The treatment of rheumatic carditis: a review and meta-analysis

The Role of Inflammation and Oxidative Stress in Rheumatic Heart Disease

Rheumatic heart disease (RHD), an acquired valvular disease, remains an important cause of morbidity and mortality in developing countries. This chronic illness starts from untreated streptococcal throat infection, resulting in acute rheumatic fever (ARF) in susceptible individuals. Repeated infections lead to a chronic phase characterized by the damage of heart valves. Inflammation has been found to play important role in the development of this disease. All the studies presented in this review clearly show the involvement of the inflammatory state in the progression of this disease. However, the exact role of cytokines in inflammation sites remains to be examined, since most studies have so far focused on peripheral blood. Such analysis would provide information on inflammatory mechanisms in situ.

Acute Fulminant Group A Beta-Hemolytic Streptococcus-Associated Carditis: A Case Report and Literature Review

Group A beta-hemolytic streptococcus (GAS) is a gram-positive bacteria found in the upper respiratory tract that can cause disease with a wide gamut of symptoms ranging from pharyngitis to peritonsillar abscess, pneumonia, meningitis, and acute rheumatic fever (ARF). The primary goal of antibiotic therapy is to prevent complications of the primary infection such as ARF. ARF is defined by the revised Jones criteria. The Jones criteria have been modified to account for the moderate- to high-risk populations. The mechanism of the development of ARF from pharyngitis is not well understood, but the leading theory is molecular mimicry. The host’s own immune system that responds to bacterial virulence factors develops autoantibodies that attack the host tissue. ARF typically develops two to four weeks post pharyngitis. Markers such as antistreptolysin O rise by week 2-3. The rapid streptococcal antigen is often negative by the time ARF develops.

We present a case of a 23-year-old male with no past medical history who presented with a chief complaint of fever and sore throat for one week associated with new-onset chest pain. The patient had a fever with normal blood pressure. Labs showed mild leukocytosis, elevated troponin I, and positive Group A strep polymerase chain reaction (PCR). He was initially treated with aspirin 81 mg, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs) in the emergency room. The patient was subsequently started on prednisone 60 mg as he showed no clinical improvement. His initial echocardiography (ECHO) showed a left ventricular ejection fraction (LVEF) of 55%. Repeat ECHO showed LVEF of 45% with regional wall motion abnormalities (RWMA). His cardiac troponin continued to rise with EKG changes on day 7. With the addition of steroids, the patient’s clinical symptoms, as well as EKG and ECHO findings, improved. The patient was discharged with penicillin benzathine for 12 weeks.

Case reports of acute carditis presenting concomitantly with pharyngitis are limited. The diagnosis of post-streptococcus complications relies on antistreptolysin O titer (ASOT) serology. With the increased availability of more acute diagnostic markers such as PCR, troponin, and ECHO, GAS confirmation can potentially be obtained within one hour and maybe in the future in the diagnosis of early-onset ARF.

The association of plasma high-sensitivity C-reactive protein level with rheumatic heart disease: The possible role of inflammation

Background

Currently, it is not clear whether recurrent traumatic events lead to progression of rheumatic heart disease (RHD) after the incident of acute rheumatic fever or a persistent inflammatory state at the site of the valves. The aim of this study was to assess the possible association between plasma high sensitive C Reactive Protein (hs-CRP) level as an indicator of inflammation and RHD.

Materials & methods

Ninety patients with RHD and 90 healthy controls who had undergone complete echocardiographic examination were enrolled in this cross-sectional study. A score was given to each patient according to the severity of valvular involvement. Plasma hs-CRP level was checked for each patient by ELISA method twice with two-week interval, and the mean hs-CRP was calculated.

Results

The mean plasma hs-CRP level in the case group was significantly higher compared to its level in the control group (2.59 ± 4.82 and 0.55 ± 0.43 in the case and control groups respectively, p < 0.001). There was also a strong association between the level of plasma hs-CRP and the severity of rheumatic valvular involvement (p < 0.001).

Conclusion

The mean plasma hs-CRP level seems to have a significant association with RHD and its severity. Further studies are needed to determine the cause and effect relationship.

Interaction between cyclooxygenase and the renin-angiotensin-aldosterone system: rationale and clinical relevance

Increased understanding of pathophysiological mechanisms of cardiovascular diseases has shown that the renin-angiotensin-aldosterone system (RAAS) is activated in this setting and suggests a central role for the angiotensin-converting enzyme (ACE). ACE transforms angiotensin I (Ang I) to angiotensin II (Ang II), and also promotes the degradation of bradykinin into inactive metabolites. These bradykinins stimulate nitric oxide synthesis and vasodilatator prostaglandin synthesis via a cyclooxygenase (COX) pathway.

COX inhibitors may therefore be deleterious in cardiovascular disease and/or counteract part of ACE inhibitor (ACE-I) efficacy. This has been clearly demonstrated with non-steroidal anti-inflammatory drugs (NSAIDs), including high-dose aspirin, in avoiding their use in such patients. hypertension, coronary artery disease and chronic heart failure (CHF); most guidelines recommend avoiding their use in such patients.

Theoretically, this effect is dose-mediated and the existence of an identical deleterious effect with low-dose aspirin has been an area of intense debate. In this article, we review studies, most of them conducted in CHF, that pointed out such a possible deleterious effect and a counteraction of ACE-Is with low-dose aspirin , using various criteria of assessment.

However, there are no prospective long-term studies that have validated such an effect, and the role of other anti-aggregating agents has not been evaluated. Until such studies are published, the use of low-dose aspirin (100 mg/day) in such patients can be recommended.

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.

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 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.

Acute rheumatic fever and rheumatic heart disease in indigenous populations

Acute rheumatic fever and rheumatic heart disease are diseases of socioeconomic disadvantage. These diseases are common in developing countries and in Indigenous populations in industrialized countries. Clinicians who work with Indigenous populations need to maintain a high index of suspicion for the potential diagnosis of acute rheumatic fever, particularly in patients presenting with joint pain. Inexpensive medicines, such as aspirin, are the mainstay of symptomatic treatment of rheumatic fever; however, antiinflammatory treatment has no effect on the long-term rate of progression or severity of chronic valvular disease. The current focus of global efforts at prevention of rheumatic heart disease is on secondary prevention (regular administration of penicillin to prevent recurrent rheumatic fever), although primary prevention (timely treatment of streptococcal pharyngitis to prevent rheumatic fever) is also important in populations in which it is feasible.

Cutaneous manifestations of cardiovascular diseases

Cardiovascular diseases may affect multiple organ systems including the skin. By identification of specific cutaneous findings, dermatologists may be the first physician to diagnose an underlying cardiovascular disease. This article discusses a number of cardiac disorders with prominent skin findings in addition to general dermatologic signs suggestive of cardiovascular disease.

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.

Long term follow-up results of 139 Turkish children and adolescents with rheumatic heart disease

We aimed to evaluate the predictors of the severity of chronic rheumatic valvar disease. The long term follow-up records of 139 patients with chronic rheumatic carditis were reviewed. Children were followed-up on an outpatient basis for a period ranging from 1-16 years (5.0 +/- 3.7 years). Mitral regurgitation either isolated (51%, n=71) or combined with aortic regurgitation (AR) (49%, n=68) was observed in all cases of the initial attack of rheumatic carditis. AR at initial attack of the rheumatic carditis was found to be affected by gender (AR was more associated with males, p = 0.032), combined mitral and aortic regurgitation (CMAR), and presence of MR at initial attack (p = 0.000 and p = 0.012, respectively) with univariate analysis. The effect of CMAR on AR at initial attack was also significant by multivariate analysis (p = 0.000). CMAR, MR, and AR at initial attack had significant effects on CMAR at final evaluation (p = 0.000, p = 0.020, and p = 0.000, respectively) in univariate analysis. Multivariate analysis revealed the significant effects of CMAR and MR at initial attack on CMAR at final evaluation (p = 0.000 and p = 0.005, respectively). Univariate analysis showed that MR and AR at initial attack, and CMAR at final evaluation, had significant effects on MR at final evaluation (p = 0.000, p = 0.029, and p = 0.000, respectively). MR at initial attack and CMAR at final evaluation had significant effects on MR at final evaluation with multivariate analysis (p = 0.001 and p = 0.003, respectively). AR at final evaluation was affected by CMAR and AR at initial attack (p = 0.000 and p = 0.000, respectively), and CMAR and MR at final evaluation (p = 0.000 and p = 0.000, respectively) with both univariate and multivariate analysis. Mitral valve prolapsus was more common in patients with a longer duration (37.5%, 6 out of 16) than those with a shorter duration (11%, 14 out of 123) and the difference was significant (p = 0.020). In conclusion, the initial severity of valve involvement and the presence of CMAR at initial attack were found to be the best predictors for the severity of chronic rheumatic valvar disease in this study.

Sinomenine suppresses TNF-alpha-induced VCAM-1 expression in human umbilical vein endothelial cells

Sinomenine (SN), an alkaloid prepared from the root of Sinomenium acutum Rehd. Et wils, is used to alleviate the symptoms of rheumatism in Chinese medicine. In the present study, the potential inhibition of TNF-alpha-induced VCAM-1 expression on human umbilical vein endothelial cells (HUVECs) was evaluated in vitro. HUVECs were isolated from freshly collected umbilical cords. Positive controls were stimulated with TNF-alpha, omitting SN. Negative controls were cultured omitting TNF-alpha and SN. Experimental groups were co-cultured with TNF-alpha and SN at different concentrations (0.25, 0.5, and 1.0 mol/L), or TNF-alpha and Dexamethasone (Dex) at a concentration of 1.0 x 10(-6) mol/L. Cells were harvested after culturing with the above drugs for 12 h. VCAM-1 mRNA expression was detected by real-time quantitative PCR, and VCAM-1 expression was detected by flow cytometry. The experimental data indicated that VCAM-1 mRNA and VCAM-1 were induced by TNF-alpha. The relative VCAM-1 mRNA expression decreased in the experimental groups (p<0.05). Concentrations of SN at 0.5 and 1.0 mol/L inhibited expression of VCAM-1 (p<0.05). SN at concentration of 0.25 mol/L and Dex at concentration of 1.0 x 10(-6) mol/L did not show an inhibitory effect on VCAM-1 expression in TNF-alpha-induced HUVECs. Our preliminary data indicates that SN has an inhibitory effect in vitro on TNF-alpha-induced VCAM-1 expression at both mRNA level and protein level in HUVECs, and suggests that SN may be a novel method of immunotherapy for rheumatic carditis or rheumatic heart disease.

Pulmonary and cardiac infections in athletes

Pulmonary and cardiac infections in the athlete can have a wide range of presentations and complications. These infections may present few problems for the training athlete or become life threatening. The team physician must be able to make an accurate diagnosis, give the appropriate treatment, understand the potential complications, and ensure proper follow-up and return-to-play protocols.

Acute rheumatic fever in children: recognition and treatment

Acute rheumatic fever (ARF) is an inflammatory disease of the heart, joints, CNS, and subcutaneous tissue that develops after a pharyngeal infection by one of the group A beta-hemolytic streptococci (Streptococcus pyogenes). The pathogenesis of the disease remains an enigma and specific treatment is not available, yet prevention of initial and recurrent attacks is possible by penicillin treatment. Rheumatic fever is especially important because of the heart disease that usually ensues; as succinctly stated by Lasegue many years ago, rheumatic fever "licks the joints and bites the heart", a statement that holds true today. Rheumatic fever is no longer a significant health problem in most socioeconomically advanced countries but it still causes 25-40% of all cardiovascular disease in the world, including tropical countries where it was once believed to be rare. In many countries it causes more hospital admissions than congenital heart conditions.ARF and rheumatic heart disease - with high associated morbidity, cost, and mortality - are largely preventable. Importantly, recurrences of rheumatic fever with their increased likelihood of more severe carditis are inexpensively preventable. Primary prevention has been achieved innovatively in some countries, for example, Costa Rica, and more conventionally in some developed countries. Treatment of the acute episode controls symptoms and may limit cardiac damage.

Acute rheumatic fever

Acute rheumatic fever (ARF) and its chronic sequela, rheumatic heart disease (RHD), have become rare in most affluent populations, but remain unchecked in developing countries and in some poor, mainly indigenous populations in wealthy countries. More than a century of research, mainly in North America and Europe, has improved our understanding of ARF and RHD. However, whether traditional views need to be updated in view of the epidemiological shift of the past 50 years is still to be established, and improved data from developing countries are needed. Doctors who work in populations with a high incidence of ARF are adapting existing diagnostic guidelines to increase their sensitivity. Group A streptococcal vaccines are still years away from being available and, even if the obstacles of serotype coverage and safety can be overcome, their cost could make them inaccessible to the populations that need them most. New approaches to primary prevention are needed given the limitations of primary prophylaxis as a population-based strategy. The most effective approach for control of ARF and RHD is secondary prophylaxis, which is best delivered as part of a coordinated control programme.

Risks versus Benefits of NSAIDs Including Aspirin in Myocarditis

NSAIDs, including aspirin (acetylsalicylic acid), are frequently used and effective in a broad variety of inflammatory diseases, i.e. rheumatic carditis and pericarditis. Myocarditis may constitute another suitable indication for NSAIDs in order to relieve the symptoms of the presumed viral infection or because pericardial effusion is often associated with this condition. However, concerns have been raised about their indiscriminate use in myocarditis. To clarify this issue, we conducted a systematic review of the literature concerning myocarditis, aspirin and NSAIDs. We examined five animal studies of NSAIDs (indomethacin and ibuprofen) and aspirin in coxsackievirus B3- and B4-induced myocarditis. These studies indicated a deleterious effect of NSAIDs and aspirin in this setting, demonstrating a 2- to 3-fold increase in inflammation, myocytes necrosis and even mortality when compared with placebo. This possible deleterious effect was more predominant when NSAIDs or aspirin were administered during the acute and subacute phases of myocarditis; however, it was still noted when NSAIDs were administered during the late phase of the disease (the effect of aspirin was not evaluated in late phase studies). According to these animal studies, such effect might be attributed to decreased viral clearance (possibly via interferon inhibition) and/or exaggerated cytotoxic response (via interleukin-2 or inhibition of suppressor cells factors) and/or coronary artery spasm. We found one animal study looking at autoimmune myocarditis and it did not demonstrate any beneficial or detrimental effect of aspirin. Moreover, recent data suggest that aspirin and NSAIDs may counteract part of the efficacy of ACE inhibitors and be deleterious in chronic heart failure. Taken together, these studies point to a possible deleterious effect of aspirin and NSAIDs in human myocarditis. In view of these animal studies and in the absence of controlled studies of aspirin or NSAIDs in human myocarditis, we do not recommend indiscriminate treatment with NSAIDs or high-dose aspirin in patients with myocarditis where there is no or minimal associated pericarditis.

Rheumatic Fever and Long-term Sequelae in Children

Rheumatic fever and rheumatic heart disease continue unabated, affecting young individuals in most of the developing nations. Focal outbreaks of smaller magnitude have also been reported since the mid-1980s from industrialized western nations, where this disease had almost disappeared. The introduction of penicillin in the mid-1940s has markedly changed the natural history of rheumatic fever, although the incidence of rheumatic fever declined in developed nations even before that, mainly due to better living conditions. Treatment of rheumatic fever chiefly involves the use of antibiotics (penicillin) and anti-inflammatory drugs, like salicylates or corticosteroids, to eradicate Streptococci. Patients with severe carditis, congestive heart failure, or pericarditis are best treated with corticosteroids because these are more potent anti-inflammatory agents than salicylates. Salicylates may be sufficient for cases with mild or no carditis. The treatment must be continued for 12 weeks. Several studies have shown that valvular regurgitation, and not myocarditis, is the cause of congestive heart failure in active rheumatic carditis. Therefore, surgery with mitral valve replacement or repair is indicated in cases with intractable hemodynamics due to mitral regurgitation. The development of chronic valvular lesion after an episode of rheumatic fever is dependent upon the presence or absence of carditis in the previous attack and compliance with secondary prophylaxis. Recurrences due to inadequate penicillin prophylaxis are responsible for hemodynamically significant chronic valvular lesions requiring surgery. Primary prevention of rheumatic fever is fraught with difficulties and may not be feasible in most of the countries where the disease is rampant. Secondary prevention, ie, preventing recurrence of rheumatic fever, is the appropriate strategy with proven efficacy. A repository form of penicillin, benzathine penicillin G, given as an intramuscular injection at 3 weekly intervals in the dose of 1,200,000 U, remains the treatment of choice for secondary prevention of rheumatic fever. Alternative antibiotics may be used in those allergic to penicillin. An effective and safe vaccine against rheumatic fever is not yet available.

Treatment of rheumatic carditis

Rheumatic fever and rheumatic heart disease continue unabated in most of the developing nations, affecting young individuals. Focal outbreaks of smaller magnitude have also been reported since mid 1980s from industrialized western nations, where this disease had almost disappeared. Introduction of penicillin in mid 1940s had markedly changed the natural history of rheumatic fever, although the incidence of rheumatic fever declined in developed nations before that, due to better living conditions. Treatment of rheumatic fever chiefly involves use of antibiotics (penicillin) to eradicate streptococci, and anti-inflammatory drugs like salicylates or corticosteroids. Patients with severe carditis, congestive heart failure and/or pericarditis are best treated with corticosteroids as these are more potent anti-inflammatory agents than salicylates. Salicylates may be sufficient for cases with mild or no carditis. The treatment must be continued for 12 weeks. Several studies have shown that valvular regurgitation, and not myocarditis, is the cause of congestive heart failure in active rheumatic carditis. Therefore surgery with mitral valve replacement or repair is indicated in cases with intractable hemodynamics due to mitral regurgitation. Development of chronic valvular lesion after an episode of rheumatic fever is dependent upon presence or absence of carditis in the previous attack and compliance with secondary prophylaxis. Recurrences due to inadequate penicillin prophylaxis are responsible for hemodynamically significant chronic valvular lesions requiring surgery.

Rheumatic fever

Rheumatic fever is a multisystem inflammatory disease that occurs as a delayed sequel to group A streptococcal pharyngitis. It is less common than it was 50 years ago but is still a major cause of heart disease in developing areas of the world. The relationship between the site of infection, the type of causative organism, and susceptibility of the host is essential in the development of the disease. Its major clinical manifestations include carditis, migratory polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. It can manifest as an acute febrile illness consisting of migratory polyarthritis involving the large joints, as carditis and valvulitis, or as Sydenham's chorea with involvement of the central nervous system. The disorder in its milder form resolves itself without sequelae. Carditis is the condition most associated with increased mortality and morbidity and may be fatal in its severe forms. Penicillin is the most appropriate primary and secondary prophylaxis. Anti- inflammatory agents provide symptomatic relief but do not prevent rheumatic heart disease.

Rheumatic fever in the 21st century

In the first half of the twentieth century, the group A streptococcus (GAS) was established as the sole etiologic agent of acute rheumatic fever (ARF). In the century's latter half, the clinical importance of variation in the virulence of strains of GAS has become clearer. Although still obscure, the pathogenesis of ARF requires primary infection of the throat by highly virulent GAS strains. These contain very large hyaluronate capsules and M protein molecules. The latter contain epitopes that are cross-reactive with host tissues and also contain superantigenic toxic moieties. In settings where ARF has become rare, GAS pharyngitis continues to be common, although it is caused by GAS strains of relatively lower virulence. These strains, however, colonize the throat avidly and stubbornly. Molecularly distinct pyoderma strains may cause acute glomerulonephritis, but they are not rheumatogenic, even though they may secondarily colonize and infect the throat. Guidelines for the diagnosis, treatment, and prevention of GAS pharyngitis and ARF are reviewed with particular reference to the prevalence of the latter in the community.

Intravenous immunoglobulin in acute rheumatic fever: a randomized controlled trial

BACKGROUND

Acute rheumatic fever (ARF) remains the leading cause of acquired heart disease in children worldwide. No therapeutic agent has been shown to alter the clinical outcome of the acute illness. Immunological mechanisms appear to be involved in the pathogenesis of ARF. Intravenous immunoglobulin (IVIG), a proven immunomodulator, may benefit cardiac conditions of an autoimmune nature. We investigated whether IVIG modified the natural history of ARF by reducing the extent and severity of carditis.

METHODS AND RESULTS

This prospective, double-blind, randomized, placebo-controlled trial evaluated IVIG in patients with a first episode of rheumatic fever, stratifying patients by the presence and severity of carditis before randomization. Patients were randomly allocated to receive 1 g/kg IVIG on days 1 and 2 and 0.4 g/kg on days 14 and 28, or they received a placebo infusion. Clinical, laboratory, and echocardiographic evaluation was performed at 0, 2, 4, 6, 26, and 52 weeks. Fifty-nine patients were treated, of whom 39 had carditis (including 4 subclinical) and/or migratory polyarthritis (n=39). There was no difference between groups in the rate of normalization of the erythrocyte sedimentation rate or acute-phase proteins at the 6-week follow-up. On echocardiography, 59% in the IVIG group and 69% in the placebo group had carditis at baseline. There was no significant difference in the cardiac outcome, including the proportion of valves involved, or in the severity of valvar regurgitation at 1 year. At 1 year, 41% of the IVIG and 50% of the placebo group had carditis.

CONCLUSIONS

IVIG did not alter the natural history of ARF, with no detectable difference in the clinical, laboratory, or echocardiographic parameters of the disease process during the subsequent 12 months.

Rheumatic Fever

There have been numerous reports stating that treatment of acute rheumatic fever with either aspirin or corticosteroids does not alter the long-term outcome of rheumatic heart disease. Yet, it should be emphasized that most of these studies were carried out with the first generic corticosteroids before the advent of the more active and more potent corticosteroid agents. In spite of this caveat, there is no question that all the clinical and laboratory parameters of inflammation (erythrocyte sedimentation rate, C-reactive protein) return to normal much more rapidly with corticosteroids than with aspirin alone. It is therefore our belief that steroids should be used when clinical and laboratory evidence of carditis exists, and aspirin should be reserved for cases of acute rheumatic arthritis with no evidence of carditis. The incidence of long-term valvular disease in active carditis may be decreased with steroid therapy. For example, the number of valve replacements differs markedly in centers that do use steroids and in those that do not. In Capetown, South Africa, where steroids are routinely used for carditis, valve replacement is quite rare. In contrast, in Johannesburg, where steroids are rarely used, the rate of valve replacement is quite high. The racial backgrounds of both groups of patients are similar, thus eliminating the question of racial differences. Concerning secondary prophylaxis, there is also controversy concerning the best second-line therapy. It is now well known that monthly intramuscular injections of benzathine penicillin are really effective for only 20 days. Thus, there is a window in which penicillin coverage is not adequate. To circumvent this problem, some investigators give benzathine penicillin every 3 weeks. These injections are quite painful, however, and it has been our "rule" that compliance with this treatment is inversely proportional to the ratio of the size of the child to the mother. In our own experience over 30 years with the follow-up of more than 300 patients with acute rheumatic fever, careful discussion of the consequences of missing oral doses has been adequate to insure proper compliance. An analysis of our patients on oral penicillin prophylaxis compared with other groups using benzathine penicillin revealed that there was very little difference in recurrence rate.