Medicine: Return of A Childhood Scourge

"We thought it was over," says Blaise Congeni, chief of infectious diseases at Children's Hospital in Akron. "Now all of a sudden, it's back." The object of Dr. Congeni's concern: rheumatic fever, the fearsome scourge that killed or crippled thousands of American children annually during the first half of the century. Last year doctors reported hundreds of cases of a disease that had all but disappeared from the U.S. more than a decade ago. First spotted in Utah in 1985, the new miniepidemic has hit cities in Ohio and $ western Pennsylvania, as well as Denver, Boston and Dallas. At two hospitals in Salt Lake City, doctors who normally see only six new cases each year have treated 150 youngsters in the past 24 months. Worse, physicians, who have never fully understood what causes rheumatic fever, have few clues to explain its re-emergence. The culprit could be an unfamiliar strain of bacteria -- or simply relaxed vigilance against a forgotten foe.

This time around, rheumatic fever may be more dangerous than ever. The disease can scar heart valves, with fatal results. Years ago about half of rheumatic-fever victims developed heart problems; the current illness seems to attack cardiac muscle more frequently. Doctors can minimize the damage by giving patients steroids to ease the inflammation. However, in about 50% of cases, scarred valves must be surgically repaired.

Moreover, rheumatic fever now often strikes without warning. In the past the disease followed within weeks of painful streptococcal throat infections. But the majority of recent victims have experienced only mild symptoms of strep throat, if any. Thus parents have not become alarmed until after the persistent fever and tender joints characteristic of rheumatic fever begin. "If children don't have a clinical sore throat, no one thinks of strep," says Pediatrician Ellen Wald at Children's Hospital of Pittsburgh. As a result, youngsters have gone untreated even though doctors can usually prevent rheumatic fever with penicillin. Warns Jane Schaller, chief pediatrician at New England Medical Center in Boston: "Parents will have to pay more attention to what appears to be a simple cold."

Searching for an answer, researchers have focused on the bacterial strains that cause strep throat. They isolated bacteria whose presence coincided with the renewed outbreaks of rheumatic fever. The microbes proved to be mucoid strep, a form that was prevalent more than 20 years ago. "It seemed that this may be an important clue," says Edward Kaplan, professor of pediatrics at the University of Minnesota Medical School. "We hadn't had much rheumatic fever, then we get these mucoid strains. Maybe they were responsible." There was a problem, however: the mucoid strains also showed up where there was no rheumatic fever.

Because there is no vaccine or cure for the disease, prevention is still the best bet. "I'd recommend that any sore throat be cultured," New England's Schaller says. Other experts are worried that parents and doctors too young to remember the rheumatic-fever wards of the past may not recognize the warning signs of a forgotten menace until too late.