Review of 609 patients with rheumatic fever in terms of revised and updated Jones criteria

Incidence and clinical characteristics of acute rheumatic fever in Turkey: Results of a nationwide multicentre study

AIM

To evaluate the incidence and clinical features of acute rheumatic fever (ARF) in Turkey, following the revised Jones criteria in 2015.

METHODS

This multicentre study was designed by the Acquired Heart Diseases Working Group of the Turkish Pediatric Cardiology and Pediatric Cardiac Surgery Association in 2016. The data during the first attack of 1103 ARF patients were collected from the paediatric cardiologists between 1 January 2016 and 31 December 2016.

RESULTS

Turkey National Institute of Statistics records of 2016 were used for the determination of ARF incidence with regard to various cities and regions separately. The estimated incidence rate of ARF was 8.84/100 000 in Turkey. The ARF incidence varied considerably among different regions. The highest incidence was found in the Eastern Anatolia Region as 14.4/100 000, and the lowest incidence was found in the Black Sea Region as 3.3/100 000 (P < 0.05). Clinical carditis was the most common finding. The incidence of clinical carditis, subclinical carditis, polyarthritis, aseptic monoarthritis, polyarthralgia and Sydenham's Chorea was 53.5%, 29.1%, 52.8%, 10.3%, 18.6% and 7.9%, respectively. The incidences of clinical carditis, subclinical carditis, polyarthritis and polyarthralgia were found to be significantly different among different regions (P < 0.05).

CONCLUSION

The findings of this nationwide screening of ARF suggest that Turkey should be included in the moderate-risk group.

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.

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.

Rheumatic Fever prevention program: long-term evolution and outcomes

This investigation aims to analyze the profile of long-term evolution of rheumatic fever in children and adolescents and outcomes after the control of recurrences. The cohort involved 702 patients followed from 1.3 to 16.9 years covering the two periods, before and after the implementation of a prevention program. Besides the establishment of the Reference Center in the State of Minas Gerais and the implementation of strategies to promote the compliance to prophylaxis, a project for education of health professionals was carried out in 23 cities. In addition to the clinical and epidemiological profile, the severity of the disease was analyzed. Mixed lesions were found in 27.1%, valvar regurgitation in 72.9%, and complete regression of the valvar lesions was seen in 34.4% of the patients, mostly presenting mild dysfunctions. The recurrence rate per patient-year was 0.058 and out of a total of 85 recurrences, 21.4% occurred in the first and 7.5% in the second period. More severe degrees of carditis and significant valvar sequels presented a higher prevalence in patients with recurrences. The comparative analysis between the two periods showed no changes regarding the age at the primary attack, gender, type, and site of valvar lesions and affected joints; however, important modifications in the indices of severity were observed after the control of recurrences. A significant decrease in the prevalence of severe carditis, obstructive valvar sequels, hospital admissions, surgical approach, and deaths was seen. This investigation showed that although the clinical profile of presentation remains unchanged, the control of repeated attacks can improve the morbimortality rates. In this context, the secondary prophylaxis should be the first priority in the control of the disease in developing countries, taking into account the difficulties found for effective primordial and primary prevention.

Rheumatic silent carditis: echocardiographic diagnosis and prognosis of long-term follow up

BACKGROUND

Rheumatic fever and rheumatic heart disease continue to be an important public health problem in developing countries. Doppler echocardiography is now widely used for early detection and recurrence of clinical evident carditis (CC) and silent (subclinical) carditis (SC). The aim of this study was to determine the frequency of SC and to compare clinical and echocardiographic features of CC and SC.

METHODS

A total of 156 consecutive patients diagnosed with acute rheumatic fever were included in the study. The patients without clinical evidence but with echocardiographic findings of carditis were diagnosed as having SC.

RESULTS

Acute rheumatic fever was diagnosed in 156 patients, and 103 of these (66%) had carditis. The prevalence of SC was 28.2% among these 103 patients. Seventy-four of the patients with carditis were followed up for >1 year, and 20 of those had SC. Valvular regurgitation disappeared completely in 18.5% and improved in 45.5% of the CC patients. The recovery and improvement rates in the SC group were 15% and 30%, respectively.

CONCLUSION

It is suggested that Doppler echocardiography be performed in all patients with suspected acute rheumatic fever for early detection of SC. Echocardiography should be used as a diagnostic criterion in order not to miss a diagnosis of SC.

The heart and pediatric rheumatology

Recent advances in Kawasaki disease have included attempts to define genes involved in its pathogenesis. There have been recent advances in the studies of rheumatic carditis, leading to a better understanding of the mechanism of the disease. Histologic evaluation of patients with neonatal lupus erythematosus has revealed fibrosis with collagen deposition and calcification of the atrioventricular node. Therapy for cardiac involvement in systemic juvenile idiopathic arthritis should involve treatment of the underlying disease and systemic inflammatory state, and typically includes nonsteroidal antiinflammatory drugs, corticosteroids, disease-modifying drugs, and biologic therapies targeting tumor necrosis factor-alpha, interleukin-1, and interleukin-6.

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.

Changes of manifestations of 122 patients with rheumatic fever in South China during last decade

The main objective of this study is to investigate changes of features of rheumatic fever (RF) in recent 10 years. A total of 315 patients with RF during 1985–1995 (group 1) and 1997–2007(group 2) were selected. Their manifestations were compared. Results show that the female/male ratio was 2.0. Group 2 had higher rate of low-grade fever and carditis, and lower rate of heart failure, lower positive rate of C-reactive protein and antistreptolycin o than group 1. In group 2, 61.4% patients fulfilled the updated Jones criteria, however, 76.2% fulfilled 2002–2003 WHO criteria. Diagnosing rheumatic carditis, sensibility and specificity of lymphocyte procoagulant activity (PCA) were 79.1 and 71.4%, respectively, and those of antibody to streptococcal polysaccharide (ASP) were 70.3 and 70%, respectively. Follow-up data of 35 cases were available. Recurrent rate of RF was 62.8%. Only 1/3 cases received regular secondary prevention. In conclusion, mild carditis was increasing. PCA and ASP were valuable tests for diagnosing rheumatic carditis. Atypical cases and secondary prevention need more attention.

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.

Sydenham's chorea: a practical overview of the current literature

Sydenham's chorea is characterized by uncoordinated movements, emotional instability, and hypotonia. It can occur up to several months after group A beta-hemolytic Streptococcus infection. A diagnosis of Sydenham's chorea in a patient with acute chorea involves an application of the Jones criteria and the exclusion of other causes of chorea. In patients with an atypical history or hemichorea, cranial magnetic resonance imaging is indicated to exclude other cerebral pathologies. A pathogenesis has not been elucidated, and therapy has not been investigated in placebo-controlled trials. Antibiotic treatment and a 2-week or 3-week schedule of antibiotic prophylaxis are recommended. If the chorea is severe, valproate or carbamazepine can be effective. In more severely affected patients, dopamine receptor blocking agents or corticosteroids can be used.

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.

[Acute rheumatic fever: 27 year experience from the Montreal's pediatric tertiary care centers]

OBJECTIVES

To examine the epidemiology, clinical characteristics and outcomes in a cohort of children with acute rheumatic fever (RF) over the past 27 years in Montreal.

METHODS

The medical records of patients younger than 18 years of age hospitalized and diagnosed with RF in Montreal between January 1979 and December 2005 were reviewed.

RESULTS

Among the initial 134 charts selected, 36 children were already followed-up for chronic RF and the remaining 98 patients (51 % females) who fulfilled the Jones criteria for acute RF were included in the analysis. The mean age at diagnosis was 10.1 +/- 3.0 years (range: 3-17). Over the 27-year study period, there was a mean incidence of 3.6 patients/year without peaks, but onset occurred in the last 15 years in almost two-thirds of the patients. Forty-nine percent of the patients were Canadian-born non-aboriginal (CbnA) and the remaining patients were Canadian-born aboriginal (CbA) or foreign-born (Fb). Carditis was diagnosed in 73 % of the patients and Sydenham's chorea in 49 %. Of the CbnA children, 39 % had carditis compared with 61 % of children from other ethnic groups (P = 0.003). However, the form of presentation was chorea in 69 % of CbnA children vs. 31 % of children from other ethnic groups (P < 0.001). No deaths were attributable to acute RF although 2 % of the patients relapsed during the study period. Severe cardiac sequelae requiring valve replacements occurred in 6.1 %.

CONCLUSION

The incidence of acute RF in Montreal was low but consistent over the 27-year study period. Clinical presentation varied depending on ethnicity.

Defining the metabolic syndrome construct: Multi-Ethnic Study of Atherosclerosis (MESA) cross-sectional analysis

OBJECTIVE

It is controversial whether the clustering of certain metabolic abnormalities should be separately designated as the metabolic syndrome. We operationalized the "syndrome" concept and tested whether the metabolic syndrome was compatible with these operational constructs.

RESEARCH DESIGN AND METHODS

The baseline cross-section of the Multi-Ethnic Study of Atherosclerosis recruited a population-based cohort of 6,781 individuals, aged 45-84 years, from six communities in the U.S. Metabolic syndrome components (waist circumference, blood pressure, fasting serum HDL cholesterol, triglycerides, and plasma glucose), homeostasis model assessment (HOMA) of insulin resistance (fasting glucose x insulin), and intimal-medial thickness (IMT) in the common and internal carotid arteries by B-mode ultrasound were measured.

RESULTS

Higher syndrome component count is associated with higher HOMA levels (trend P < 0.001). Given the prevalence of individual components, the nonprevalence of any component or the co-prevalence of four or five components is greater than expected (chi2 P < 0.001). After accounting for the additive association of each component, the current definition of metabolic syndrome (co-prevalence of three or more components) does not have supra-additive association with thicker IMT in the common carotid (men: P = 0.075, women: P = 0.949) or internal carotid artery (men: P = 0.106, women: P = 0.121).

CONCLUSIONS

The metabolic syndrome did not have supra-additive association with IMT, but its components clustered greater than chance expectation and a higher component count was associated with greater insulin resistance. The metabolic syndrome was compatible with two of three "syndrome" constructs tested.