stalwarts often claimed.  This also is a partial similimum as we can see the scrotal swelling is better as it is within the ability of Rhodo­dendron to palliate.  But the appetite has decreased, which can never happen when the remedy is the SIMILIMUM.  Yet due impor­tance was not given to this symptom and Rhododendron was con­tinued.

4. 10/9/99->Appearance of two new symptoms can be seen.  Offen­sive discharge from the ear & crack in the folds of the neck.  This could be a symptom proving of Rhododendron, or a disease progression leading to expression of constitutional symptoms.

5. 1/10/99-> Child developed high fever & urticaria after it started raining.  This is obviously a symptom of Rhododendron.  Is it a proving?  Or is it the Rhododendron constitution of the child showing its expressions?

6. 1/10/99->On Antidoting with Camphor the disappearance of fever & urticaria on the next day shows that it was a proving of Rhododendron, And the persistence of offensive ear discharge & crack in the neck folds indicate that these are constitutional symptoms of the child.

7. 2/10/99-> We have the original picture of the disease.  The symptoms very clearly indicate Calcarea carb.  But Belladonna was given & Sulphur was asked to be taken on improvement.  The red­ness of the anus made me think of Sulphur. (Prescription based upon single symptom is not correct in homoeopathy).  The follow up on 12/10/99 clearly shows that the child has improved only partially.  It was not a “RAPID CURE-AS IT IS TERMED”.  I misun­derstood, that lack of result was probably due to a low potency, and Sulphur IM was given. But even after this, the child is not better, indicating a wrong prescription.

8. Calcarea carb IM prescribed on 21/10/99 was definitely indi­cated as we can see in the follow ups.

9. 27/11/99 to 7/12/99->These follow ups show that the generals are better though the skin & scrotal swelling are the same.  The ear discharge has responded and appetite is good.  But the mis­take was probably “Infrequent Repetition of Calcarea carb”.  It is stressed by Dr.Douglas M. Borland, in his Children Types, that Calcarea should be repeated frequently as and when needed in infants & small children.  But in adults infrequent repetition is the rule.

10. The child has no complaints for about a month after the visit on 20/12/99.  This again indicates that Calcarea carb has helped the child except for scrotal swelling, which is same.

11. 15/1/2000->The child presented with acute symptoms of Nux.vomica & Nux helped the child.  The child was better for 1 1/2 months, even the scrotal swelling improving.

12. 2/3/2000->The symptoms clearly call for Calcarea carb again but unnecessarily Nux.vom was given because I found that the scrotal swelling improved each time I prescribed Nux.vom, when indicated in earlier circumstances.  It can be seen in the next follow up that Nux.vom. was an unnecessary prescription, as the child had developed diarrhoea with undigested food in stool & the child vomitted milk after nursing (proving of Nux vomica!) Yet the scrotal swelling was better.  I continued Nux.vom. But lucky for me, when the medicines got over, they couldn’t come to me due to personal reasons and the child got better each day.

13. 21/3/2000->Symptom picture clearly indicates Lycopodium & the difference can be clearly seen in the follow up on 5/4/2000.

14. The recurrence of ear discharge after Sulphur, and improve­ment of all complaints, indicates the attempt of the body to expell the excess body fluids, thus causing a reduction in the hydrocele further.

15. The child started sucking its thumb again after Sulphur.  This symptom along with increased head perspiration, made me think of Calcarea carb, once again.

After this the child was better for about three months, when he came for Plica Polonica, which improved with Vinca minor.

Upto date, the child has no complaints due to any natural dis­ease.

My Learning

Zig-Zag prescribing is obviously a feature of beginners like me.  But the only way to improve is “RETROSPECTWE CASE STUDIES”.

This case could have been cured faster with Sulphur Calcarea and Lycopodium, given as and when indicated, with acutes, like Bell & Nux used more cautiously.

We accepted this case mainly for the merit of the study in it.  The author deserves special mention for the effort in his retro­spective learning and inferences, which are sufficient enough necessitating no further comments.  A more experienced expert may cure the case in a much shorter time, ‘as it is termed’ by Cal­carea, complimenting it with Sulphur or Lycopodium.  And we get as much less learning from it also.  That is why we invite more such articles from young Homoeopaths, which will be invaluable to themselves and also to scores of other similar struggling physi­cians.

As for his thinking aloud about the curability of surgical diseases, we would like to emphasise that there is nothing as incurable ‘unless there are irreversible’ pathological changes.  So except for the diseases brought out by any external exciting causes (‘causa occassionalis’) for which their removal is (some­times only) needed for a return to normality, in all other mal­adies there will be a stage when it will be perfectly curable.  The only obstacle to cure in many instances being the physicians’ timidity in making possible the impossible-EB.

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A Study of Rheumatic Fever

 By. Dr.K.K.Anoob. BHMS

Rheumatic fever is an inflammatory disease occurring as a delayed sequel to pharyngeal infection with group haemolytic streptococci.

It involves principally heart, joints, central nervous system, skin, subcutaneous tissue etc. Clinically it is characterized by

Fever

Polyarthritis

Carditis

Chorea

Skin manifestations

Pleurisy etc.

The classical work in the field of acute rheumatic fever was published in 1836 by Jean –Bapite Builliard and in 1889 by Walter B Cheadle.

Ludwig Aschoff described specific rheumatic lesions in the myocardium in 1904.

John’s criteria for the guidance of the diagnosis of acute rheumatic fever were published by T.Ducket-John MD in 1944 and have been revised byAmerican heart association.

Etiology and Pathology

The association between septic throat and rheumatic fever was noted in the 19th century and in 1930 there were many reports of outbreaks of rheumatic fever following tonsillitis or scarlet fever especially in closed communities

The development of serological tests for streptococcal infection established the role of Group –A-Haemolytic streptococci

The way in which the streptococci causes rheumatic fever is still only partially understood. The characteristic of streptococcus is critical and the organism must be able to attach firmly to the pharyngeal cells and produce brisk antigenic response.

Impetigo producing strains do not cause rheumatic fever. Pharyngeal root of infection is necessary to initiate the rheumatic process.

The direct relationship to pathogenesis is however unproven, and streptococcus induced autoimmunity as a mechanism to explain the rheumatic process remains a popular concept.

The disease represents a damaging immune response on the part of host to an antecedent group-A- streptococci infection involving microbial agents cross reacting with the target organ.

Incidence and Epidemiology.

Acute rheumatic fever is common in developing countries and in poor socio economic groups.

Group-A-Haemolytic streptococci may occur as a commensal in the throat in smaller population of people, some time they will become virulent and produce outbreaks of upper respiratory tract infection especially in children living in closed communities like school and dormitories.

Since over-crowding and poor living conditions predispose to the spread of infections rheumatic fever is more common among the poor socio economic group

Risk of developing rheumatic fever after an attack of streptococcal tonsillitis is 0.3-5%.

The most vulnerable age group is 5-15 yrs.

Both sexes are affected but there is a female predisposition noticed in many cases.

Environmental, bacterial and host factors appear to play roles in the development of rheumatic fever Factors like lassitude, altitude, dampness, overcrowding, economic factors and age affect the incidence of rheumatic fever.

Pathology 

Pathological process consists of  Exudative stage, seen in acute stage and a Proliferative stage which is a more prolonged process.

In exudative stage fibrinoid necrosis of connective tissue is seen. Inflammatory lesion is followed by oedema of collagen fibres, which later undergoes fragmentation, and there is alteration in the staining properties.

Hallmark of proliferative phase is Aschoff bodies, a proliferative lesion with a central core of necrotic material surrounded by large cells polymorphic nucleus and basophilic cytoplasm and an outer layer of lymphocytes. These bodies have widespread distribution in connective tissues including joints, tendons, and blood vessels .In the heart, they are found in myocardial tissues.

Heart

Heart is the site of most characteristic and consequential involvement, all its layers ie endocardium, myocardium, and pericardium may be involved, generalized involvement give rise to the term rheumatic pancarditis.

Myocardium

The most characteristic and specific pattern of rheumatic inflammation is found in the myocardial Aschoff’s bodies, a granuloma which is  pathognomonic of rheumatic fever.

In many areas the inflammatory lesion is accompanied by swelling and fragmentation of collagen fibres and alteration in the staining properties of the ground substances of connective tissues called the fibrinoid necrosis of the collagen.

Aschoff’s bodies with less exudative and more proliferative changes may persist for many years as a lingering traces of chronic rheumatic inflammation in patients with rheumatic heart diseases, long after the rheumatic fever is clinically quiescent. Eventually the Aschoff’s bodies are converted into a spindle shaped or triangular scar lying between muscle bundle and surrounding blood vessels.

Endocardium

Affects valvular and mural endocardium and produces verrucous valvulitis of acute rheumatic fever which leads to the most serious cardiac damage. It may heal by fibrous thickening and adhesion of the valve commissures and chordae tendinae leading to variable degrees of valvular regurgitation and stenosis.

Deformity resulting in functional impairment of the heart occurs most commonly in mitral and aortic valves less frequently in tricuspid and almost never in pulmonary valves. The scarring after mural endocarditis may be seen as Mac callum’s patches in posterior wall of left atrium

Pericardium

Rheumatic pericarditis is a fibrinous inflammation. Pericarditis shows a bread and butter appearance on microscopy. Pericardial effusion may also develop.

Extra cardiac lesions

Involvement of joints is characterized by exudative rather than prolifarative changes and healing occurs without any structural changes and deformity.

Subcutaneous nodules are seen in acute phase of the disease. These nodules are composed by granulomas with localized areas of fibrinoid swelling of subcutaneous collagen bundles and perivascular collection of large cells with pale nuclei and prominent nucleoli.

Pulmonary and pleural lesions are less specific and less characteristic. 

Clinical features

The major clinical manifestations by which rheumatic fever can be recognized are

Polyarthritis 

Carditis

Chorea

Erythema marginatum

Subcutaneous nodules .

Prodromal symptoms

Prodromal symptoms include,

·    Epistaxis

·    Erythema nodosum

·    Vague discomfort.

It starts with remittent or intermittent pyrexia with characteristic sweating, followed by polyarthritis and carditis.

Arthritis

·  Classic attack of rheumatic fever starts as an acute migratory polyarthritis accompanied by signs and symptoms of an acute febrile illness.

·  Large joints of the extremities are most frequently involved with acute inflammation and exquisite pain, which makes the subject immobile.

·  Knees and ankles are most commonly involved followed by hip, elbows, wrist, shoulder etc.

·  Small joints of the hands and feet and axial joints are rarely involved.

·  As pain and swelling subsides in one joint other joints tend to become involved.This type of migratory nature is not a must Some times several joints may be involved at one time.

Carditis

There may be clinical features of

·      Endocarditis

·      Myocarditis

·      Pericarditis in varying combinations.

Endocarditis

This is evidenced by the appearance of murmurs or change in quality of already existing murmurs.

Mitral, aortic, tricuspid and pulmonary valves are affected in the order of frequency.

Acute valvulitis may lead to mitral and aortic regurgitation; some times a low pitched middiastolic murmur may be heard in the mitral area due to acute mitral valvulitis called cary-coombes murmur. It is transient and disappears as the valvulitis subsides.

As the valvulitis heals fibrosis occurs and these distort the valve apparatus resulting in stenosis and regurgitate lesions.

Myocarditis

Clinical manifestations include

·      Tachycardia out of proportion to fever.

·     Arrhythmia.

·     Gallop rhythm and

·     Congestive cardiac failure.

Arrhythmias includes

·     Frequent ectopics

·     Paroxysmal tachycardia

·     Atrial fibrillation

·     Heart block.

Pericarditis

Clinically manifested as

·     Chest pain

·     Presence of pericardial rub

·     Small pericardial effusion.

Rheumatic Chorea

(Sydenham’schorea,St.vitus dance,minor chorea)

·     This is a disorder of central nervous system characterized by sudden aimless irregular movements often accompanied by muscle weakness and emotional instability

·     Chorea sets in much later than the other manifestations of rheumatic fever but in many cases it may be the only abnormality encountered.

·     It is most common in females.

·     Involuntary movements, which are quasi-purposive, nonrepetition, rapid and jerky characterize this chorea, and these involve many distal joints.

·     Upper limbs are most commonly involved but lower limbs, face and tongue may also be involved to a lesser extent.

·     Emotional disturbances aggravate the chorea.

·     Limbs are hypotonic and when hands are outstretched they assume a characteristic posture called choreic posture.

·     Movement disappears in sleep.

·     Chorea is self-limiting and disappears completely with in weeks or months without leaving neurological sequelae.

·     Subject developing chorea having higher chance of cardiac involvement.                                      

Skin manifstations

Subcutaneous nodules

Usually small, peasized painless swelling over bony prominence and frequently go unnoticed by patients. The skin moves freely over them.

Characteristic lesions on extensor tendons of hand and feet, the elbows, margins of patellae, scalp and over spinous process of vertebrae.

Usually appear in patients with long standing carditis

Erythema marginatum

These are erythematous non pruritic annular lesions having clear centres with  serpiginous borders

Seen over anterior aspect of the chest, abdomen and thighs

They spread peripherally and spread with centre cleaning. The rashes usually fade within 24 hrs, but occur over a period of months, this may also occur in drug reactions and in acute glomerulonephritis.

Other rheumatic manifestations include Pleurisy, pneumonitis etc.

Cuurse and prognosis

Rheumatic fever tends to subside spontaneously over a period of weeks or months. At times the arthritis subsides but the cardiac manifestation may progress.

The course of this disease extends over several months or a few years with remissions and relapses.

Mortality in acute phase is due to cardiac failure or heart block.

Risk of developing cardiac lesions and worsening of the existing lesions is increased with successive relapses.

Diagnosis

            Clinically rheumatic fever should be considered in all cases of prolonged fevers in India.Rapid pulse, arthritis, skin manifestation and carditis are suggestive of the diagnosis. Streptococcal infection may be demonstrable either by throat swab culture or by serological methods.

Serodiagnosis

1.    Anti streptolysine O (ASO)

2.      Antistreptokinase (ASK)

3.    Anti deoxy riboneucleotidase B (Anti DNASeB)

4.    Anti nicotinamide - adenine dineucleotidase (Anti NADase)

5.    Anti Hyaluronidase (AA)

6.    Anti Streptozyme test.

ASO titre has been widely accepted as one of the more easily available diagnostic test and any value?

Above 250 Todd units in adults and 333 Todd units in children is suggestive.

About 20% of patients in the early stages of acute rheumatic fever and most patients who present with chorea, have a low or border line ASO titre. In these cases it is advisable to obtain a different streptococcal antibody test like Anti DNA seB or Anti Hyaluronidase.

Anti streptozyme test is a haem agglutination reaction to a concentrate of extracellular streptococcal antigens absorbed to red blood cells. This is a very sensitive test.

Acute phase reactants.

These are lab tests that are helpful in the acute phase of the illness.

Values of ESR and C- reactive proteins are elevated.

There may be neutrophill leucocytosis.

Presence of carditis is suggested by ECG abnormalities which may show sinus tachycardia, ectopic beat or first or second degree heart block-Voltage of QRS is low,ST elevation,T wave depression.

            Modified Jone’s criteria (1965) is the accepted criteria for diagnosis.

Major criteria denote more specific lesions, were as Minor criteria are nonspecific

For diagnosis of a case of rheumatic fever two major criterias or one major and two minor criterias should be present In Indian subjects polyarthralgia is also taken as a major criteria if supported by an evidence of streptococcal infection.

Major criteria

1.   Carditis

2.   Polyarthritis

3.   Chorea

4.      Subcutaneous nodules.

5.   Erythema marginatum.

Minor criteria

1.   Previous rheumatic fever or history of rheumatic heart diseases.

2.   Fever

3.   Acute phase reactants

4.      Prolongation of PR interval.

All these major and minor criterias should be associated with the evidence of preceding streptococcal infection.

Differential Diagnosis.

Acute rheumatic fever should be distinguished from other form of poly arthritis.

Gonococcal polyarthritis.

Subacute bacterial endocarditis

Persistent viremeas.

Rubella

Hepatitis B   etc.

Migratory nature and absence of deformity suggest the diagnosis.

Treatment.

Strict bed rest until the acute phase   is over. Reactants are normal for two successive weeks. Treatment should be continued till ESR becomes normal.

Medicines like Rhus tox, Pulsatilla, Aconite, Calc carb, Chamomilla, Colchicum  etc are very important in treatment. Medicines like Medorrhinum, Tuberculinum, Syphillinum are useful as intercurrent remedies.

Repertorial study

 In most of the repertories we can see rubrics related to rheumaticfever,some of them are direct and some are indirect.

On many instances we can’t get a direct rubric for rheumatic fever so we have to search for rubric related to the symptomatology of rheumatic fever.

In Kent’s repertory:

Chest, inflammation

Heart, endocardium, rheumatic

Pericardium,

Pleura, rheumatic.

Chest, murmur.

Chest, pain,

Heart, rheumatic.

Generalities,

Chorea, rheumatic.

Generalities,         

Pain, wandering shifting.

Skin,

Induration, nodule etc.

In Boeninghausen’s Characteristics and Repertory:

Fever, pathological types,

Rheumatic fever.

Circulation,

Palpitation, Rheumatic metastasis from. Etc.

In Murphy’s repertory

Fever

Rheumatic fever.

Heart,

Valvular diseases.

Rheumatic pain in.

Murmurs.

Pericarditis, rheumatic.

Myocarditis.

Endocarditis, rheumatic.

Nerves,

Chorea, rheumatic.  Etc.

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