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Kumar M, Little J, Pearce S, MacDonald B, Greenland M, Tarca A, Ramsay J, Katzenellenbogen J, Yim D. Clinical profile of paediatric acute rheumatic fever and rheumatic heart disease in Western Australia: 1987 to 2020. J Paediatr Child Health 2024; 60:375-383. [PMID: 39051449 DOI: 10.1111/jpc.16617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/03/2024] [Accepted: 07/06/2024] [Indexed: 07/27/2024]
Abstract
AIM To describe the clinical profile of acute rheumatic fever (ARF) presentations to paediatric cardiology tertiary services in Western Australia (WA). METHODS A retrospective clinical audit of individuals with confirmed ARF referred to the only paediatric tertiary cardiac service in WA (1 January 1987 to 31 December 2020). Comparisons between inpatient, outpatient, remote and non-remote groups were assessed. RESULTS Four hundred seventy-one episodes of ARF in 457 individuals (235 male; median age = 8 years) met clinical criteria. The majority were Aboriginal and Torres Strait Islander children (91.2%), with 62.1% living in remote areas. The number of ARF and rheumatic heart disease (RHD) diagnoses per year increased from 1987 to 2017 with notable peaks in 2013 and 2017. The average annual incidence of tertiary-referred ARF in WA of 4-15-year-olds from 1987 to 2020 was 4.96 per 100 000. ARF features included carditis (59.9%), chorea (31%), polyarthritis (30%) and polyarthralgia (24.2%). RHD was evident in 61.8% of cases and predominantly manifested as mitral regurgitation (55.7%). Thirty-four children (7.4%) with severe RHD underwent valvular surgery. 12% had at least one recurrent ARF episode. Remote individuals had more than double the rate of recurrence compared to non-remote individuals (P = 0.0058). Compared to non-remote episodes, remote presentations had less polyarthritis (P = 0.0022) but greater proportions of raised ESR (P = 0.01), ASOT titres (P = 0.0073), erythema marginatum (P = 0.0218) and severe RHD (P = 0.0133). CONCLUSION The high proportion of Aboriginal and Torres Strait Islander Australians affected by ARF/RHD in WA reflects the significant burden of disease within this population. Children from remote communities were more likely to present with concurrent severe RHD. Our study reinforces the persisting need to improve primary and secondary ARF initiatives in rural and remote communities.
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Affiliation(s)
- Mohit Kumar
- The University of Western Australia, Perth, Western Australia, Australia
| | - James Little
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Sarah Pearce
- The University of Western Australia, Perth, Western Australia, Australia
| | - Bradley MacDonald
- The University of Western Australia, Perth, Western Australia, Australia
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Adrian Tarca
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - James Ramsay
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Judith Katzenellenbogen
- The University of Western Australia, Perth, Western Australia, Australia
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Deane Yim
- The University of Western Australia, Perth, Western Australia, Australia
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
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Mullane MJ, Thomas HM, Carapetis JR, Lizama C, Billingham W, Cooper MN, Everest C, Sampson CR, Newall N, Pearce S, Lannigan F, McNulty E, Cresp R, Mace AO, Barrow T, Bowen AC. Tonsils at Telethon: developing a standardised collection of tonsil photographs for group A streptococcal (GAS) research. Front Pediatr 2024; 12:1367060. [PMID: 38725980 PMCID: PMC11079290 DOI: 10.3389/fped.2024.1367060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Group A streptococcus (GAS) infections, such as pharyngitis and impetigo, can lead to rheumatic fever and rheumatic heart disease (RHD). Australian Aboriginal and Torres Strait Islander populations experience high rates of RHD and GAS skin infection, yet rates of GAS pharyngitis are unclear. Anecdotally, clinical presentations of pharyngitis, including tonsillar hypertrophy and sore throat, are uncommon. This study aimed to develop a standardised set of tonsil photographs and determine tonsil size distribution from an urban paediatric population. Methods A prospective cohort of children aged 3-15 years were recruited at the public events "Discover Day" and "Telethon Weekend" (October 2017) in Perth, Western Australia, Australia. Tonsil photographs, symptomatology, and GAS rapid antigen detection tests (RADT) were collected. Tonsil size was graded from the photographs using the Brodsky Grading Scale of tonsillar hypertrophy (Brodsky) by two independent clinicians, and inter-rater reliability calculated. Pharyngitis symptoms and GAS RADT were correlated, and immediate results provided. Results Four hundred and twenty-six healthy children participated in the study over three days. The median age was seven years [interquartile range (IQR) 5.9-9.7 years]. Tonsil photographs were collected for 92% of participants, of which 62% were rated as good-quality photographs and 79% were deemed of adequate quality for assessment by both clinicians. When scored by two independent clinicians, 57% received the same grade. Average Brodsky grades (between clinicians) were 11%, 35%, 28%, 22% and 5% of grades 0,1,2,3 and 4, respectively. There was moderate agreement in grading using photographs, and minimal to weak agreement for signs of infection. Of 394 participants, 8% reported a sore throat. Of 334 GAS RADT performed, <1% were positive. Discussion We report the first standardised use of paediatric tonsil photographs to assess tonsil size in urban-living Australian children. This provides a proof of concept from an urban-living cohort that could be compared with children in other settings with high risk of GAS pharyngitis or rheumatic fever such as remote-living Australian Indigenous populations.
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Affiliation(s)
- Marianne J. Mullane
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Hannah M. Thomas
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Jonathan R. Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Catalina Lizama
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Wesley Billingham
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Matthew N. Cooper
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Christine Everest
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Claudia R. Sampson
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Nelly Newall
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Sarah Pearce
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Francis Lannigan
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Eamonn McNulty
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Rebecca Cresp
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Ariel O. Mace
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
| | - Tina Barrow
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Asha C. Bowen
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, WA, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
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Pickering J, Sampson C, Mullane M, Sheel M, Barth DD, Lane M, Walker R, Atkinson D, Carapetis JR, Bowen AC. A pilot study to develop assessment tools for Group A Streptococcus surveillance studies. PeerJ 2023; 11:e14945. [PMID: 36935916 PMCID: PMC10022509 DOI: 10.7717/peerj.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/02/2023] [Indexed: 03/15/2023] Open
Abstract
Introduction Group A Streptococcus (GAS) causes pharyngitis (sore throat) and impetigo (skin sores) GAS pharyngitis triggers rheumatic fever (RF) with epidemiological evidence supporting that GAS impetigo may also trigger RF in Australian Aboriginal children. Understanding the concurrent burden of these superficial GAS infections is critical to RF prevention. This pilot study aimed to trial tools for concurrent surveillance of sore throats and skins sore for contemporary studies of RF pathogenesis including development of a sore throat checklist for Aboriginal families and pharynx photography. Methods Yarning circle conversations and semi-structured interviews were performed with Aboriginal caregivers and used to develop the language and composition of a sore throat checklist. The sore throat story checklist was combined with established methods of GAS pharyngitis and impetigo surveillance (examination, bacteriological culture, rapid antigen detection and serological tests) and new technologies (photography) and used for a pilot cross-sectional surveillance study of Aboriginal children attending their health clinic for a routine appointment. Feasibility, acceptability, and study costs were compiled. Results Ten Aboriginal caregivers participated in the sore-throat yarning circles; a checklist was derived from predominant symptoms and their common descriptors. Over two days, 21 Aboriginal children were approached for the pilot surveillance study, of whom 17 were recruited; median age was 9 years [IQR 5.5-13.5], 65% were female. One child declined throat swabbing and three declined finger pricks; all other surveillance elements were completed by each child indicating high acceptability of surveillance assessments. Mean time for screening assessment was 19 minutes per child. Transport of clinical specimens enabled gold standard microbiological and serological testing for GAS. Retrospective examination of sore throat photography concorded with assessments performed on the day. Conclusion Yarning circle conversations were effective in deriving culturally appropriate sore throat questionnaires for GAS pharyngitis surveillance. New and established tools were feasible, practical and acceptable to participants and enable surveillance to determine the burden of superficial GAS infections in communities at high risk of RF. Surveillance of GAS pharyngitis and impetgio in remote Australia informs primary RF prevention with potential global translation.
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Affiliation(s)
- Janessa Pickering
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
| | - Claudia Sampson
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
| | - Marianne Mullane
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
| | - Meru Sheel
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Acton, ACT, Canberra, Australia
| | - Dylan D. Barth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Perth, Western Australia
| | - Mary Lane
- Broome Regional Aboriginal Medical Service, Broome, Australia
| | - Roz Walker
- School of Population and Global Health, University of Western Australia, Perth, Australia
- Ngank Yira Institute for Change, Murdoch University, Perth, Australia
| | - David Atkinson
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
| | - Jonathan R. Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Nedlands, Perth, Australia
| | - Asha C. Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia., Perth, Australia
- School of Medicine, University of Western Australia, Crawley, Perth, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Nedlands, Perth, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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Salinas Salvador B, Moreno Sánchez A, Carmen Marcén G, Molina Herranz D, Arana Navarro T, García Vera C. Retrospective study on the effectiveness and safety of the shortened 5- to 7-day antibiotic regimen for acute streptococcal pharyngotonsillitis compared to the classic 10-day regimen. An Pediatr (Barc) 2022; 97:398-404. [PMID: 36302708 DOI: 10.1016/j.anpede.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/03/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Antibiotherapy regimens for management of acute streptococcal pharyngitis traditionally last 10 days, but the development of resistance to different antimicrobials has motivated the exploration of shorter courses. MATERIAL AND METHODS We selected patients given a diagnosis of streptococcal pharyngitis in 2 paediatric caseloads of 1 primary care centre between June 2016 and April 2020. We compared outcomes in patients treated with 8- to 10-day courses versus 5- to 7-day courses. RESULTS The analysis included 350 care episodes (252 patients). Sixty-four percent were managed with 8- to 10-day courses of antibiotherapy (group 1) and 36% with 5- to 7-day courses (group 2). There were no significant differences in the incidence of streptococcal pharyngitis or scarlet fever in the 3 months that followed (OR, 0.98; 95% confidence interval [CI], 0.46-2.03), with similar percentages in both groups (9.8% vs 9.5%). Overall, without differentiating based on the type of infection (streptococcal pharyngitis, scarlet fever or other streptococcal infections), we found similar outcomes (OR, 0.81; 95% CI, 0.41-1.59): 13.4% in group 1 and 11.1% in group 2. We also found no differences in the frequency of adverse events documented in the health records (OR, 0.29; 95% CI, 0.04-2.44): 2.7% in group 1 and 0.8% in group 2. CONCLUSIONS In our experience, a shorter antibiotic course (5-7 days) is not less effective or more unsafe for management of acute streptococcal pharyngitis than the traditional 10-day course.
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Affiliation(s)
| | | | - Gema Carmen Marcén
- Servicio de Pediatría, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Salinas Salvador B, Moreno Sánchez A, Carmen Marcén G, Molina Herranz D, Arana Navarro T, García Vera C. Estudio retrospectivo sobre la efectividad y seguridad de la pauta antibiótica reducida a 5-7 días en la faringoamigdalitis aguda estreptocócica comparada con la pauta clásica de 10 días. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Illán Ramos M, Sagastizabal Cardelús B, García Ron A, Guillén Martín S, Berzosa Sánchez A, Ramos Amador JT. Chorea as the presenting feature of acute rheumatic fever in childhood; case reports from a low-prevalence European setting. BMC Infect Dis 2021; 21:322. [PMID: 33827439 PMCID: PMC8025313 DOI: 10.1186/s12879-021-06005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 03/22/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite a notable decrease in acute rheumatic fever (ARF) incidence in the past few decades, there are still cases in our setting. Sydenham chorea (SC) may be the initial manifestation for this condition in childhood in a significant proportion of children. We report two cases of choreoathetosis in children as the first manifestation of ARF. CASE PRESENTATION A previously healthy 8-year-old boy presented with right hemichorea with a predominance in the brachial region, orofacial dyskinesias and speech difficulties for the past 2 weeks. The only medical history of interest was a common catarrhal illness 3 weeks before and nonspecific bilateral tenosynovitis in both feet since a year prior. A brain computerized tomography was normal and the echocardiogram showed mild mitral and aortic regurgitation, meeting ARF criteria. He demonstrated clinical improvement with treatment based on prednisone and carbamazepine. The second patient was a 10-year-old girl with choreic movements of the right half of the body and repetitive right eye closure of 1 week duration. She had symptoms of fever and rash the previous week and pharyngitis that resolved without antibiotic 2 months before. Blood tests revealed elevated C reactive protein (12 mg/dl) and erythrocyte sedimentation rate (96 mm/h). Brain magnetic resonance was normal and echocardiogram showed left ventricle dilation and mild mitral regurgitation, leading to the diagnosis of ARF. Due to neurological involvement, she received corticosteroids and intravenous immunoglobulin treatment, with worsening of neurological symptoms that required valproic acid with remission of the hemichorea. In addition skin lessions compatible with erythema marginatum appeared on the upper limbs. CONCLUSIONS SC should be the main diagnostic consideration in cases of hemichorea with normal neuroimaging in children. The cases reported highlight the need to maintain a high index of suspicion even in settings where incidende of ARF is low and the need to perform cardiological investigations in all patients with suspected SC, due to the possibility of subclinical valve lesions. Good adherence to secondary prophylaxis is crucial to avoid chorea relapses and worsening valve disease.
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Affiliation(s)
- Marta Illán Ramos
- Department of Paediatrics, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | | | - Adrián García Ron
- Department of Paediatrics, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sara Guillén Martín
- Department of Paediatrics, Hospital Universitario de Getafe, Getafe, Madrid, Spain
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Barth DD, Daw J, Xu R, Enkel S, Pickering J, McRae T, Engel ME, Carapetis J, Wyber R, Bowen AC. Modes of transmission and attack rates of group A Streptococcal infection: a protocol for a systematic review and meta-analysis. Syst Rev 2021; 10:90. [PMID: 33789732 PMCID: PMC8011413 DOI: 10.1186/s13643-021-01641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/19/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Group A Streptococcus (Strep A) is an important cause of mortality and morbidity globally. This bacterium is responsible for a range of different infections and post-infectious sequelae. Summarising the current knowledge of Strep A transmission to humans will address gaps in the evidence and inform prevention and control strategies. The objective of this study is to evaluate the modes of transmission and attack rates of group A streptococcal infection in human populations. METHODS This systematic review protocol was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-analysis Protocols (PRISMA-P) 2015 Statement. Using a comprehensive search strategy to identify any transmission studies that have been published in English since 1980, full-text articles will be identified and considered for inclusion against predefined criteria. We will include all studies reporting on Strep A transmission, who have identified a mode of transmission, and who reported attack rates. Risk of bias will be appraised using an appropriate tool. Our results will be described narratively and where feasible and appropriate, a meta-analysis utilizing the random-effects model will be used to aggregate the incidence proportions (attack rates) for each mode of transmission. In addition, we will also evaluate the emm genotype variants of the M protein causing Strep A infection and the association with transmission routes and attack rates, if any, by setting, socioeconomic background and geographical regions. DISCUSSION We anticipate that this review will contribute to elucidating Strep A modes of transmission which in turn, will serve to inform evidence-based strategies including environmental health activities to reduce the transmission of Strep A in populations at risk of severe disease. TRIAL REGISTRATION Systematic review registration: PROSPERO ( CRD42019138472 ).
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Affiliation(s)
- Dylan D. Barth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
| | - Jessica Daw
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
| | - Ruomei Xu
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
| | - Stephanie Enkel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
| | - Janessa Pickering
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
| | - Tracy McRae
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
| | - Mark E. Engel
- AFROStrep Registry, Department of Medicine, The University of Cape Town, Cape Town, South Africa
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia
| | - Rosemary Wyber
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
- The George Institute for Global Health, Sydney, New South Wales Australia
| | - Asha C. Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia Australia
- The University of Western Australia, Perth, Western Australia Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia
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Acute rheumatic fever in south-east of Turkey: clinical features and epidemiological evaluation of the patients over the last 25 years. Cardiol Young 2020; 30:1086-1094. [PMID: 32611460 DOI: 10.1017/s1047951120001596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Acute Rheumatic Fever: A Disease of the Past? Case Rep Infect Dis 2020; 2020:1470697. [PMID: 32089911 PMCID: PMC7031718 DOI: 10.1155/2020/1470697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction. Acute rheumatic fever (ARF) is a manifestation of the nonsuppurative sequelae of Streptococcus pyogenes infection. Herein, two cases of ARF are presented to highlight that this disease is present in urban cities, can be diagnosed in otherwise healthy children, and that its diagnosis may be challenging, or marred with confounders, leading to delays in diagnosis. Case Report. Two unrelated children, age 7 and 9, presented to an urban hospital in Canada with unique manifestations of ARF. Diagnosis of ARF in the first patient was interrupted by a course of steroids which masked symptoms leading to therapeutic delays. The second patient presented with facial droop and symptoms thought to be viral, thus leading to misdiagnosis as Bell's palsy. Discussion/Conclusion. ARF is more common in underserviced and marginalized populations, which may lead clinicians in urban centers to overlook signs or symptoms suggestive of ARF because they no longer see this condition routinely, or they believe it is a disease of the past.
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Katzenellenbogen JM, Bond-Smith D, Seth RJ, Dempsey K, Cannon J, Nedkoff L, Sanfilippo FM, de Klerk N, Hung J, Geelhoed E, Williamson D, Wyber R, Ralph AP, Bessarab D. The End Rheumatic Heart Disease in Australia Study of Epidemiology (ERASE) Project: data sources, case ascertainment and cohort profile. Clin Epidemiol 2019; 11:997-1010. [PMID: 31814772 PMCID: PMC6863132 DOI: 10.2147/clep.s224621] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/25/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support policy recommendations for eliminating RHD, but available data are fragmented and incomplete. The End RHD in Australia: Study of Epidemiology (ERASE) Project aims to provide a comprehensive database of ARF and RHD cases in Australia as a basis for improved monitoring and to assess prevention and treatment strategies. The objective of this paper is to describe the process for case ascertainment and profile of the study cohort. PATIENTS AND METHODS The ERASE database has been built using linked administrative data from RHD registers, inpatient hospitalizations, and death registry data from 2001 to 2017 (mid-year). Additional linked datasets are available. The longitudinal nature of the data is harnessed to estimate onset and assess the progression of the disease. To accommodate systematic limitations in diagnostic coding for RHD, hospital-only identified RHD has been determined using a purposefully developed prediction model. RESULTS Of 132,053 patients for whom data were received, 42,064 are considered true cases of ARF or RHD in the study period. The patient population under 60 years in the compiled dataset is more than double the number of patients identified in ARF/RHD registers (12,907 versus 5049). Non-registered patients were more likely to be older, non-Indigenous, and at a later disease stage. CONCLUSION The ERASE Project has created an unprecedented linked administrative database on ARF and RHD in Australia. These data provide a critical baseline for efforts to end ARF/RHD in Australia. The methodological work conducted to compile this database resulted in significant improvements in the robustness of epidemiological estimates and entails valuable lessons for ARF/RHD research globally.
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Affiliation(s)
- Judith M Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
- Group A Streptococcus Research Group, Telethon Kids Institute, Perth, WA, Australia
| | - Daniela Bond-Smith
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Rebecca J Seth
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Karen Dempsey
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Jeffrey Cannon
- Group A Streptococcus Research Group, Telethon Kids Institute, Perth, WA, Australia
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Nicholas de Klerk
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
- Group A Streptococcus Research Group, Telethon Kids Institute, Perth, WA, Australia
| | - Joe Hung
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Elizabeth Geelhoed
- School of Allied Health, The University of Western Australia, Perth, WA, Australia
| | - Daniel Williamson
- Aboriginal and Torres Strait Islander Health Branch, Queensland Health, Brisbane, QLD, Australia
| | - Rosemary Wyber
- Group A Streptococcus Research Group, Telethon Kids Institute, Perth, WA, Australia
- Office of the Chief Scientist, The George Institute for Global Health, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Dawn Bessarab
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - On behalf of the ERASE Collaboration Study Group
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
- Group A Streptococcus Research Group, Telethon Kids Institute, Perth, WA, Australia
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- School of Allied Health, The University of Western Australia, Perth, WA, Australia
- Aboriginal and Torres Strait Islander Health Branch, Queensland Health, Brisbane, QLD, Australia
- Office of the Chief Scientist, The George Institute for Global Health, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
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11
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Group A Streptococcus T Antigens Have a Highly Conserved Structure Concealed under a Heterogeneous Surface That Has Implications for Vaccine Design. Infect Immun 2019; 87:IAI.00205-19. [PMID: 30936156 DOI: 10.1128/iai.00205-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/25/2019] [Indexed: 12/20/2022] Open
Abstract
Group A Streptococcus (GAS) (Streptococcus pyogenes) is an important human pathogen associated with significant global morbidity and mortality for which there is no safe and efficacious vaccine. The T antigen, a protein that polymerizes to form the backbone of the GAS pilus structure, is a potential vaccine candidate. Previous surveys of the tee gene, which encodes the T antigen, have identified 21 different tee types and subtypes such that any T antigen-based vaccine must be multivalent and carefully designed to provide broad strain coverage. In this study, the crystal structures of three two-domain T antigens (T3.2, T13, and T18.1) were determined and found to have remarkable structural similarity to the previously reported T1 antigen, despite moderate overall sequence similarity. This has enabled reliable modeling of all major two-domain T antigens to reveal that T antigen sequence variation is distributed along the full length of the protein and shields a highly conserved core. Immunoassays performed with sera from immunized animals and commercial T-typing sera identified a significant cross-reactive antibody response between T18.1, T18.2, T3.2, and T13. The existence of shared epitopes between T antigens, combined with the remarkably conserved structure and high level of surface sequence divergence, has important implications for the design of multivalent T antigen-based vaccines.
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12
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Affiliation(s)
| | - Robert M Hand
- Telethon Kids InstituteUniversity of Western Australia Perth WA
| | - Rosemary Wyber
- Telethon Kids InstituteUniversity of Western Australia Perth WA
- George Institute for Global Health Sydney NSW
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13
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Jack S, Moreland NJ, Meagher J, Fittock M, Galloway Y, Ralph AP. Streptococcal Serology in Acute Rheumatic Fever Patients: Findings From 2 High-income, High-burden Settings. Pediatr Infect Dis J 2019; 38:e1-e6. [PMID: 30256313 DOI: 10.1097/inf.0000000000002190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Globally, there is wide variation in streptococcal titer upper limits of normal (ULN) for antistreptolysin O (ASO) and anti-deoxyribonuclease B (ADB) used as an evidence of recent group A streptococcal infection to diagnose acute rheumatic fever (ARF). METHODS We audited ASO and ADB titers among individuals with ARF in New Zealand (NZ) and in Australia's Northern Territory. We summarized streptococcal titers by different ARF clinical manifestations, assessed application of locally recommended serology guidelines where NZ uses high ULN cut-offs and calculated the proportion of cases fulfilling alternative serologic diagnostic criteria. RESULTS From January 2013 to December 2015, group A streptococcal serology results were available for 350 patients diagnosed with ARF in NZ and 182 patients in Northern Territory. Median peak streptococcal titers were similar in both settings. Among NZ cases, 267/350 (76.3%) met NZ serologic diagnostic criteria, whereas 329/350 (94.0%) met Australian criteria. By applying Australian ULN titer cut-off criteria to NZ cases, excluding chorea, ARF definite cases would increase by 17.6% representing 47 cases. CONCLUSIONS ASO and ADB values were similar in these settings. Use of high ULN cut-offs potentially undercounts definite and probable ARF diagnoses. We recommend NZ and other high-burden settings to use globally accepted, age-specific, lower serologic cut-offs to avoid misclassification of ARF.
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Affiliation(s)
- Susan Jack
- From the Centre for International Health, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.,Institute of Environmental Science and Research, Wellington, New Zealand
| | - Nicole J Moreland
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | | | - Marea Fittock
- Northern Territory Rheumatic Heart Disease Control Program
| | - Yvonne Galloway
- Institute of Environmental Science and Research, Wellington, New Zealand
| | - Anna P Ralph
- Royal Darwin Hospital.,Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
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14
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Abstract
The Jones criteria of 2 major criteria or 1 major plus 2 minor criteria that have been classically used to establish the diagnosis have been significantly modified in 2015 by the American Heart Association. The criteria now include the utilization of echocardiography and Doppler color flow mapping as diagnostic tools for carditis, along with defining criteria in relation to overall population risk, delineating low- versus moderate-high risk populations. Monoarthritis and polyarthralgia are now major criteria for moderate- to high-risk groups.
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15
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Oliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG. Group A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006335. [PMID: 29554121 PMCID: PMC5875889 DOI: 10.1371/journal.pntd.0006335] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/29/2018] [Accepted: 02/21/2018] [Indexed: 01/22/2023] Open
Abstract
Objective Antibiotic treatment of Group A Streptococcus (GAS) pharyngitis is important in acute rheumatic fever (ARF) prevention, however clinical guidelines for prescription vary. GAS carriers with acute viral infections may receive antibiotics unnecessarily. This review assessed the prevalence of GAS pharyngitis and carriage in different settings. Methods A random-effects meta-analysis was performed. Prevalence estimates for GAS+ve pharyngitis, serologically-confirmed GAS pharyngitis and asymptomatic pharyngeal carriage were generated. Findings were stratified by age group, recruitment method and country income level. Medline and EMBASE databases were searched for relevant literature published between 1 January 1946 and 7 April 2017. Studies reporting prevalence data on GAS+ve or serologically-confirmed GAS pharyngitis that stated participants exhibited symptoms of pharyngitis or upper respiratory tract infection (URTI) were included. Included studies reporting the prevalence of asymptomatic GAS carriage needed to state participants were asymptomatic. Results 285 eligible studies were identified. The prevalence of GAS+ve pharyngitis was 24.1% (95% CI: 22.6–25.6%) in clinical settings (which used ‘passive recruitment’ methods), but less in sore throat management programmes (which used ‘active recruitment’, 10.0%, 8.1–12.4%). GAS+ve pharyngitis was more prevalent in high-income countries (24.3%, 22.6–26.1%) compared with low/middle-income countries (17.6%, 14.9–20.7%). In clinical settings, approximately 10% of children swabbed with a sore throat have serologically-confirmed GAS pharyngitis, but this increases to around 50–60% when the child is GAS culture-positive. The prevalence of serologically-confirmed GAS pharyngitis was 10.3% (6.6–15.7%) in children from high-income countries and their asymptomatic GAS carriage prevalence was 10.5% (8.4–12.9%). A lower carriage prevalence was detected in children from low/middle income countries (5.9%, 4.3–8.1%). Conclusions In active sore throat management programmes, if the prevalence of GAS detection approaches the asymptomatic carriage rate (around 6–11%), there may be little benefit from antibiotic treatment as the majority of culture-positive patients are likely carriers. Treating sore throats caused by Group A Streptococcus infections (GAS pharyngitis) with antibiotics is important for preventing acute rheumatic fever (ARF). It is impossible to distinguish patients with true GAS pharyngitis infections from GAS carriers with pharyngitis caused by viral infections when throat swab culturing alone is used to diagnose GAS pharyngitis. Carriers are not likely to benefit from antibiotic treatment, but may receive treatment unnecessarily. Reported rates of GAS pharyngitis and carriage vary considerably depending on the setting. Thus it is difficult to ascertain which groups are likely to benefit significantly from active sore throat management programmes which treat GAS pharyngitis in order to prevent ARF. We performed a meta-analysis to estimate the prevalence of GAS pharyngitis and asymptomatic carriage in different settings. Approximately 10% of all children swabbed for a sore throat in clinical settings have true GAS pharyngitis, but this increases to around 55% if the children have GAS detected in their throat using swab cultures. In active sore throat management programmes, the prevalence of GAS detection is lower than in clinical settings and if it declines towards 8% (the asymptomatic carriage level), there may be little benefit in treating GAS culture-positive patients with antibiotics.
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Affiliation(s)
- Jane Oliver
- University of Otago Wellington, Newtown, Wellington, New Zealand
| | | | - Nevil Pierse
- University of Otago Wellington, Newtown, Wellington, New Zealand
| | - Nicole J. Moreland
- Maurice Wilkins Centre and School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Deborah A. Williamson
- University of Otago Wellington, Newtown, Wellington, New Zealand
- Department of Microbiology and Immunology, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Michael G. Baker
- University of Otago Wellington, Newtown, Wellington, New Zealand
- * E-mail:
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16
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Oliver JR, Pierse N, Stefanogiannis N, Jackson C, Baker MG. Acute rheumatic fever and exposure to poor housing conditions in New Zealand: A descriptive study. J Paediatr Child Health 2017; 53:358-364. [PMID: 28052445 DOI: 10.1111/jpc.13421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/31/2016] [Accepted: 10/31/2016] [Indexed: 11/29/2022]
Abstract
AIM Acute rheumatic fever (ARF) is an important public health problem in low- and middle-income countries and in certain populations in high-income countries. Indigenous Australians, and New Zealand Māori and Pacific people, have incidence rates among the highest in the world. We aimed to investigate ARF cases' housing conditions and sore throat treatment to identify opportunities for improving ARF prevention in New Zealand. METHODS Recently diagnosed cases and their care givers were interviewed. Information was obtained about the cases' demographics, housing circumstances and conditions, and sore throat treatment preceding ARF. RESULTS We interviewed 55 cases. Most (75%) lived in rental housing and reported multiple measures of deprivation. Common exposures were household crowding (58%), bed-sharing (49%), dampness and mould (76%), cold (82%) and co-habiting with smokers (71%). Experiencing sore throat in the weeks before ARF was recalled by 62%, with 29% seeing a doctor or nurse and 13% of the total sample receiving antibiotics. CONCLUSIONS The environmental conditions reported could contribute to high group A Streptococcus transmission and susceptibility to infection, thus increasing ARF risk. Sore throat treatment has important limitations as an intervention, particularly as 38% of participants did not recall sore throat preceding the diagnosis. The results support the need to improve rental housing. Interventions promoting minimum enforceable standards in social housing and private rental sectors (such as a housing warrant of fitness) could support these changes. A rigorous investigation, such as a case control study, is needed to explore risk factors further.
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17
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Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:15. [PMID: 28285457 PMCID: PMC5346434 DOI: 10.1007/s11936-017-0513-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Abstract
Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic disease commonly causing premature morbidity and mortality among the global poor. Standard clinical prevention and treatment is based on studies from the early antimicrobial era, as research investment halted soon after the virtual eradication of the disease from developed countries. The emergence of new global data on disease burden, new technologies, and a global health equity platform have revitalized interest and investment in RHD. This review surveys past and current evidence for standard RHD diagnosis and treatment, highlighting gaps in knowledge.
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Affiliation(s)
- Shanti Nulu
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, 641 Huntington Avenue, Boston, MA 02115, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gene F Kwan
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA; Section of Cardiovascular Medicine, Boston University Medical Center, Boston University School of Medicine, 88 East Newton Street, D8, Boston, MA 02118, USA.
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19
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Oliver J, Baker MG, Pierse N, Carapetis J. Comparison of approaches to rheumatic fever surveillance across Organisation for Economic Co-operation and Development countries. J Paediatr Child Health 2015; 51:1071-7. [PMID: 26174709 DOI: 10.1111/jpc.12969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/29/2022]
Abstract
AIM Rheumatic fever (RF) prevention, control and surveillance are increasingly important priorities in New Zealand (NZ) and Australia. We compared RF surveillance across Organisation for Economic Co-operation and Development (OECD) member countries to assist in benchmarking and identifying useful approaches. METHODS A structured literature review was completed using Medline and PubMed databases, investigating RF incidence rates. Surveillance methods were noted. Health department websites were searched to assess whether addressing RF was a Government priority. RESULTS Of 32 OECD member countries, nine reported RF incidence rates after 1999. Highest rates were seen in indigenous Australians, and NZ Māori and Pacific peoples. NZ and Australian surveillance systems are highly developed, with notification and register data compiled regularly. Only these two Governments appeared to prioritise RF surveillance and control. Other countries relied mainly on hospitalisation data. There is a lack of standardisation across incidence rate calculations. Israel and Italy may have relatively high RF rates among developed countries. CONCLUSIONS RF lingers in specific populations in OECD member countries. At a minimum, RF registers are needed in higher incidence countries. Countries with low RF incidences should periodically review surveillance information to ensure rates are not increasing.
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Affiliation(s)
- Jane Oliver
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nevil Pierse
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
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20
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Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. HEART ASIA 2015; 7:7-11. [PMID: 27326214 DOI: 10.1136/heartasia-2015-010648] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 12/21/2022]
Abstract
The Jones criteria has longed served as the primary guideline for diagnosing acute rheumatic fever (ARF). However, since the first iteration in 1944, the global epidemiology of ARF and our knowledge regarding the variability of its presentation have changed. In 2015, the American Heart Association took on an ambitious and successful revision, which accounts for these changes. For the first time, the criteria consider the risk within a population and offer two separate diagnostic pathways that prioritise specificity among those at low risk and sensitivity among those at moderate/high risk. Echocardiography is now recommended in all patients with suspected or confirmed ARF, and subclinical carditis can fulfil a major criterion for ARF in all populations. Finally, new and specific criteria are provided for the diagnosis of ARF recurrences. These changes improve the diagnosis of ARF among moderate/high-risk populations and re-establish the Jones criteria as the international gold standard for ARF diagnosis. It is our hope that they will also serve as a catalyst in the global community to increase advocacy, improve case detection, and invest in new research techniques that could ultimately control global ARF in our lifetimes.
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Affiliation(s)
- Andrea Beaton
- Children's National Health System, Cardiology , Washington DC , USA
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, and Princess Margaret Hospital for Children , Subiaco, Western Australia , Australia
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21
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Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, Remenyi B, Taubert KA, Bolger AF, Beerman L, Mayosi BM, Beaton A, Pandian NG, Kaplan EL. 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. Circulation 2015; 131:1806-18. [PMID: 25908771 DOI: 10.1161/cir.0000000000000205] [Citation(s) in RCA: 369] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Barker CL, Ross M. Paediatric aeromedical retrievals in the 'Top End' of the Northern Territory. Aust J Rural Health 2015; 22:29-32. [PMID: 24460997 DOI: 10.1111/ajr.12087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The primary objective of this study was to describe the remote paediatric aeromedical population of the 'Top End' of the Northern Territory. The secondary objective was to identify children requiring high-dependency care by the transport team. DESIGN Retrospective case review. SETTING Aeromedical service in the remote Northern Territory. PARTICIPANTS All patients under the age of 16 years transported over a one-year period between February 2012 and February 2013. OUTCOME MEASURES Age, gestation if newborn, diagnosis at referral, requirement for high-dependency care and transport team members. RESULTS Seven hundred eighty-nine children were transported with an average age of 4.4 years (range 0 days to 16 years). Nursing staff transferred 646 (82%). Respiratory problems (bronchiolitis and pneumonia) were the predominant illness type (31%). Other frequent diagnoses were trauma (11%), gastroenteritis (10%), cellulitis or abscess (9%) and the sequelae of streptococcal infection (8%). Thirty preterm infants including seven below 31 weeks gestation were transferred. Twenty-five children required high-dependency care, 15 of these on day 0 of life. Twenty-five required respiratory support, seven central venous access, four surfactant, two inotropes and one chest tubes. CONCLUSIONS The majority of paediatric aeromedical patients have an infective cause for their illness. Respiratory disease is the most common indication for aeromedical transport. The majority of patients are transferred by a flight nurse and do not require high-dependency care. The main risk factor identified for requiring high-dependency care during transport is respiratory distress in a newborn infant.
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Abstract
Few diseases have experienced such a remarkable change in their epidemiology over the past century, without the influence of a vaccine, than rheumatic fever. Rheumatic fever has all but disappeared from industrialised countries after being a frequent problem in the 1940s and 1950s. That the disease still occurs at high incidence in resource limited settings and in Indigenous populations in industrialised countries, particularly in Australia and New Zealand, is an indication of the profound effect of socio-economic factors on the disease. Although there have been major changes in the epidemiology of rheumatic fever, diagnosis remains reliant on careful clinical judgement and management is remarkably similar to that 50 years ago. Over the past decade, increasing attention has been given to rheumatic fever and rheumatic heart disease as public health issues, including in Australia and particularly in New Zealand, as well as in selected low and middle income countries. Perhaps the greatest hope for public health control of rheumatic fever is the development of a vaccine against Streptococcus pyogenes, and there are encouraging initiatives in this area. However, an effective vaccine is some time away and in the meantime public health efforts need to focus on effective translation of the known evidence around primary and secondary prophylaxis into policy and practice.
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Affiliation(s)
- Andrew C Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Group A Streptococcal Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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24
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Van Brusselen D, Vlieghe E, Schelstraete P, De Meulder F, Vandeputte C, Garmyn K, Laffut W, Van de Voorde P. Streptococcal pharyngitis in children: to treat or not to treat? Eur J Pediatr 2014; 173:1275-83. [PMID: 25113742 DOI: 10.1007/s00431-014-2395-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/29/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Controversy remains about the need for antibiotic therapy of group A streptococcal (GAS) pharyngitis in high-resource settings. Guidelines on the management of GAS pharyngitis differ considerably, especially in children. We performed a literature search on the diagnosis and treatment of GAS pharyngitis in children and compared different guidelines with current epidemiology and the available evidence on management. Some European guidelines only recommend antibiotic treatment in certain high-risk patients, while many other, including all American, still advise antimicrobial treatment for all children with GAS pharyngitis, given the severity and re-emerging incidence of complications. Empirical antimicrobial treatment in children with sore throat and a high clinical suspicion of GAS pharyngitis will still result in significant overtreatment of nonstreptococcal pharyngitis. This is costly and leads to emerging antibiotic resistance. Early differential diagnosis between viral and GAS pharyngitis, by means of a 'rapid antigen detection test' (RADT) and/or a throat culture, is therefore needed if 'pro treatment' guidelines are used. CONCLUSION Large scale randomized controlled trials are necessary to assess the value of antibiotics for GAS pharyngitis in high-resource countries, in order to achieve uniform and evidence-based guidelines. The severity and the possibly increasing incidence of complications in school-aged children suggests that testing and treating proven GAS pharyngitis can still be beneficial.
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Affiliation(s)
- Daan Van Brusselen
- Department of Pediatrics, University of Leuven, Herestraat 49, 3000, Leuven, Belgium,
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25
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Moreland NJ, Waddington CS, Williamson DA, Sriskandan S, Smeesters PR, Proft T, Steer AC, Walker MJ, Baker EN, Baker MG, Lennon D, Dunbar R, Carapetis J, Fraser JD. Working towards a Group A Streptococcal vaccine: Report of a collaborative Trans-Tasman workshop. Vaccine 2014; 32:3713-20. [DOI: 10.1016/j.vaccine.2014.05.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/01/2014] [Indexed: 11/25/2022]
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Lawrence JG, Carapetis JR, Griffiths K, Edwards K, Condon JR. Reply to letter regarding article, "Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia, 1997 to 2010". Circulation 2014; 129:e397. [PMID: 24637438 DOI: 10.1161/circulationaha.114.008028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joanna G Lawrence
- Department of Paediatrics, Royal Children's Hospital, Melbourne, Australia
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Spina GS, Sampaio RO, Branco CE, Miranda GB, Rosa VEE, Tarasoutchi F. Incidental histological diagnosis of acute rheumatic myocarditis: case report and review of the literature. Front Pediatr 2014; 2:126. [PMID: 25478552 PMCID: PMC4238348 DOI: 10.3389/fped.2014.00126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 10/30/2014] [Indexed: 11/13/2022] Open
Abstract
Rheumatic fever (RF) remains endemic in many countries and frequently causes heart failure due to severe chronic rheumatic valvular heart disease, which requires surgical treatment. Here, we report on a patient who underwent an elective surgical correction for mitral and aortic valvular heart disease and had a post-operative diagnosis of acute rheumatic carditis. The incidental finding of Aschoff bodies in myocardial biopsies is frequently reported in the nineteenth-century literature, with prevalences as high as 35%, but no clinical or prognostic data on the patients is included. The high frequency of this finding after cardiac surgery in classical reports suggests that these patients were not using secondary prophylaxis for RF. We discuss the clinical diagnosis of acute rheumatic myocarditis in asymptomatic patients and the laboratorial and imaging methods for the diagnosis of acute rheumatic carditis. We also discuss the prognostic implications of this finding and review the related literature.
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Affiliation(s)
- Guilherme S Spina
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
| | - Roney O Sampaio
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
| | - Carlos E Branco
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
| | - George B Miranda
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
| | - Vitor E E Rosa
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
| | - Flávio Tarasoutchi
- Valvular Heart Disease Department, Heart Institute (InCor), University of São Paulo Medical School , São Paulo , Brazil
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Abstract
Group A streptococcus (GAS) or Streptococcus pyogenes has been recognised as an important human pathogen since early days of modern microbiology, and it remains among the top ten causes of mortality from an infectious disease. Clinical manifestations attributable to this organism are perhaps the most diverse of any single human pathogen. These encompass invasive GAS infections, with high mortality rates despite effective antimicrobials, toxin-mediated diseases including scarlet fever and streptococcal toxic shock syndrome, the autoimmune sequelae of rheumatic fever and glomerulonephritis with potential for long-term disability, and nuisance manifestations of superficial skin and pharyngeal infection, which continue to consume a sizable proportion of healthcare resources. Although an historical perspective indicates major overall reductions in GAS infection rates in the modern era, chiefly as a result of widespread improvements in socioeconomic circumstances, this pathogen remains as a leading infectious cause of global morbidity and mortality. More than 18 million people globally are estimated to suffer from serious GAS disease. This burden disproportionally affects least affluent populations, and is a major cause of illness and death among children and young adults, including pregnant women, in low-resource settings. We review GAS transmission characteristics and prevention strategies, historical and geographical trends and report on the estimated global burden disease attributable to GAS. The lack of systematic reporting makes accurate estimation of rates difficult. This highlights the need to support improved surveillance and epidemiological research in low-resource settings, in order to enable better assessment of national and global disease burdens, target control strategies appropriately and assess the success of control interventions.
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