Lesson of the week: difficulties in diagnosing acute rheumatic fever-arthritis may be short lived and carditis silent

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

Atypical Articular Presentations in Indian Children With Rheumatic Fever

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acute rheumatic fever in First Nations communities in northwestern Ontario: Social determinants of health "bite the heart"

OBJECTIVE

To document a case series of 8 young First Nations patients diagnosed with acute rheumatic fever (ARF), a preventable disease that resulted in the death of 2 patients, in northwestern Ontario in the context of late diagnosis, overcrowded housing, and inadequate public health response.

DESIGN

Retrospective case series over an 18-month period.

SETTING

Remote First Nations communities in northwestern Ontario.

PARTICIPANTS

Eight patients with ARF.

MAIN OUTCOME MEASURES

Incidence, mortality, residual rheumatic heart disease, time to diagnosis, barriers to diagnosis and treatment, housing situation of patients, patient demographic characteristics (age, sex), and investigation results.

RESULTS

The incidence of ARF in this population was 21.3 per 100,000, which is 75 times greater than the overall Canadian estimated incidence. The average patient age was 9.4 years. Most cases developed joint findings, and 5 of the surviving patients had rheumatic heart disease when they received echocardiography. The average time to diagnosis was 88 days. Two 4-year-old children died from ARF. Most patients lived in inadequate and crowded housing.

CONCLUSION

This rare disease still exists in remote First Nations communities. These communities demonstrate an incidence equal to that in aboriginal communities in Australia and New Zealand, which have among the highest international incidence of ARF. Primordial prevention, including improved on-reserve housing, is urgently needed. Case detection and ongoing surveillance for primary and secondary prophylaxis requires a well resourced regional strategy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The 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.

Diagnosis of rheumatic carditis in Mongolian children

Purpose

The aim of this study was to evaluate the clinical and echocardiographic findings in patients with acute rheumatic fever (ARF) and rheumatic heart diseases (RHD) and to compare echocardiographic findings with the clinical symptoms for the detection of subclinical carditis.

Methods

The study included 156 patients who meet the modified criteria of Jones. M-mode echocardiography was performed using a Sonos-1000 echo machine and 3.5-MHz transducer.

Results

Total of 156 patients with acute RF and RHD (median age 11.9, standard deviation 3.32, range 5–17, male to female ratio 1:1.4) were evaluated. All patients were divided into 2 groups according their diagnosis. The first group included 71 (45.5%) patients with a first onset of rheumatic fever (ARF), the second group—86 (54.5%) patients with a recurrent rheumatic fever (RHD). By echocardiography, 21 (20.1%) patients of first group, who had clinically isolated polyarthritis and chorea were diagnosed a first degree of mitral regurgitation and mitral valve thickening, which is the characteristic finding of rheumatic carditis. Out of all patients, mitral valve regurgitation was detected by 2D echocardiography in 146 (93.5%) patients. The cause of mitral valve regurgitation was annular dilatation in 48%, mitral valve prolapse in 10% and fibrotic change of valve in 42%.

Conclusion

Mitral regurgitation is the most common finding on Doppler color imaging in patients with the rheumatic carditis. In patients clinically manifesting only polyarthritis and/or chorea, we should exclude the subclinical carditis that can be easily detected by echocardiography. The presence of subclinical carditis should be accepted as an evidence of carditis.

Acute disseminated encephalomyelitis associated with acute rheumatic fever

An 8-year-old boy developed acute disseminated encephalomyelitis, 2 weeks after an episode of acute rheumatic fever. The disease was succesfully treated with high-dose methylprednisolone. A wide range of neurologic disorders is associated with streptococcal disease. Poststreptococcal acute disseminated encephalomyelitis was previously reported in children, but to our knowledge, this is the first case report of rheumatic fever complicated by acute disseminated encephalomyelitis. This case supports the hypothesis that rheumatic fever, a late complication of streptococcal infections, may be associated with acute disseminated encephalomyelitis.

Update on acute rheumatic fever: it still exists in remote communities

OBJECTIVE

To remind physicians who work with aboriginal populations of the ongoing prevalence of acute rheumatic fever and to review the recent evidence on presentation, treatment, and secondary prophylaxis.

SOURCES OF INFORMATION

The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched from 1996 to 2007 with a focus on prevention, epidemiology, and disease management. Case series data from medical records at the Sioux Lookout Meno Ya Win Health Centre in Ontario were also used.

MAIN MESSAGE

Acute rheumatic fever is still a clinical entity in aboriginal communities in northwest Ontario. Identification, treatment, and secondary prophylaxis are necessary.

CONCLUSION

Acute rheumatic fever is not a forgotten disease and still exists in remote areas of Canada.

Acute rheumatic fever and its consequences: a persistent threat to developing nations in the 21st century

Acute rheumatic fever (ARF) is an autoimmune, multi-system response secondary to molecular mimicry following Lancefield group A streptococcus (GAS) pharyngitis; it is now most commonly found in the pediatric populations of developing nations. The major source of morbidity and mortality of ARF stems from rheumatic heart disease (RHD), although the cardinal symptoms of the disease also include polyarthritis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum. Therapy is aimed towards treating the initial GAS infection, using anti-inflammatory medications for acute symptoms and surgery to correct RHD. Secondary prevention is crucial, given the high risk of recurrence, and includes long-term antibiotic prophylaxis. However, vaccination towards GAS may soon be on the horizon, which may assist in both decreasing the risk of initial infection in naïve patients and helping to lower the risk of recurrence.

First-episode versus recurrent acute rheumatic fever: is it different?

BACKGROUND

Recurrent episodes of acute rheumatic fever (RF) can lead to rheumatic heart disease with considerable disability and mortality in children. RF can recur in the absence of secondary prophylaxis. The differences in clinical manifestations and outcome between first-episode and recurrent RF have been less studied.

METHODS

A cross-section of patients under 14 years was studied for 2 years (2003-2005) in order to compare the clinical, laboratory, echocardiographic profile and outcome of first-episode RF with recurrent attacks, and risk factors for recurrence and mortality. Patients without a previous history of RF and/or mitral stenosis (MS) and/or aortic stenosis (AS) were defined as first-episode patients, and patients with previous history of RF and/or MS and/or AS, were defined as recurrent RF patients based on the Jones criteria.

RESULTS

Of 51 patients in total, 26 had first-episode RF and 25 had recurrent RF. Arthritis occurred in a significantly higher number of first-episode patients (P = 0.047) whereas shortness of breath (SOB; P = 0.003), palpitation (P = 0.034), and aortic regurgitation (AR; P = 0.001) occurred in a significantly higher number of recurrent RF patients. Audible murmur of corresponding echocardiographic regurgitation was present in all recurrent RF patients whereas audible murmur was present in 61.5% and echocardiographic regurgitation in 81% in first-episode patients (P = 0.007). Palpitation, SOB, audible murmur, thrill, age and AR on admission were independent predictors of recurrence. Palpitation, age and AS on admission were independent predictors of mortality.

CONCLUSIONS

Subclinical carditis occurred only in the first-episode patients, which requires further evaluation for clinical significance. Because all deaths occurred in recurrent RF group (P = 0.02), secondary prophylaxis and management of sore throat need re-emphasis.

An Update on C-reactive Protein for Intensivists

This review aims to summarise the physiology of C-reactive protein (CRP), its possible roles and limitations as an inflammatory and infective marker in intensive care medicine, and also the emerging roles of CRP in the pathogenesis of cardiovascular and autoimmune diseases. Observational and animal studies on uses of CRP were retrieved from the PubMed database without any language restrictions. Quantitative data were not pooled because of the heterogeneity of patient characteristics and disparate ways in which CRP was studied. Serum CRP concentrations are determined by the synthetic rate of its production in the liver regulated predominantly by interleukin-6. It has a half-life of 19 hours and is relatively slow in its onset and offset in response to an acute inflammatory process when compared to procalcitonin. It has some favourable properties and limitations as an inflammatory marker. An elevated CRP concentration is not specific to infections and the absolute CRP concentrations cannot be used to differentiate between bacterial, fungal and severe viral infections. The dynamic response of CRP to therapy that aims to modify the underlying inflammatory process and the clinical context of a patient are of pivotal importance when CRP concentrations are interpreted. CRP is found to be a significant partaker and prognostic factor in a wide range of cardiovascular and chronic diseases. In summary, CRP concentration is an important prognostic factor of many acute and chronic diseases. Serial CRP measurements may be useful to reflect a patient's response to therapy that aims to modify the underlying inflammatory process.

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

BACKGROUND

To investigate the findings and prognosis of rheumatic fever (RF) patients seen in the past 20 years and to compare the last two decades.

METHODS

The medical records of all RF patients admitted to Gazi University Department of Pediatric Cardiology during 1982-2002 were reviewed. The decade from 1.1.1982 to 31.12.1991 was designated as 1980s and the following decade as the 1990s.

RESULTS

Among the 609 RF cases, there was no difference between the two decades regarding mean age, male/female ratio, most of the minor manifestations and findings of the preceding streptococcal infection. As the rate of carditis declined in 1990s, rates of arthritis and chorea increased. Severity of carditis and admissions with reactivation decreased during 1990s. The two decades did not differ regarding mean age, gender ratio, pericarditis rate, number and type of valvular involvement and sequel of carditis cases. Severity of carditis and number of valvular involvement influenced the first-year prognosis. Almost one-third of the arthritis cases had monoarthritis in both decades. Atypical cases with small-joint involvement were detected number of which increased during the 1990s.

CONCLUSIONS

The two decades do not seem to differ regarding most of the manifestations of RF. More emphasis should be given to atypical cases such as small-joint involvement and monoarthritis and silent carditis.

Comparison of cardiac function and valvular damage in children with and without adenotonsillar hypertrophy

OBJECTIVE

Comparison of cardiac function in children with and without adenotonsillar hypertrophy.

METHODS

We examined 28 pediatric patients with adenotonsillar hypertrophy mean aged 7.3+/-2.9 years comprised of 14 females and 14 males (group I). The control group were chosen from 35 healthy sex and age matched children mean aged 7.37+/-2.7 years (group II). Both groups were examined by an otorhinolaryngologist and adenotonsillar hypertrophy was diagnosed with nasal endoscopic method or lateral neck X-ray. All the patients in group I underwent adenotonsillectomy. Cardiologic and echocardiographic examinations were performed in both groups. Echocardiographic examination was done twice in group I (preoperative and postoperative first month) however in group II only once. Preoperative findings of group I compared with the findings of group II. Preoperative and postoperative echocardiographic findings were also compared within group I. The chi-square test and the independent paired-sample t-test were used for statistical analysis.

RESULTS

The tricuspid end-diastolic time was the only significant difference in echocardiographic findings between the two groups (104.8+/-28.8 ms versus for 86.4+/-17.32 ms p<0.05). There was no statistical difference between preoperative and postoperative echocardiographic findings in group I. Brady-tachyarrhythmia was detected on electrocardiography - performed with 24h ambulatory electrocardiography - in one patient. To our surprise, in group I five patients had cardiac valve damage: mitral and/or aortic valve insufficiency. These findings were interpreted as silent carditis.

CONCLUSION

There was no significant difference in right ventricular function between the children with and without adenotonsillar hypertrophy. Whereas, there was shortening of tricuspid end-diastolic time in group I. However, five patients having adenotonsillar hypertrophy developed a cardiac dysfunction which was not observed in the control group. Therefore, we assumed a correlation between adenotonsillar hypertrophy and possible silent carditis following frequent tonsillitis.