The role of echocardiography in diagnosing carditis in the setting of acute rheumatic fever

Association of autoimmune pancreatitis with Raghib syndrome

Key Clinical Message

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis scarcely found in children. Raghib syndrome is a rare congenital heart defect known as persistent left superior vena cava (LSVC) draining into the left atrium. Total signs of Raghib syndrome in AIP case accompanied by an IgG4-related disease were described.

Abstract

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis scarcely found in children. Raghib syndrome is a rare congenital heart defect known as persistent left superior vena cava (LSVC) draining into the left atrium. Here, we describe Raghib syndrome in AIP case accompanied by an IgG4-related disease (AIP/IgG4RD). A 13-year-old boy presented with a 3-month history of fever and abdominal pain. The laboratory findings showed SGOT and SGPT, ALP was increased, while amylase and γ-GT were normal. Immunoglobulins were normal, except for IgG. Endosonography, spiral CT of the abdomen, and cholangiopancreatography showed an enlargement of the pancreas. Contrast echocardiography discovered opacification of the coronary sinus and left atrium. Transesophageal echocardiography for LSVC revealed a dilatation in the coronary sinus, indicating persistent LSVC. Following the injection of agitated saline into the left antecubital vein, bubbles entered both left and right atria in LSVC. It is reasonable to exclude some of these rare disorders as Raghib syndrome, in cases that will be started on medications like corticosteroids, which increases the susceptibility to thromboembolic events.

Post partum dyspnoea: look beyond the lungs

The aetiology of acute-onset dyspnoea in the post partum period is diverse. However, subtle clinical and radiological findings assist in early diagnosis and definitive management, thereby conferring better prognosis and survival. https://bit.ly/361b4qm.

Atypical Articular Presentations in Indian Children With Rheumatic Fever

BACKGROUND

The objective of the study was to describe the clinical characteristics of atypical articular presentations during the initial outbreak and recurrence in patients with acute rheumatic fever (ARF) in the paediatric age group.

METHODS

This was a retrospective, observational study conducted between January 2012 and December 2014 on all suspected cases of acute rheumatic fever (ARF) fulfilling either WHO 2004 or Australian guidelines with atypical articular manifestations ie, presence of at least one of the following features: duration of symptoms more than 3 weeks; monoarthritis/arthralgia; involvement of small joints of hand and feet and/or cervical spine and/or hip joint; and, not responding to salicylates in 1 week.

RESULTS

'Atypical' pattern was present in 63% (39/62) of patients with articular manifestations, of which arthralgia was a common manifestation (57%). Polyarticular afflictions were predominately non-migratory (additive) in both atypical (74%; 29/39) and typical (82%; 18/23) groups. Monoarticular (33%) affliction of the joints constituted a significant disease manifestation. Time from onset to diagnosis was >3 weeks in 79% of patients while small joints involvement and axial joint involvement occurred in half of the cases (51%). Inadequate response to NSAIDs was found in three (7%) cases.

CONCLUSION

Atypical manifestations in ARF may well be mistaken for a connective tissue disorder, post streptococcal reactive arthritis and septic arthritis. Physicians should be made aware of these features to prevent diagnostic dilemma, and to effect institution of appropriate management including penicillin prophylaxis.

Significance of silent carditis and investigation of follow-up signs in acute rheumatic fever

AIM

This study aimed to demonstrate the importance of ECHO in the diagnosis and long-term follow-up of silent carditis.

MATERIAL & METHODS

This study included 182 (157 arthritis; 25 chorea) patients out of 214 patients who had been diagnosed with acute rheumatic fever for the first time. All of the patients were scanned with ECHO between specific intervals.

RESULTS

While there was no recovery observed in isolated aortic insufficiency during long-term follow-up, recovery in isolated mitral insufficiency was found. As the follow-up time of the mitral and aortic insufficiencies became longer, there was an increase in recovery in aortic insufficiency.

CONCLUSION

Follow-up results of silent carditis support that ECHO should be among the major criteria used to diagnose rheumatic carditis.

Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association

BACKGROUND

Acute rheumatic fever remains a serious healthcare concern for the majority of the world's population despite its decline in incidence in Europe and North America. The goal of this statement was to review the historic Jones criteria used to diagnose acute rheumatic fever in the context of the current epidemiology of the disease and to update those criteria to also take into account recent evidence supporting the use of Doppler echocardiography in the diagnosis of carditis as a major manifestation of acute rheumatic fever.

METHODS AND RESULTS

To achieve this goal, the American Heart Association's Council on Cardiovascular Disease in the Young and its Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee organized a writing group to comprehensively review and evaluate the impact of population-specific differences in acute rheumatic fever presentation and changes in presentation that can result from the now worldwide availability of nonsteroidal anti-inflammatory drugs. In addition, a methodological assessment of the numerous published studies that support the use of Doppler echocardiography as a means to diagnose cardiac involvement in acute rheumatic fever, even when overt clinical findings are not apparent, was undertaken to determine the evidence basis for defining subclinical carditis and including it as a major criterion of the Jones criteria. This effort has resulted in the first substantial revision to the Jones criteria by the American Heart Association since 1992 and the first application of the Classification of Recommendations and Levels of Evidence categories developed by the American College of Cardiology/American Heart Association to the Jones criteria.

CONCLUSIONS

This revision of the Jones criteria now brings them into closer alignment with other international guidelines for the diagnosis of acute rheumatic fever by defining high-risk populations, recognizing variability in clinical presentation in these high-risk populations, and including Doppler echocardiography as a tool to diagnose cardiac involvement.

Postpartum Acute Pulmonary Oedema with Sub clinical Rheumatic Heart Disease

Acute dyspnea with pulmonary oedema in postpartum is uncommon but life-threatening event. Contributing factors for pulmonary oedema include, administration of tocolytics, underlying cardiac disease, iatrogenic fluid overload and preeclampsia acounting 0.08% of pregnancies. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration and pulmonary oedema are some of the potentially devastating conditions that should be considered by the attending physician. Here, we report a case of postpartum acute pulmonary oedema referred to causality after an emergency caesarean section in a private hospital. No matter what the underlying pathology, prompt administration and appropriate resuscitation is always the first priority. Only after the patient has been stabilized attention must be turned to diagnosis and specific treatment. A diagnosis of severe Mitral Stenosis, probably of rheumatic origin was made after stabilizing the patient.

Prevalence of rheumatic heart disease in a public school of Belo Horizonte

BACKGROUND

Previous studies indicate that compared with physical examination, Doppler echocardiography identifies a larger number of cases of rheumatic heart disease in apparently healthy individuals.

OBJECTIVES

To determine the prevalence of rheumatic heart disease among students in a public school of Belo Horizonte by clinical evaluation and Doppler echocardiography.

METHODS

This was a cross-sectional study conducted with 267 randomly selected school students aged between 6 and 16 years. students underwent anamnesis and physical examination with the purpose of establishing criteria for the diagnosis of rheumatic fever. They were all subjected to Doppler echocardiography using a portable machine. Those who exhibited nonphysiological mitral regurgitation (MR) and/or aortic regurgitation (AR) were referred to the Doppler echocardiography laboratory of the Hospital das Clínicas of the Universidade Federal of Minas Gerais (HC-UFMG) to undergo a second Doppler echocardiography examination. According to the findings, the cases of rheumatic heart disease were classified as definitive, probable, or possible.

RESULTS

Of the 267 students, 1 (0.37%) had a clinical history compatible with the diagnosis of acute rheumatic fever (ARF) and portable Doppler echocardiography indicated nonphysiological MR and/or AR in 25 (9.4%). Of these, 16 (6%) underwent Doppler echocardiography at HC-UFMG. The results showed definitive rheumatic heart disease in 1 student, probable rheumatic heart disease in 3 students, and possible rheumatic heart disease in 1 student.

CONCLUSION

In the population under study, the prevalence of cases compatible with rheumatic involvement was 5 times higher on Doppler echocardiography (18.7/1000; 95% CI 6.9/1000-41.0/1000) than on clinical evaluation (3.7/1000-95% CI).

The pattern of acute rheumatic fever in children: Experience at the children's hospital, Riyadh, Saudi Arabia

BACKGROUND

The study was carried out in Riyadh City Hospital to determine the hospital prevalence of acute rheumatic fever (ARF), its characteristics and to determine the proportion of the ARF population that have recurrent attacks.

METHODS

The study was an analysis of 83 children with ARF, admitted to the Children's Hospital, Riyadh, over a 10-year period (1994-2003). The diagnosis of ARF was based on clinical features as defined in the modified Jones criteria with evidence of recent streptococcal infection. The diagnosis of recurrence of rheumatic fever in children with rheumatic heart disease was based on the presence of one major criterion apart from carditis or two minor criteria, in addition to evidence of preceding streptococcal infection.

RESULTS

The mean age at presentation was 9 years. In 31 (37%) cases, arthritis was the only major Jones criterion. In 30 (36%) others, arthritis was associated with carditis and in 3 (4%), with chorea. Cardiac involvement was documented in 44 (53%) cases; it occurred alone in 5 (6%), with arthritis in 30 (36%), and with chorea in 9 (11%) others. Among the 44 with carditis, the pattern of cardiac involvement was valvular only (mild carditis) in 30 (68%), while it was severe in the remaining 14 (32%) cases who also had heart failure. The involvement of the mitral valve alone occurred in 26 (59%) cases in the form mitral regurgitation, while both aortic and mitral valve regurgitation were present in 11 (25%) cases, and aortic valve regurgitation alone in four (9%) others. Chorea was the only major criterion of ARF in 5 children (6%), while it occurred in association with other major criteria in 12 (15%) others. Nineteen (23%) children had recurrent attacks of ARF.

CONCLUSION

ARF continues to occur in Saudi Arabia in the period (1994-2003), despite the progress made in the socio-economic development of the country, and this is often associated with severe cardiac involvement.

The logic for extending the use of echocardiography beyond childhood to detect subclinical rheumatic heart disease

Rheumatic heart disease is the only residual morbidity, and the sole cause of mortality, from rheumatic fever. Echocardiography is ideally suited to confirm and follow the course of rheumatic heart disease. Additionally, both minimal valvar pathology in children, and extensive valvar pathology in adults, may not cause a murmur and can be detected only by echocardiography. Whenever possible, echocardiography should be routinely employed for management of patients with rheumatic fever or suspected rheumatic fever.

The efficacy of echocardiographic criterions for the diagnosis of carditis in acute rheumatic fever

BACKGROUND

There is a great need for echocardiographic criterions for accurate diagnosis of carditis in acute rheumatic fever.

AIM

To test the efficacy of proposed echocardiographic criterions for the diagnosis of carditis.

MATERIALS AND METHODS

We studied 333 patients suspected of having acute rheumatic fever, undertaking detailed clinical examination, laboratory tests and meticulous echocardiography in each case. We used previously established echocardiographic criterions for the diagnosis of carditis and subclinical valvitis. In 220 cases (66.06%), both the echo criterions, and the Jones' criterions, gave positive results. In 52 cases (15.61%), we found evidence of subclinical carditis, in that clinically no murmur was heard, meaning the Jones' criterions were negative, but the echocardiographic evaluation was positive. In 4 patients clinically diagnosed as having carditis, the Jones' criterions were positive, but echocardiographic evaluation showed them to have congenitally malformed hearts. In another 57 cases (17.11%), the Jones' criterions were negative, as were the results of echocardiographic evaluation. These patients were taken as control subjects. On this basis, the echocardiographic criterions had sensitivity of 81% and specificity of 93%.

CONCLUSION

Using our echocardiographic criterions, it is possible to make a precise diagnosis of carditis or subclinical valvitis. Hence, echocardiography should, in future, be included as a major criterion in the Jones' system.

[Relapsing annular erythema following streptococcal throat infection in an adult patient: Adult erythema marginatum associated with rheumatic fever]

BACKGROUND

Erythema marginatum is one of the main Jones diagnostic criteria for rheumatic fever. However, since it rarely occurs in industrialized countries, this diagnosis is seldom suspected, especially in adult patients.

CASE REPORT

We report a case of an annular facial eruption associated with fever and polyarthralgia seen twice in a 30-year-old woman following episodes of streptococcal throat infection.

DISCUSSION

This case report underlines the fact that the rheumatic fever has not completely disappeared in the highly developed countries. Dermatologists should be careful not to overlook its clinical manifestations and should be vigilant about potential cardiac complications.

Subclinical valvulitis in children with acute rheumatic Fever

Doppler echocardiography facility is now available in most parts of the world and its routine use for the initial diagnosis of acute rheumatic fever (ARF) might enhance its early detection and, hence, prevention of rheumatic recurrences. To add to the existing evidence and to reemphasize the need of including echocardiography as a diagnostic criterion for ARF, we investigated the pattern and prevalence of subclinical valvulitis by Doppler echocardiography in patients with ARF manifesting as either pure chorea or isolated arthritis but without clinical signs of carditis. This prospective study was carried out in a single center over a period of 6 months (June to December 2006). Thirty patients with ARF, 16 males and 14 females, aged 4-15 years (mean: 10 +/- 3.2) presenting with either chorea or isolated arthritis were included by convenience sampling. Evidence of carditis as detected by echocardiography was present in 21 patients (70%). Chorea was the presenting feature in 19 patients (63%), followed by migratory polyarthritis in 11 (37%). Among patients with chorea, 13 (68%) had evidence of carditis. Mitral regurgitation (MR) was present in all 13, being isolated in 11 and with aortic regurgitation (AR) in 2 patients. In patients with migratory polyarthritis, 8 (73%) had evidence of carditis, all with isolated MR. Echocardiography detected subclinical valvulitis in at least 70% of patients with ARF presenting with either rheumatic chorea or migratory arthritis but no clinical evidence of carditis. MR was the predominant lesion present in all patients either in isolation (90%) or in combination with AR (10%). We suggest that Doppler echocardiography be performed in all patients with suspected ARF and evidence of subclinical valvulitis be used as a diagnostic criterion.