A doctor's diary

Medical stories, health, and wellness


James, a 12-year-old boy, is propped up in bed. He is visibly struggling to catch a breath. The shortness of breath has been worsening progressively over the last couple of weeks.

Basic activities such as walking to the bathroom, and washing his face leave him gasping for breath – like a person who just completed a two-hundred-meter sprint.

His feet and stomach are massively swollen. The doctor said that a lot of fluid is accumulating in his body.

A few meters away from him, his distraught mother is making endless phone calls. She is appealing to friends and family members to help her raise millions of Kenyan shillings that James needs for a valve replacement surgery.

James has been diagnosed with Congestive Heart Failure (CHF) secondary to Rheumatic Heart Disease (RHD) – a disease that starts in the throat.

James is just one of more than 30 million people across the world who are living with Rheumatic Heart Disease. More than 200, 000 people die annually from this preventable disease.


Strep throat

Strep throat

“Strep throat” is a sore throat that is caused by a bacterium – Streptococcus pyogenes, also called Group A Streptococcus (GAS).

When the bacterium attacks the throat, it leaves you with a painful throat that makes swallowing difficult. It can also leave you with a dry scratchy throat.

Strep throat is most common in children aged between 5 and 15 years because:

  • Their ability to fight off infections (immunity) is not yet fully developed.
  • Community settings such as schools, and daycares promote the spread of streptococcus bacteria.
  • They are less likely to adhere to hygiene practices that reduce the spread of the streptococcus bacterium when compared to adults.
  • They have larger tonsils that make it easy for the bacterium to attack the throat.

Strep throat is also common in immunocompromised people (people whose immunity has been lowered) such as:

  • People living with HIV and AIDs.
  • People on long-term steroid therapy.
  • Post-organ transplant people who are on immunosuppressive therapy.
  • People with both solid and hematological cancers.
  • People undergoing chemotherapy, or radiotherapy.
  • The elderly people, especially those living in nursing homes.

Strep throat is just one of the causes of a sore throat. Other causes of sore throats include:

  1. Viral infections like common cold, influenza virus (flu), corona virus (COVID -19). Viral infections are associated with other symptoms such as nasal stuffiness, a running nose, headaches, and generalized body aches.
  2. Gastroesophageal reflux disease (GERD) – the acid in the stomach travels up the esophagus and corrodes the throat.
  3. Irritants such as chemicals, spicy foods, extremely hot or cold foods, alcohol consumption, tobacco smoking, and smoke.
  4. Allergies.

Strep throat symptoms

Strep throat symptoms

Sore is the most common symptom of a strep throat. Other symptoms include:

  • Odynophagia, or painful swallowing. This occurs because the throat, and tonsils – that lie at the back of the mouth – become red, and swollen.
  • White patches, or streaks of pus, may be visible on the swollen, and reddened tonsils.
  • A fever of more than 101 F (38 degrees Celsius).
  • Chills.
  • Generalized body malaise.
  • Headaches.
  • Lymphadenopathy – Swollen lymph nodes at the neck region.
  • Nausea and vomiting may occur, especially in children who are aged less than 5 years.

How is strep throat spread?

Streptococcus pyogenes is a highly contagious bacterium. As a result, it is common in community settings such as schools, daycares, camps, and nursing homes.

It is spread from one person to another though air droplets mainly. Droplets are released into the environment when an infected person, or a carrier coughs or sneezes. A carrier is a person who carries the Streptococcus pyogenes bacterium in their throat or skin, but do not show any signs or symptoms.

Coughing is one of the main way through which strep throat is spread from one person to another. Photo by Towfiqu barbhuiya

Strep throat is also spread through direct contact. Activities such as shaking hands, hugging, and kissing are common ways for spreading strep throat. Any form of skin-to-skin contact with an infected person or carrier facilitates the spread of strep throat.

When infected people and carriers cough, the droplets are transferred to surfaces. Therefore, strep throat can be spread through contact surfaces such as door knobs. It can also be spread by sharing personal items such as drinking glasses, plates, and spoons.


Strep throat progresses into congestive heart failure through three main stages:

Stage 1: Development of rheumatic fever (RF).

Stage 2: Development of rheumatic heart disease (RHD).

Stage 3: Development of congestive heart failure (CHF).

Development of rheumatic fever (RF)

A strep throat infection develops into rheumatic fever if it is untreated or if it is undertreated.

When the Streptococcus pyogenes (GAS) attacks the throat, it prompts the body to produce antibodies (chemicals that help the body to fight off an infection).

Streptococcus pyogenes (GAS) contains a protein called M-protein. The structure of the M-protein mimics the structure of proteins found in the heart valves. It also mimics the structure of some proteins found in the brain, joints, and the skin.

When the body produces antibodies against Streptococcus pyogenes, the antibodies mistakenly attack the heart valves, and other organs that contain proteins whose structure looks like the structure of M- protein in Streptococcus pyogenes.

Rheumatic fever develops between one week, and one month of developing a strep throat infection.

How do you know that your strep throat infection is developing into a rheumatic fever?

  • Left sided chest pain – Left sided chest pain is due to carditis (swelling of the heart tissues) due to attack by the antibodies.
Left sided chest pains
  • Migratory joint pains – You will start to experience pain that moves from one joint to another. Often, one joint begins to feel better before the pain moves to another joint.
  • You may experience nodules under your skin. Skin nodules caused by rheumatic fever are painless, and freely mobile. They can be as small as a grain of finger millet, or as big as a marble. Typically, they occur at the back (along the spine), at the elbow, at the knee, and over the knuckles.
Subcutaneous nodules for rheumatic fever
Subcutaneous nodules at the back, along the spine
  • A skin rash on the arms, legs, and the trunk. The rash is usually spherical, reddish in color, and contains a white or pink center.
Erythema marginatum
Erythema marginatum, a rash associated with rheumatic fever.
  • Chorea – Purposeless, and uncontrollable jerky movements of the arms, legs, and the face.
  • Prolonged fever.

Development of rheumatic heart disease (RHD)

If rheumatic fever is not treated adequately, it leads to development of rheumatic heart disease (RHD). RHD occurs when there is permanent damage to the heart valves. The damage occurs due to attack by the antibodies that the body produces against Streptococcus pyogenes.

The damage to heart valves is permanent. Valve replacement surgery is the only option for reversing rheumatic heart disease. Medications prescribed to rheumatic heart disease (RHD) patients are meant to relieve the symptoms of congestive heart failure.

Development of congestive heart failure (CHF)

Congestive heart failure occurs when the heart is incapable of pumping enough blood to all the tissues in the body. CHF happens when a part of the heart (in this case the heart valves) is not working properly.

Some of the signs and symptoms of congestive heart failure include:

  • Difficulty in breathing/ Shortness of breath.
  • Exercise intolerance.
  • Persistent coughing and wheezing, especially with activity, or when lying down flat.
  • Bilateral lower limb swelling.
  • Palpitations, or an irregular heart rate.
  • Swelling of the abdomen.

How do I prevent strep throat from progressing to congestive heart failure?

Preventing yourself from contracting, and spreading strep throat

Strep throat infection is a very common, and highly contagious disease. However, there are measures that can help you reduce the risk of contracting the infection.

These measures include:

  • Personal hand hygiene. Streptococcus pyogenes can be found on contact surfaces such as door knobs, and tables that we touch every day. It is spread to the throat during eating and drinking. Washing hands with clean water and soap before handling foods reduces the risk of contracting the bacteria from contact surfaces.
Hand washing
Hand washing reduces spread of strep throat infection.
  • Washing your hands also prevents you from transferring the bacteria to contact surfaces if you are sick (You could also be a carrier).
  • Fruits, and other foods that are consumed raw should be washed with clean water and soap to kill the bacteria.
  • Avoid sharing drinking glasses, cups, plates, and spoons. Utensils should be washed with clean water and soap before they are used by another person.
  • Cover your mouth while coughing, or sneezing. This prevents spread of Streptococcus pyogenes through air droplets.
Cover your mouth when coughing, or sneezing.
  • If you are infected, stay away from community settings such as schools, and daycares until your fever goes away.
Masks help prevent transmission of streptococcus pyogenes bacteria
Wear a face mask if you have been diagnosed with a strep throat infection.

Adequate treatment of strep throat infection

Strep throat infections should be treated with a course of antibiotics. The antibiotic of choice for treatment of strep throat infections is penicillin, or amoxycillin.

Other antibiotics that are used for the treatment of strep throat infection include azithromycin , and cephalosporins such as cefotaxime and cefuroxime.

The goal of treatment is to relieve symptoms, kill the streptococcus pyogenes bacteria, and prevent development of complications. Talk to your doctor about the diagnosis of strep throat infection, and the right antibiotic for you.

Antipyretics like aspirin, acetaminophen, and ibuprofen will help you reduce fevers, and the pain caused by strep throat infection.

You will feel relief 24 to 48 hours after starting your antibiotic treatment. However, antibiotics should be taken for the duration that has been prescribed by your doctor to prevent the development of antibiotic resistance.

Strep throat infection is the only type of sore throat that needs antibiotic therapy. Other types of sore throats can be managed by painkillers, antipyretics, and home therapies.

Strep throat infection
Reddened and swollen tonsils, with white patches.

Difference between strep throat, and other types of sore throats:

  • Strep throat comes with a sore throat without a cough, and cold symptoms such as a running nose, nasal stuffiness, and itchy eyes.
  • Strep throat causes red spots on the roof of the mouth.
  • Strep throat makes the tonsils at the back of the mouth red and swollen. The tonsils may also have a few white patches.

Treatment of rheumatic fever

The goals of treating rheumatic fever include: (a) Relieving symptoms (b)Treating a current strep throat infection (c) Preventing recurrence of strep throat infections and (d) preventing progression to rheumatic heart disease (RHD).

Aspirin, and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are used to reduce pain, fever.

Antibiotics (Penicillin, and amoxycillin) are used to treat strep throat infections.

Steroids such as prednisolone are used to reduce the swelling (inflammation) caused by the attack by antibodies on heart valves.

Secondary prophylaxis with intramuscular benzathine penicillin injections monthly for at least 5 years.

Living with rheumatic heart disease (RHD)

Rheumatic heart disease occurs when heart valves (especially the mitral valve) are permanently damaged. This damage occurs because the antibodies that our bodies produce attack both the Streptococcus pyogenes bacteria that causes strep throat infection and normal tissues such as the valves in our hearts.

A diagnosis of rheumatic heart disease (RHD) may come as a shock, and leave you at a loss – not knowing what to do next.

I do not know exactly what it feels like to receive a diagnosis of rheumatic heart disease; but having diagnosed and treated a few patients with rheumatic heart disease, I can offer a few tips that can help you navigate this difficult phase of your life.


Your doctor will prescribe diuretics – to help your body get rid of excess fluid. When your heart is not working properly, fluid always accumulate in your body. This accumulation of fluid may make your feet, and abdomen swell from time to time. It may also accumulate in your lungs, making it difficult to breath – and make you lose your breath.

While these drugs may not heal your heart valves, they help in preventing further deterioration of the condition of your heart. Therefore, it is important that you adhere to your doctor’s prescription to prevent your heart from further damage.

In addition to the diuretics, your doctor may also prescribe anticoagulants. When your heart valve has a defect, you are at a high risk of forming blood clots in your heart. These clots could leave your heart when blood is being pumped out, and lead to more complications such as strokes.

You will need a close follow-up at a cardiology clinic near you. Also, contact your doctor whenever you develop a symptom – however small. Avoid taking over-the-counter medications without contacting your doctor.

Secondary prophylaxis

Your doctor will recommend a monthly injection. The intramuscular benzathine penicillin injection prevents your body from other strep throat infections.

Depending upon the severity of your rheumatic heart disease (RHD), you might need the monthly injection for life. If you have undergone surgery for rheumatic heart disease, or you were diagnosed with severe rheumatic heart disease, you will need the injection for a lifetime.

When you adhere to these monthly injections, you reduce the risk of recurrent strep throat infections, and further damage to your heart.

Joining a support group

You may consider joining a support group. Support groups will connect you to other people who are living with RHD. These connections enable you to: (a) learn from first hand experiences of other victims (b) learn coping strategies, and (c) receive emotional support.

However, be wary of taking medical advice from social support groups. Always discuss any medical decision with your doctor before hand.

Also, contact a professional counsellor whenever you feel overwhelmed. You can schedule either an online or in-person consultation.

Heart surgery

If your heart failure symptoms are very severe, or are not responding to treatment, your doctor may recommend heart surgery. The heart surgery involves repairing the damaged valves, or replacing the damaged valve entirely with a prosthetic valve.

Patients who have undergone valve replacement therapy must be on secondary prophylaxis with monthly penicillin injections for life. This prevents infection of the prosthetic valves, or repaired valve.

Avoid strenuous activities

If you have congestive heart failure (CHF) secondary to rheumatic heart disease (RHD) your doctor will exempt you from strenuous activities such as running, and heavy manual work.

Your doctor will also exempt you from strenuous activities if you have undergone valve replacement surgery, or any form of open heart surgery.



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About Me

A passionate medical doctor with special interest in research, surgery, and medical entrepreneurship. Loves writing!


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