Rheumatic fever in children: a 15-year experience in a developing country

Outcomes of rheumatic fever in Uganda: a prospective cohort study

BACKGROUND

Rheumatic heart disease is the largest contributor to cardiac-related mortality in children worldwide. Outcomes in endemic settings after its antecedent illness, acute rheumatic fever, are not well understood. We aimed to describe 3-5 year mortality, acute rheumatic fever recurrence, changes in carditis, and correlates of mortality after acute rheumatic fever.

METHODS

We conducted a prospective cohort study of Ugandan patients aged 4-23 years who were diagnosed with definite acute rheumatic fever using the modified 2015 Jones criteria from July 1, 2017, to March 31, 2020, enrolled at three rheumatic heart disease registry sites in Uganda (in Mbarara, Mulago, or Lira), and followed up for at least 1 year after diagnosis. Patients with congenital heart disease were excluded. Patients underwent annual review, most recently in August, 2022. We calculated rates of mortality and acute rheumatic fever recurrence, tabulated changes in carditis, performed Kaplan-Meier survival analyses, and used Cox regression models to identify correlates of mortality.

FINDINGS

Data were collected between Sept 1 and Sept 30, 2022. Of 182 patients diagnosed with definite acute rheumatic fever, 156 patients were included in the analysis. Of these 156 patients (77 [49%] male and 79 (51%) female; data on ethnicity not collected), 25 (16%) died, 21 (13%) had a cardiac-related death, and 17 (11%) had recurrent acute rheumatic fever over a median of 4·3 (IQR 3·0-4·8) years. 16 (24%) of the 25 deaths occurred within 1 year. Among 131 (84%) of 156 survivors, one had carditis progression by echo. Moderate-to-severe carditis (hazard ratio 12·7 [95% CI 3·9-40·9]) and prolonged PR interval (hazard ratio 4·4 [95% CI 1·7-11·2]) at acute rheumatic fever diagnosis were associated with increased cardiac-related mortality.

INTERPRETATION

These are the first contemporary data from sub-Saharan Africa on medium-term acute rheumatic fever outcomes. Mortality rates exceeded those reported elsewhere. Most decedents already had chronic carditis at initial acute rheumatic fever diagnosis, suggesting previous undiagnosed episodes that had already compounded into rheumatic heart disease. Our data highlight the large burden of undetected acute rheumatic fever in these settings and the need for improved awareness of and diagnostics for acute rheumatic fever to allow earlier detection.

FUNDING

Strauss Award at Cincinnati Children's Hospital, American Heart Association, and Wellcome Trust.

Autoimmune and Paraneoplastic Chorea: A Review of the Literature

Autoimmune chorea syndromes represent a vast array of paraneoplastic, parainfectious and idiopathic disorders. It is increasingly apparent that familiarity with these disorders is critically important, as they may be treatable or may be part of a syndrome requiring further work-up and monitoring. These disorders are mediated by an aberrant immunologic attack with resultant neuronal dysfunction, manifesting as chorea. These conditions are typically accompanied by other neurologic or systemic manifestations. In this review we outline the clinical features, epidemiologic factors, and delineate the specific antibodies associated with each of these autoimmune mediated disorders. We highlight up to date information regarding this heterogeneous group of disorders, including a discussion of parainfectious Sydenham's chorea; paraneoplastic syndromes associated with CRMP-5 (collapsin response mediated protein-5/CV2) and ANNA-1 (antineuronal nuclear antibody / Hu) antibodies, in addition to neuronal antibody-associated disorders including anti-NMDAR, LGI1 (leucine-rich glioma inactivated-1) and CASPR2 (contactin associated protein-2). We discuss the more recently described entities of IgLON5, which has evidence of both immunologic and degenerative pathophysiology, in addition to PDE-10A antibody-associated chorea. We also outline chorea secondary to systemic diseases including Systemic Lupus Erythematosus (SLE) and Primary Antiphospholipid Syndrome (PAPS). We provide a framework for diagnosis and treatment.

Comprehensive Review of Cardiovascular Diseases, Diabetes, and Hypercholesterolemia in Lebanon

The Middle East and North Africa regions, including Lebanon, have recently witnessed rapid urbanization and modernization over the last couple of decades that has led to a dramatic transformation affecting lifestyle and diet. The World Health Organization reports that the leading cause of death in Lebanon is due to cardiovascular disease (CVD) at 47% of all-cause mortality. Over the last 30 years, especially the last 10, the population of Lebanon has changed dramatically due to the effect of wars in the region and refugees seeking asylum. With a population of around 4.5 million and a relatively high rate of consanguinity in Lebanon, a variety of novel mutations have been discovered explaining several familial causes of hypercholesterolemia, diabetes mellitus, congenital heart disease, and cardiomyopathies. Due to the Syrian civil war, 1.5 million Syrian refugees now reside in Lebanon in either low-income housing or tented settlements. A National Institutes of Health study is examining diabetes and CVD in Syrian refugees in comparison to native Lebanese. We provide the first review of CVD in Lebanon in its metabolic component including coronary artery disease and its risk factors, mainly hyperlipidemia and diabetes mellitus, and its structural component, including congenital heart disease, valvular heart disease, cardiomyopathies, and heart failure. The knowledge in this review has been compiled to guide clinicians and assist researchers in efforts to recognize risk factors for disease, improve delivery of health care, and prevent and treat CVDs in Lebanon, both for the native Lebanese and Syrian refugees.

Clinical Profile and Management of Rheumatic Heart Disease in Children and Young Adults at a Tertiary Cardiac Center in Indonesia

Introduction: Rheumatic heart disease (RHD) remains a major public health issue affecting children and young adults in developing countries. This study aimed to evaluate the clinical characteristics, management, and reactivation of RHD among children and young adults.

Patients and Methods: This was a hospital-based retrospective study conducted at the National Cardiovascular Center Harapan Kita, Indonesia; we retrieved relevant data from patients diagnosed with RHD between 2012 and 2018.

Results: Two hundred and seventy-nine patients were diagnosed with rheumatic heart disease, of whom 108 were children (mean age of 12.02 ± 3.36 years) and 171 were young adults (mean age was 24.9 ± 3.84). RHD was more common in female than in male young adults (1.5:1). Hospitalization due to RHD complications such as congestive heart failure was seen in 11.11% of cases in children, while pulmonary hypertension was present in 19.95% young adult cases. Reactivation of RHD occurred in 17.2% (48/279) cases, significantly in children (p < 0.001). Overall, the mitral valve (either isolated or combined) was the organ most affected in children (39.13%) and young adults (44.81%). Isolated mitral regurgitation was more common in children (13/21, 61.9%), while isolated mitral stenosis was more common in young adults (19/47, 40.42%). There was a high rate of rheumatic tricuspid valve disease in all populations (193/279, 69.17%) and reported involvement of pulmonary regurgitation (46/279, 16.48%). Multivalve lesions were more common than single lesions in both groups, with a combination of mitral and tricuspid regurgitation the predominant type in children (32/43, 74.41%) and mixed mitral lesion and tricuspid regurgitation in young adults (22/72, 30.56%). We observed a significant occurrence of quadrivalve lesions in children (p = 0.039). Valve repair was more common in children (49.07%) and replacement in young adults (32.16%), with low in-hospital mortality. Compliance with secondary prophylaxis was a significant challenge.

Conclusion: Chronic RHD often presented with complications of the disease or reactivation of rheumatic fever (RF). Inadequate treatment of RF/RHD leads to extensive valvular damage and consequent disabilities. Efforts toward active early diagnosis and prompt treatment of RF/RHD and effective preventive measures are essential.

Acute rheumatic fever in south-east of Turkey: clinical features and epidemiological evaluation of the patients over the last 25 years

This study evaluates clinical and epidemiological features of acute rheumatic fever using the data of last 25 years in our hospital in south-east of Turkey. The medical records of 377 patients with acute rheumatic fever admitted to Pediatric Cardiology Department of Çukurova University during 1993-2017 were retrospectively analysed. Two hundred and six patients were admitted between 1993 and 2000, 91 between 2001 and 2008, and 80 between 2009 and 2017. The largest age group (52%) were between 9 to 12 years of age and approximately two-thirds of the patients presented in the spring and winter seasons (62.8%). Among the major findings, the most common included carditis 83.6% (n = 315), arthritis at 74% (n = 279), Sydenham's chorea at 13.5% (n = 51), and only two patients (0.5%) had erythema marginatum and two patients (0.5%) had subcutaneous nodule. Carditis was the most common manifestation observed in 315 patients (83.6%). The most commonly affected valve was the mitral valve alone (54.9%), followed by a combined mitral and aortic valves (34%) and aortic valve alone (5.7%). Of the patients with carditis, 48.6% (n = 153) had mild carditis, of which 45 had a subclinical. Sixty-two patients (19.7%) had moderate and 100 patients (31.7%) had severe carditis. At the follow-up, 2 patients died and 16 patients underwent valve surgery. Twenty-eight (7.4%) patients' valve lesions were completely resolved. Conclusion: Although the incidence of acute rheumatic fever decreased, it still is an important disease that can cause serious increases in morbidity and mortality rates in our country.

Pulse therapy combined with oral corticosteroids in the management of severe rheumatic carditis and rebound

OBJECTIVE

The aim of the present study was to describe the clinical course, laboratory tests, and the cardiac involvement in rheumatic carditis patients in functional class III and IV, submitted to pulse therapy combined with oral prednisone.

METHODS

A total of 120 patients with severe carditis due to acute rheumatic fever were treatment with three cycles of pulse therapy combined with oral corticosteroids. The patients were followed up from the hospital admission until the end of the treatment and returned after 30, 60, and 90 days to control. The patients were evaluated by clinical, laboratory, and transthoracic echocardiogram.

RESULTS

In total, 23 (19.2%) patients at first attack of rheumatic fever and 97 (80.8%) with recurrent carditis were evaluated. Cardiac surgery was performed in 8 (6.6%) patients. The patients showed improved laboratory and radiological parameters (p<0.001) and were discharged, 74 (61.7%) in functional class I and 46 (38.3%) in functional class II. Hospitalisation time ranged from 21 to 176 days, with a mean of 69.1 days. Reduction of left atrium and ventricle diameters was observed, measured by means of transthoracic echocardiography, at hospital admission and discharge (p<0.001). None of the patients experienced rebound.

CONCLUSIONS

The pulse therapy was effective in controlling severe rheumatic carditis and the oral corticosteroid prevented rebound episodes. Prolonged hospital stay was required for the clinical stabilisation of patients and to avoid the interruption of medication.

Systematic Literature Review on the Incidence and Prevalence of Heart Failure in Children and Adolescents

While the epidemiology of adult heart failure has been extensively researched, this systematic review addresses the less well characterized incidence and prevalence of pediatric HF. The search strategy used Cochrane methodology and identified 83 unique studies for inclusion. Studies were categorized according to whether the HF diagnosis was reported as primary (n = 10); associated with other cardiovascular diseases (CVDs) (n = 49); or associated with non-CVDs (n = 24). A narrative synthesis of the evidence is presented. For primary HF, the incidence ranged from 0.87/100,000 (UK and Ireland) to 7.4/100,000 (Taiwan). A prevalence of 83.3/100,000 was reported in one large population-based study from Spain. HF etiology varied across regions with lower respiratory tract infections and severe anemia predominating in lower income countries, and cardiomyopathies and congenital heart disease major causes in higher income countries. Key findings for the other categories included a prevalence of HF associated with cardiomyopathies ranging from 36.1% (Japan) to 79% (US); associated with congenital heart disease from 8% (Norway) to 82.2% (Nigeria); associated with rheumatic heart diseases from 1.5% (Turkey) to 74% (Zimbabwe); associated with renal disorders from 3.8% (India) to 24.1% (Nigeria); and associated with HIV from 1% (US) to 29.3% (Brazil). To our knowledge, this is the first systematic review of the topic and strengthens current knowledge of pediatric HF epidemiology. Although a large body of research was identified, heterogeneity in study design and diagnostic criteria limited the ability to compare regional data. Standardized definitions of pediatric HF are required to facilitate cross-regional comparisons of epidemiological data.

Rheumatic fever: update on the Jones criteria according to the American Heart Association review - 2015

Rheumatic fever is still currently a prevalent disease, especially in developing countries. Triggered by a Group A β-hemolytic Streptococcus infection, the disease may affect genetically predisposed patients. Rheumatic carditis is the most important of its clinical manifestations, which can generate incapacitating sequelae of great impact for the individual and for society. Currently, its diagnosis is made based on the Jones criteria, established in 1992 by the American Heart Association. In 2015, the AHA carried out a significant review of these criteria, with new diagnostic parameters and recommendations. In the present study, the authors perform a critical analysis of this new review, emphasizing the most relevant points for clinical practice.

Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations

OPINION STATEMENT

Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now includes the concept of low-risk versus medium-to-high risk populations. Initiation of secondary prophylaxis and the establishment of early medium to long-term care plans is a key aspect of the management of ARF. It is a requirement to identify high-risk individuals with RHD such as those with heart failure, pregnant women, and those with severe disease and multiple valve involvement. As penicillin is the mainstay of primary and secondary prevention, further research into penicillin supply chains, alternate preparations and modes of delivery is required.

Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented.

OBJECTIVES

To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care.

METHODS

A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled.

RESULTS

Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly.

CONCLUSION

ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery.

Incidence and clinical features of acute rheumatic fever in Kayseri, Central Anatolia, 1998-2011

BACKGROUND

In developing countries, acute rheumatic fever is the most common cause of acquired heart disease in the paediatric and adolescent population. It is believed that vulnerability to developing acute rheumatic fever is associated with several factors such as socio-economic and living conditions. Aim Determine the incidence and clinical characteristics of acute rheumatic fever in the Central Anatolia region of Kayseri within the last 14 years, and to make a comparison of two 7-year periods. Material and methods We performed a retrospective analysis of 624 patients who were diagnosed with acute rheumatic fever at the Department of Pediatric Cardiology in the Medical Faculty of Erciyes University between January, 1998 and December, 2011.

RESULTS

The mean age of patients was 10.9±2.7 years. The female/male ratio was 1.4. When patients were categorised according to age groups, the largest group represented 376 patients (60.3%) aged between 10 and 14 years. The estimated incidence rate of acute rheumatic fever was 7.4/100,000 in the Central Anatolia region of Kayseri. Among the major findings, the most common included carditis at 54%, arthritis at 35%, Sydenham's chorea at 25%, and subcutaneous nodules at 0.5%, respectively. No significant difference was found between the first 7-year period and second 7-year period in distributions of age, gender, and major findings.

CONCLUSION

Although there has been socio-economic development in Turkey in the recent years, the incidence of acute rheumatic fever is still high in the Central Anatolia region of Kayseri.

Clinical spectrum of rheumatic Fever and rheumatic heart disease: a 10 year experience in an urban area of South India

Background:

Rheumatic fever (RF) is an important problem concerning developing countries like India. Rheumatic heart disease (RHD) is one of the most readily preventable chronic diseases.

Aim:

This study was done to find out the clinical profile, risk factors, compliance with treatment and outcome among RF/RHD cases so as to suggest better case management strategies.

Materials and Methods:

Clinical records of 51 RF and 71 RHD cases admitted in tertiary care hospitals in Mangalore between 2001 and 2010 were reviewed retrospectively.

Results:

Mean age of RF cases were 17.4 ± 12.1 years and RHD cases were 33.2 ± 18.6 years. More than half of RF and RHD cases were males. Commonest risk factors among RF cases were poor socioeconomic status (60.4%), history of upper respiratory tract infection before disease onset (58.8%) and undernutrition (35.3%). Commonest clinical manifestation among RF cases was fever 39 (76.5%) followed by polyarthritis 34 (66.7%). Commonest valvular lesions among RHD cases was mitral stenosis with mitral regurgitation found in 42.9% cases. Compliance of patients with prophylactic antibiotics was found to be 37 (30.3%). Mortality rate was significantly more among RHD cases (P = 0.0399).

Conclusions:

Improvement of socioeconomic and nutritional factors is an important task required for primary prophylaxis and of compliance for secondary prophylaxis of RF.

Clinical, laboratory and echocardiographic profile of acute rheumatic fever in Nepali children

BACKGROUND

Acute rheumatic fever (RF) is a common, preventable health problem in developing countries. Sporadic outbreaks and the prevalence in some indigenous populations have renewed interest in RF in developed countries also.

AIMS

To describe the clinical, laboratory and echocardiographic features, outcome and value of echocardiography in detecting valvular disease in RF.

METHODS

A prospective, cross-sectional study was conducted over 2 years. Patients under 14 years admitted to the cardiology unit of Kanti Children's Hospital, Kathmandu with RF using the Jones criteria were recruited consecutively.

RESULTS

The median age (range) of the 51 patients was 11 (5-14) years, the male:female ratio was 1.6:1 and 39% had a history of a sore throat. Clinical and laboratory features detected were as follows: carditis 92%, arthritis 33%, chorea 8%, subcutaneous nodules 4%, fever 51%, arthralgia 37%, elevated antistreptolysin O titre 94%, elevated CRP 78%, prolonged PR interval 45%, pericardial effusion 22% and cardiac failure 28%. In total, 36 patients (71%) complained of joint pains. A murmur on auscultation was significantly associated with underlying diseased valves confirmed by echocardiography (p=0.001). A murmur was audible in 78.4% and diseased valves were confirmed by echocardiography in 88.2%. The mitral valve was the most commonly involved valve (82%) and mitral regurgitation the commonest lesion (24%). A thickened mitral valve predicted carditis (p=0.007). Five (10%) patients died.

CONCLUSION

Inclusion of echocardiographic evidence of carditis and possibly arthralgia as major criteria would improve case detection.

[Acute rheumatic carditis in Ivory Coast: changes in prevalence during the decade 2000-2009]

BACKGROUND

Rheumatic fever and acute rheumatic carditis (ARC), though now rare in developed countries, are the main cause of acquired heart disease in children and young adults and remain endemic in developing countries. This study aims to establish the current prevalence of ARC in Ivory Coast.

PATIENTS AND METHODS

A cross-sectional retrospective study was performed between January 2000 and December 2009 in the pediatric wards of the three university hospitals in Abidjan and in the Institute of Cardiology of Abidjan. It included all patients whose final diagnosis was ARC.

RESULTS

There were 126 patients of which 57.1% were female. The mean age was 15 ± 6.7 years (range: 4 to 28 years). The average annual prevalence was 12.6 cases, with two peaks observed during the years 2004 (27 cases) and 2005 (20 cases). The hospital prevalence of ARC in the 10-year period was 1.1‰ which is less than in previous decades. The principal presentation leading to discovery of the ARC was heart failure (68.9%). This symptom was due to significant valvular regurgitation with dilatation of the cardiac chambers observed in 65.9%. Mitral regurgitation was the main lesion observed (87.3%). Apart from the cases of isolated pericarditis and three cases of mild mitral regurgitation, all other patients were suffering from valvular lesions as a result of previous rheumatic fever.

CONCLUSION

A decrease in the hospital prevalence of ARC was observed. However the cases that were seen were diagnosed late and had a tendency to be severe.

Follow-up of rheumatic carditis treated with steroids

OBJECTIVE

To present the long-term follow-up of children hospitalised for severe rheumatic carditis who were treated with corticosteroids.

METHODS

This is a retrospective analysis of the outcome of 242 patients with severe rheumatic carditis after discharge from two public hospitals in Niteroi, Brazil. We followed up 118 patients for 4 years or more, with an average of 7.7 years. They were treated with antibiotics to accomplish bacterial eradication and either intravenous methylprednisolone - 40 cases - or oral prednisone - 78 patients - to treat carditis. They were followed up in outpatient clinic.

RESULTS

Cardiac failure was categorised as classes III and IV according to the New York Heart Association classification. In the intravenous corticosteroid group, 21 cases (52.5%) had isolated mitral valve regurgitation, 12 (30%) had mitral plus aortic involvement, and seven (17.5%) had aortic lesion only. In the oral prednisone group, 45 (58%) had mitral valve regurgitation only, 27 (34%) had mitral plus aortic involvement, and six (8%) had aortic lesion only. A total of 28 children were in their first disease attack, of whom 19 (68%) had a rupture of chordae tendineae. A total of 58 patients (49%) sustained recurrence of carditis because of neglected secondary prophylaxis. In all, 19 cases (16%) underwent cardiac surgery - valve replacement or valvuloplasty. In 33% of the cases, the outcome was favourable - asymptomatic at follow-up. The overall mortality rate was 6.8%.

CONCLUSION

Many critically ill patients who complied with secondary prophylaxis were left with minor injuries, whereas those who neglected it or abandoned it had serious sequelae. The rate of abandonment and loss to follow-up was very high. Many cases (49%) were re-hospitalised because of carditis recurrence.

Acute rheumatic fever in the Central Anatolia Region of Turkey: a 30-year experience in a single center

The study was carried out in Dr. Sami Ulus Children's Hospital to investigate and to compare the incidence and findings of acute rheumatic fever patients (ARF) seen in the past 30 years. The medical records of 1,115 patients with ARF admitted to Dr. Sami Ulus Children's Hospital Department of Pediatric Cardiology during 1980-2009 were retrospectively analyzed. Twenty-one percent of those patients were admitted between 1980 and 1989, 44.6% between 1990 and 1999, and 34.2% between 2000 and 2009. The highest incidence was detected in the second decade with a rate of 60.0:100,000. Male/female ratio was 1:18. The age of patients ranged between 2 and 15 years. Carditis was detected in 64.7% of patients, arthritis in 59.1%, and chorea in 14.1%. Mitral regurgitation was the most common echocardiographic finding. Heart failure was detected in 13.8%. Recurrent attacks occurred in 8.1% of patients. The median follow-up was 6.8 years (range, 1.2-10.5 years). The prevalence of chronic rheumatic valvular disease was 58%. Mortality rate was 0.8%.

CONCLUSION

Although the incidence of ARF has decreased in the last decade, it still continues to be an important public health problem in Turkish pediatric population.

Do rates of arthritis and chorea predict the incidence of acute rheumatic fever?

BACKGROUND

Acute rheumatic fever (ARF), a major cause of acquired heart disease worldwide, remains a significant public health problem. However, the precise incidence of ARF in Africa, where a large number of cases occur, remains unknown. We hypothesize that focused attention on non-cardiac features of ARF, namely joint manifestations and chorea, might enhance its detection in settings with limited resources.

METHODS

This hypothesis was tested by reviewing the medical records at Vanderbilt Children's Hospital from 1998 to 2008. In addition, an extensive literature review of published studies was performed to assess rates of joint findings or chorea in confirmed cases of ARF.

RESULTS

Fifty-nine new cases of ARF were diagnosed in children at Vanderbilt from 1998 to 2008. Of these cases, 91% presented with joint manifestations or chorea, and 80% satisfied major Jones criteria findings of polyarthritis or chorea. These findings are consistent with literature published from our region and internationally.

CONCLUSIONS

Most patients presenting with ARF have either joint symptoms or chorea, features that could be recognized by community health workers and individuals with limited medical training. The referral of patients presenting with these manifestations for further evaluation might improve detection rates of ARF in resource-limited countries and lead to improved estimates of disease burden.

Prevalence of rheumatic heart disease among school-children in Aden, Yemen

BACKGROUND

Rheumatic heart disease (RHD) is an important contributor to cardiovascular disease in children and adults in Yemen. This is the first report to determine the prevalence of RHD among school-children in the city of Aden.

METHODS

A cross-sectional case-finding survey of RHD was conducted in 6000 school-children aged 5-16 years. Echocardiography was undertaken in those with clinical signs of organic heart disease.

RESULTS

The prevalence of RHD was 36·5/1000 school-children, which is one of the highest reported among school echocardiography surveys in the world. RHD was more common in 10-16-year-old students. RHD was diagnosed in more than one member of the families of 53 (24·2%) of the children. Mitral regurgitation (MR) was detected in 49·8%, 26·6% had MR with mitral valve prolapse and 17·8% had combined MR and aortic regurgitation. Fifty-eight children were diagnosed with congenital heart disease (CHD), representing a prevalence of 9·7/1000. The main types of CHD were mitral valve prolapse, patent ductus arteriosus, atrial septal defect, pulmonary stenosis and aortic stenosis. Congenital mitral valve prolapse found in 36 children was three times more common in males than females. Children with RHD were more likely to be from low-income families with poor housing and greater overcrowding (49·3%, 39·3% and 64·8%) than children with CHD (44·8%, 32·8% and 48·3%, respectively).

CONCLUSIONS

The high prevalence of RHD is a major public health problem in Yemen. Urgent screening surveys and an RHD prophylactic programme of appropriate management of group A β-haemolytic streptococcal pharyngotonsilitis are required.

The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns around the world. Despite decreasing incidence, there is still a significant disease burden, especially in developing nations. This review provides background on the history of ARF, its pathology and treatment, and the current reported worldwide incidence of ARF and prevalence of RHD.

Frequência de internações por febre reumática em um hospital pediátrico de referência em um período de 20 anos

OBJETIVO: Analisar a frequência de internações por febre reumática e as características dos pacientes portadores desta doença internados no Hospital Infantil Joana de Gusmão, Florianópolis (SC), entre 1986 e 2006. MÉTODOS: Estudo observacional, transversal, de eixo temporal, realizado por meio da análise dos prontuários médicos de pacientes com o diagnóstico, internados em 1986, 1991, 1996, 2001 e 2006. A coleta de dados incluiu faixa etária, sexo, evidência de estreptococcia prévia, manifestações clínicas (critérios revisados de Jones) e evolução. A análise foi descritiva. RESULTADOS: Nos anos analisados, houve 99 internações, sendo 59 em 1986, 17 em 1991, oito em 1996, 12 em 2001 e três em 2006. Predominou a faixa etária de cinco e 15 anos e 51% da amostra era composta por meninos. Observou-se anticorpo antiestreptolisina O elevado em 54% dos pacientes. Dentre as manifestações maiores de Jones, predominou a cardite (73%), seguida de artrite (44%) e coreia (14%). Insuficiência mitral foi a valvopatia mais frequente e o percentual de insuficiência cardíaca congestiva nos casos com cardite diminuiu de 51% (1986) para zero (2006). A reinternação por recidiva ocorreu em 31% dos casos, com um óbito. CONCLUSÕES: Houve declínio expressivo do número de hospitalizações por febre reumática ao longo dos anos. A queda do percentual de insuficiência cardíaca congestiva sugere um perfil de menor gravidade dos casos. O alto número de recidivas aponta para possível falha na profilaxia secundária.

Cardiac operations for North American children with rheumatic diseases: 1985-2005

Certain pediatric rheumatic diseases are known to affect the heart, sometimes requiring surgical intervention. The Pediatric Cardiac Care Consortium database was used to characterize cardiac surgical intervention among children with rheumatic diseases from 1985 to 2005. From this large database, the records for patients younger than 21 years who underwent cardiac surgery for any rheumatic disorder were extracted. The data collected included the type of procedure performed, the age at the time of the procedure, and the year the procedure was performed. The 261 pediatric patients identified underwent 361 cardiac surgical procedures for complications of rheumatic heart disease (RHD; 160 patients), neonatal lupus (NLE; 53 patients), Kawasaki disease (KD; 28 patients), systemic lupus erythematosus (SLE; 13 patients), and juvenile rheumatoid arthritis (JRA; 7 patients). Multiple procedures were performed for 23% of the patients. The most common procedures included pacemaker implantations among infants with NLE, coronary artery bypass grafts for KD primarily in 5- to 15-year-olds, and cardiac valve operations among adolescents with RHD, SLE, and JRA. Six perioperative deaths occurred. The proportion of annual pediatric cardiac surgical volume attributable to rheumatic diseases did not change during the period studied. Despite advances in their medical care, children with rheumatic diseases continue to sustain measurable morbidity and mortality due to the cardiovascular manifestations of their disease.

Mitral balloon valvuloplasty in a child by hybrid approach

Rheumatic fever is the main etiology for valvular heart diseases in children. Valvular insufficiencies are frequent, and development of disease at an earlier age results in severe valvular damage. In this report we present a 9-year-old child with rheumatic heart disease who was admitted to our clinic with hemoptysis and haematemesis caused by mitral stenosis (MS) resulting in pulmonary venous hypertension. The child was treated with mitral balloon valvuloplasty by hybrid approach. Percutaneous mitral balloon valvuloplasty is used for management of MS in adults, but it is less frequently used in children because of its high rate of complications. Because of the severity of disease with which this patient presented, as well as her younger age and lower weight, we preferred to use the hybrid approach, and the results were favorable. In conclusion, in patients with special conditions, hybrid mitral valvuloplasty through the right upper pulmonary vein should be considered when managing children with similar conditions.

Gene profiling of left ventricle eccentric hypertrophy in aortic regurgitation in rats: rationale for targeting the β-adrenergic and renin-angiotensin systems

Aortic valve regurgitation (AR) imposes a severe volume overload to the left ventricle (LV), which results in dilation, eccentric hypertrophy, and eventually loss of function. Little is known about the impact of AR on LV gene expression. We, therefore, conducted a gene expression profiling study in the LV of rats with acute and severe AR. We identified 64 genes that were specifically upregulated and 29 that were downregulated out of 21,910 genes after 2 wk. Of the upregulated genes, a good proportion was related to the extracellular matrix. We subsequently studied a subset of 19 genes by quantitative RT-PCR (qRT-PCR) to see if the modulation seen in the LV after 2 wk persisted in the chronic phase (after 6 and 12 mo) and found that it did persist. Knowing that the adrenergic and renin-angiotensin systems are overactivated in our animal model, we were interested to see if blocking those systems using metoprolol (25 mg·kg−1·day−1) and captopril (100 mg·kg−1·day−1) would alter the expression of some upregulated LV genes in AR rats after 6 mo. By qRT-PCR, we observed that upregulations of LV mRNA levels encoding for procollagens type I and III, fibronectin, atrial natriuretic peptide, transforming growth factor-β2, and connective tissue growth factor were totally or partially reversed by this treatment. These observations provide a molecular rationale for a medical strategy aiming these systems in the medical treatment of AR and expand the paradigm in the study of this form of LV volume overload.

Valve repair with autologous pericardium for organic lesions in rheumatic tricuspid valve disease

BACKGROUND

Surgical repair of pathologic tricuspid valve disease often fails because of severe anatomic distortion of the valve apparatus, particularly in patients with rheumatic heart disease. This usually leads to tricuspid valve replacement despite the associated prosthesis-related complications. This study examines our experience of tricuspid valve repair with autologous pericardium for organic rheumatic tricuspid valve disease.

METHODS

From 1996 to 2007, 31 patients underwent repairs for rheumatic tricuspid valve disease characterized by retracted leaflets and inadequate leaflet area. The patients, aged 14 to 56 years, had a mean New York Heart Association (NYHA) class of 2.9 +/- 0.6. All patients presented with severe tricuspid regurgitation and coexisting left-sided heart valve disease. Glutaraldehyde-treated autologous pericardial patch was used to augment tricuspid valve leaflets. Other techniques were applied as needed, including commissurotomy, leaflet mobilization, annuloplasty, and prosthetic ring implantation. Concomitant operations included left-sided valve replacement in all, and left atrial thrombus removal in 3 patients. Follow-up duration was 4 to 126 months.

RESULTS

No deaths or late reoperations occurred. All patients demonstrated clinical improvements on follow-up. Echocardiographic studies before hospital discharge showed less than mild tricuspid regurgitation in all patients. The most recent echocardiographic follow-up showed no tricuspid regurgitation in 10 patients (32.3%), trivial regurgitation in 12 (38.7%), mild regurgitation in 8 (25.8%), and moderate regurgitation in 1 (3.2%).

CONCLUSIONS

In selected patients, organic rheumatic tricuspid valve disease can be treated with pericardial patch to augment the retracted leaflets in combination with other techniques. Follow-up reveals excellent tricuspid valve function.

Rheumatic chorea: relationship to systemic manifestations and response to corticosteroids

OBJECTIVE

To describe Sydenham chorea among children in a cohort of patients with rheumatic fever (RF).

STUDY DESIGN

An existing database was used to identify demographic characteristics, clinical manifestations, and therapy in persons with RF identified in Salt Lake City, Utah, from 1985 through January 2002.

RESULTS

Of 584 cases in the database, 537 (91%) were new-onset RF (median age of 10 years) and 177 (33%) had chorea. Patients with chorea were more often female (OR = 0.37, 95% CI = 0.25-0.55, P < .0001) and were less likely to have carditis or arthritis. Prednisone treatment may lead to a shortened course of chorea (4.0 weeks in prednisone-treated [n = 32] vs 9.0 weeks in untreated [n = 14]; P < .0001). Among 33 patients seen at a median of 10.3 years (range 6.3-14.9 years) after their initial bout of chorea, 20% reported residual tremor or mood swings. Ten of the 33 (30%) had one or more recurrences of chorea.

CONCLUSIONS

Chorea affected one-third of the children with RF. Patients with chorea were less likely to have severe cardiac or rheumatologic complications of RF. Therapy with prednisone shortened the duration of rheumatic chorea; some reported recurrences of chorea and had minor neurologic sequelae.

Sydenham's chorea: a clinical follow-up of 65 patients

Sydenham's chorea, the neurological manifestation of rheumatic fever, is the most common acquired chorea of childhood. In this retrospective study, the authors aim to present the clinical and laboratory findings of 65 Sydenham's chorea patients, followed up in a clinic over less than 7 years. The mean age at the onset of the symptoms was 11.7 +/- 2.6 years (range, 6-17 years). Of the patients, 63% were female and 37% were male (male/female: 1.7/1). Chorea was generalized in 78.5% of the patients, right hemichorea in 12.3%, and left hemichorea 9.2%. There was a history of rheumatic fever in 30.8% of the patients. Echocardiographic study showed cardiac valve involvement in 70.5% of 61 patients. Brain magnetic resonance imaging, which was performed on only 18 patients, was evaluated as normal in all. Electroencephalography was also performed on only 18 patients and showed abnormal waves in 50% of them. Pimozide was mostly the first choice of drug therapy. Nevertheless, drug therapy was not needed in 18.5% of the patients. The recovery period of the first attack of the chorea was 1 to 6 months in 51.7% of the patients. The recurrence rate was 37.9%. In conclusion, Sydenham's chorea is still an important health problem in Turkey with respect to its morbidity.

Jones criteria and underdiagnosis of rheumatic fever

OBJECTIVE

The authors attempt to determine whether typical clinical and laboratory manifestations of acute rheumatic fever (ARF) are in accordance to what has been traditionally described and how useful the Jones criteria are for diagnosis.

METHODS

Data from 81 cases of ARF were retrospectively collected.

INCLUSION CRITERIA

5 to 15 years of age and diagnosis of ARF confirmed by 2 or more rheumatologists, sustained for at least 6 months and two or more visits.

RESULTS

Girls had more chorea (23/50.0% vs. 5/14.3%)(p< 0.0001). Cardiovascular (65/80.2%) and joint involvements (63 / 77.8%) were the most frequent manifestations. Fever was noted in roughly half of the patients. Arthritis was more frequent than arthralgia (47/58.0% vs. 16/19.8%, respectively) (p< 0.0001); however, no specific pattern of joint involvement was found to be more prevalent. Mitral insufficiency was the most frequently detected echocardiographic sign (53 / 93.0%) and its association with aortic insufficiency was noted in 27 / 47.4% patients. Only 24 / 29.6% patients fulfilled Jones criteria for ARF requiring an evidence of previous group-A streptococcal infection (GASI). When compulsory GASI was disregarded, this number rose to 71/87.7% patients (p< 0.0001).

CONCLUSION

Girls were more affected by chorea; heart valves and joints were equally affected and represented the major clinical features; no specific pattern of joint involvement (eg.: migratory arthritis) could be labeled as typical; and strict adherence to Jones criteria, with compulsory documentation of a previous GASI, may lead to underdiagnosis of ARF.

Clinical value of NT-ProBNP and BNP in pediatric cardiology

BACKGROUND

Although less common than in adults, heart disease is a significant cause for morbidity and death in infants and children. Congenital structural cardiac anomalies and acquired heart diseases may result in heart failure.

METHODS AND RESULTS

Available data suggest that the natriuretic peptide system has a similar role in health and disease in the pediatric age group as in adults. In healthy infants and children, levels of B-type natriuretic peptide (BNP) and the N-terminal segment of its pro-hormone (NT-proBNP) are elevated in the first few days after birth. Thereafter, their levels decrease and remain relatively constant throughout childhood. Infants and children with heart disease that causes significant pressure or volume overload of the right or the left ventricle have elevated BNP and NT-proBNP levels. In children with congestive heart failure, BNP and NT-proBNP levels correlate with functional capacity. Both peptides can differentiate cardiac from pulmonary causes in infants with respiratory distress. Limited data suggest that these peptides may also serve as markers in cyanotic, obstructive, and inflammatory heart diseases.

CONCLUSION

The present data suggest that both NT-proBNP and BNP are markers for heart disease in infants and children. Their use may improve clinical practice in pediatric cardiology.

Rheumatic fever: the relationship between clinical manifestations and laboratory tests

OBJECTIVES

To determine the relationship between the severity of clinical features of rheumatic fever (RF), and antistreptolysin O titre (ASOT) and/or erythrocyte sedimentation rate (ESR).

METHODS

Clinical and laboratory data from 102 children with RF who had been admitted at a university hospital in Tehran between 1992 and 2002 were reviewed retrospectively. In order to categorize the severity of clinical manifestations of disease, patients were divided into three groups. Those with arthritis alone were defined as group A, carditis with or without arthritis as group B and carditis (with or without arthritis) with congestive heart failure as group C.

RESULTS

Thirty-one cases were enrolled in group A, 39 in group B, and 32 in group C. We didn't find a significant relationship between the severity of clinical presentation of disease and ASOT (P = 0.89) and ESR (P = 0.24). Seventy-two patients presented with first attack and 30 had recurrences. The frequency of congestive heart failure (CHF) in first attacks was 31.2%vs 68.8% in recurrences (P < 0.0001). No Significant relationship was found between the number of involved valves and ASOT (P = 0.4) or ESR (P = 0.8).

CONCLUSION

Variable clinical presentation of disease and increasing intensity of cardiac involvement is not related to the ASOT or ESR levels.

Outcomes of mitral valve replacement in children: A competing-risks analysis

OBJECTIVE

We sought to define patient characteristics, outcomes, and associated factors after mitral valve replacement in children.

METHODS

We included 104 children undergoing at least one mitral valve replacement between 1980 and 2003 and reviewed clinical records. Competing-risks methodology was used to determine time-related prevalence and associated risk factors after initial mitral valve replacement for death and repeat replacement.

RESULTS

The underlying mitral valve disease was congenital in 83%, rheumatic in 13%, Marfan syndrome in 3%, and isolated endocarditis in 1%, with 64% having primarily regurgitation, 16% having stenosis, 20% having both, and 32% having undergone previous valvotomy, valvuloplasty, or repair. There were 137 valve replacements, with 26 patients having more than one. Valve prosthesis type was St Jude Medical in 37%, Bjork-Shiley in 25%, Carbomedics in 20%, Ionescu-Shiley in 10%, and other types in 8%. Both early and late complications were common. Median age at the initial replacement was 5.9 years (range, birth to 19 years). Competing-risks analysis predicted 19% to have died at 15 years after initial replacement, with risk factors including noncongenital valve morphology, lower weight, and longer duration of cardiopulmonary bypass. A repeat replacement was predicted for 71%, with risk factors including the presence of multiple left-heart obstructive lesions and Ionescu-Shiley valve prosthesis.

CONCLUSIONS

Mitral valve replacement might be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. However, with the appropriate selection of the prosthetic valve and reduction of cardiopulmonary bypass time, surgeons might decrease mortality and increase prosthesis longevity.

Current Status of Surgery for Rheumatic Carditis in Children

BACKGROUND

The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results.

METHODS

From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation.

RESULTS

Mean age at operation was 13.5 +/- 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 +/- 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II.

CONCLUSIONS

Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.

Rheumatic fever and rheumatic heart disease: clinical profile of 550 cases in India

BACKGROUND

The aims and objectives of this paper were to analyze the clinical presentation of children with rheumatic fever (RF) and rheumatic heart disease (RHD), to determine the cardiac sequel of RF and valvular affection due to RF, and to study clinical manifestations in recurrences of RF.

METHODS

Our study, a retrospective analysis, was conducted at a tertiary-care teaching hospital with specialty follow-up clinic for patients with RF/RHD. This retrospective study was conducted to include a period of 31 years (from January 1971 through December 2001). Pre-completed case protocols of patients with RF/RHD were analyzed to record the following information: demographic data; clinical features on admission/presentation; relevant investigations; recurrences; cardiac valvular affection, and outcome. Modified Jones' criteria were used for diagnosis of RF.

RESULTS

The study included 550 patients. Mean age of presentation was 9.62 years and sex ratio was 1.15:1 favoring males. A total of 250 patients presented with initial/first attack of RF. Arthritis and carditis were seen in 169 (67.6%) and 105 cases (42%), respectively. Chorea was seen in 47 cases (18.8%) and erythema marginatum, in four. A total of 224 patients presented with recurrence of RF (with pre-existing RHD). Arthritis and carditis were seen in 109 (48.66%) and 178 cases (79.46%), respectively, in these patients; 76 cases presented with chronic RHD. Mitral regurgitation was the most common cardiac valvular lesion observed (150 cases) followed by a combination of mitral stenosis and mitral regurgitation (98 cases). Congestive cardiac failure was seen in 201 cases (36.54%) and infective endocarditis in 30 (5.45%). 2-D echocardiography and/or color Doppler was performed in 201 patients (36.54%). Average duration of follow-up was 3.19 years; 74.72% of cases were lost to follow-up. Benzathine penicillin prophylaxis was regular in 42.18% cases. Positive family history of RF/RHD was present in 2% of cases. Twenty three patients (4.18%) died.

CONCLUSIONS

Arthritis was the most common manifestation in the initial attack of RF, while carditis was the most common manifestation in patients presenting with rheumatic recurrences (with pre-existing RHD) and mitral regurgitation was the most common valvular lesion. Rate of patient dropout from penicillin prophylaxis was high. Clinical manifestations in initial/first attack of RF have not significantly changed in the last 31 years.

Sydenham's chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens

BACKGROUND

Sydenham's chorea is still the most frequently seen form of acquired chorea in childhood in developing world despite the use of antibiotics. It is a debilitating illness lasting for weeks or months and requires drug therapy.

OBJECTIVE

To evaluate and compare the efficacies of sodium valproate and carbamazepine in the treatment of the choreiform movements in Sydenham's chorea.

DESIGN

A prospective trial carried out with 24 children with Sydenham's chorea.

PATIENTS

Twenty-four patients were divided into two groups having similar demographic and clinical properties. One group (n = 17) was given carbamazepine (15 mg/kg per day) and the other (n = 7) was given sodium valproate (20-25 mg/kg per day). As soon as the symptoms were taken under control, doses of the drugs were tapered slowly. The duration of the drug use was recorded. The time of response to therapy was compared between the groups and the patients were monitored for the adverse effects.

RESULTS

There was no significant difference between the groups with respect to the time of clinical improvement and time of complete remission, duration of the therapy and the recurrence rates. Clinical improvement began by 8.0 +/- 4.0 days in sodium valproate and 7.4 +/- 8.2 days in carbamazepine group (P = 0.88). In the whole group no adverse effect was seen due to the drugs.

CONCLUSION

Carbamazepine and valproic acid are equally effective and safe drugs in the treatment of choreiform movements in Sydenham chorea.