Diagnosis of active rheumatic carditis. The echoes of change

Echocardiographic Screening for Rheumatic Heart Disease: A Brief History and Implications for the Future

Transthoracic echocardiography is the gold standard for early detection of rheumatic heart disease (RHD) in asymptomatic children living in high-risk regions. Advances in technology allowing miniaturisation and increased portability of echocardiography devices have improved the accessibility of this vital diagnostic tool in RHD-endemic locations. Automation of image optimisation techniques and simplified RHD screening protocols permit use by non-experts after a brief period of training. While these changes are welcome advances in the battle to manage RHD, it is important that the sensitivity and specificity of RHD detection be maintained by all echocardiography users on any device to ensure accurate and timely diagnosis of RHD to facilitate initiation of appropriate therapy. This review of the evolution of echocardiography and its use in the detection of rheumatic valve disease may serve as a reminder of the key strengths and potential pitfalls of this increasingly relied-upon diagnostic test.

Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines

BACKGROUND

Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081).

FINDINGS

Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators.

INTERPRETATION

Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas.

FUNDING

World Health Organization.

TRANSLATIONS

For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.

Predictors of rheumatic fever in sore throat patients: a systematic review and meta-analysis

Background

Concerns about rheumatic fever (RF) drive antibiotic prescriptions for sore throat (ST) in endemic areas. Better guidance is needed on which patients are likely to develop RF in order to avoid misuse and overuse of antibiotics. Our aim was to identify predictive factors for RF in ST patients.

Methods

Multiple databases were searched to identify cohort, case–control, cross-sectional or randomised controlled trials that measured RF incidence in ST patients. An inverse variance random effects model was used to pool the data and calculate odds ratios (ORs).

Results

Seven studies with a total of 6890 participants were included: three RCTs and four observational studies. Factors significantly associated with RF development following ST were positive group A streptococcal (GAS) swab (OR 1.74 [95% confidence interval {CI} 1.13 to 2.69]), previous RF history (OR 13.22 [95% CI 4.86 to 35.93]) and a cardiac murmur (OR 3.55 [95% CI 1.81 to 6.94]). Many potential risk factors were not reported in any of the included studies, highlighting important evidence gaps.

Conclusions

ST patients in endemic areas with a positive GAS swab, previous RF history and a cardiac murmur are at increased risk of developing RF. This review identifies vital gaps in our knowledge of factors predicting RF development in ST patients. Further research is needed to develop better clinical prediction tools and rationalise antibiotic use for ST.

A case report of isolated rheumatic tricuspid regurgitation and pericarditis

Rheumatic fever (RF) is a complex syndrome in which the human body develops antibodies against β-haemolytic streptococcus, and triggers inflammation in various organs. RF valvulitis mostly affects the mitral valve (MV) and, to a lesser extent, the aortic valve (AV). Isolated rheumatic tricuspid valve (TV) disease and pericarditis is extremely rare and is not well described in the RF guidelines. The current case demonstrates the echocardiographic findings of TV valvulitis of RF and describes the presentation and electrocardiogram (ECG) changes in pericarditis. We present the case of a 16-year-old male patient who developed upper respiratory tract infection followed by typical pericarditis chest pain. The patient had no history of joint pain or swelling, but was found to have a tricuspid regurgitation (TR) murmur upon examination. Laboratory investigations revealed an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and antistreptolysin O titres. ECG showed a wide-spread 1.5 mm upward concave ST-segment elevation. In echocardiography, the TV opened well with markedly thickened leaflets and severe TR, while the MV and AV were normal in both structure and function. The diagnosis of RF was established and treatment with high-dose aspirin and antibiotics was initiated. The treatment led to resolution of the chest pain. Our case highlights that the physical and lab findings of rheumatic TR are similar to those of rheumatic mitral regurgitation, with the exception of a high-velocity jet. Similarly, the presentations of rheumatic pericarditis are similar to other types and may also respond to high-dose aspirin. Finally, physicians should be familiar with both the common and rare complications of RF because the guidelines have placed Middle East region among the high-risk countries.

Echocardiographic Screening of Rheumatic Heart Disease in American Samoa

While rheumatic heart disease (RHD) is a treatable disease nearly eradicated in the United States, it remains the most common form of acquired heart disease in the developing world. This study used echocardiographic screening to determine the prevalence of RHD in children in American Samoa. Screening took place at a subset of local schools. Private schools were recruited and public schools underwent cluster randomization based on population density. We collected survey information and performed a limited physical examination and echocardiogram using the World Heart Federation protocol for consented school children aged 5-18 years old. Of 2200 students from two private high schools and two public primary schools, 1058 subjects consented and were screened. Overall, 133 (12.9%) children were identified as having either definite (3.5%) or borderline (9.4%) RHD. Of the patients with definitive RHD, 28 subjects had abnormal mitral valves with pathologic regurgitation, three mitral stenosis, three abnormal aortic valves with pathologic regurgitation, and seven borderline mitral and aortic valve disease. Of the subjects with borderline disease, 77 had pathologic mitral regurgitation, 12 pathologic aortic regurgitation, and 7 at least two features of mitral valve disease without pathologic regurgitation or stenosis. Rheumatic heart disease remains a major cause of morbidity and mortality worldwide. The prevalence of RHD in American Samoa (12.9%) is to date the highest reported in the world literature. Echocardiographic screening of school children is feasible, while reliance on murmur and Jones criteria is not helpful in identifying children with RHD.

Rheumatic Heart Disease in the Twenty-First Century

Rheumatic heart disease (RHD) is a chronic valvular disease resulting after severe or repetitive episodes of acute rheumatic fever (ARF), an autoimmune response to group A Streptococcus infection. RHD has been almost eliminated with improved social and health infrastructure in affluent countries while it remains a neglected disease with major cause of morbidity and mortality in many low- and middle-income countries, and resource-limited regions of high-income countries. Despite our evolving understanding of the pathogenesis of RHD, there have not been any significant advances to prevent or halt progression of disease in recent history. Long-term penicillin-based treatment and surgery remain the backbone of a RHD control program in the absence of an effective vaccine. The advent of echocardiographic screening algorithms has improved the accuracy of diagnosing RHD and has shed light on the enormous burden of disease. Encouragingly, this has led to a rekindled commitment from researchers in the most affected countries to advocate and take bold actions to end this disease of social inequality.

QT and P-wave dispersions in rheumatic heart disease: prospective long-term follow up

BACKGROUND

Simple electrocardiogram (ECG) markers have been used to evaluate conduction times. Acute rheumatic fever (ARF) is an autoimmune disease that affects these conduction times. The aim of this prospective long-term follow-up study was to evaluate QT, QTc and P-wave dispersions in children with ARF and chronic rheumatic heart disease (CRHD).

METHODS

Sixty-four patients with ARF, 33 patients with CRHD and 41 healthy, age- and sex-matched control subjects were included in the study. The ARF patients were divided into two subgroups: carditis and arthritis. Echocardiographic and ECG measurements at the onset of diagnosis and final evaluation were included.

RESULTS

QT, QTc and P-wave dispersions were significantly greater in both the ARF carditis and CRHD groups than the ARF arthritis and control subjects during the initial and final analysis (for all, P < 0.001). There was no significant statistical difference in QT, QTc and P-wave dispersion between the initial and final analysis in each groups. Severity of mitral regurgitation and left atrial enlargement were found to be positively correlated with P-wave dispersion (r = 0.438, P < 0.001; r = 0.127, P < 0.001, respectively). QT, QTc and P-wave dispersion greater than 52, 60 and 57 ms, respectively, had higher sensitivity and specificity for predicting ARF carditis.

CONCLUSION

These ECG measurements can be used in the diagnosis of ARF carditis as minor criteria with modified Jones criteria. In contrast, this increase in the dispersions is permanent in patients with ARF carditis.

Assessment of atrial electromechanical delay in children with acute rheumatic fever

PURPOSE

There may be an increase in the risk of atrial arrhythmia due to left atrial enlargement and the influence on conduction system in acute rheumatic fever. The aim of this study is to investigate atrial electromechanical delay and P-wave dispersion in patients with acute rheumatic fever.

PATIENTS

A total of 48 patients diagnosed with acute rheumatic fever and 40 volunteers of similar age, sex, and body mass index were included in the study. The study groups were compared for M-mode echocardiographic parameters, interatrial electromechanical delay, intra-atrial electromechanical delay, and P-wave dispersion.

RESULTS

Maximum P-wave duration, P-wave dispersion, and interatrial electromechanical delay were significantly higher in patients with acute rheumatic fever compared with the control group (p < 0.001). However, there was no difference in terms of intra-atrial electromechanical delay (p > 0.05). For patients with acute rheumatic fever, a positive correlation was identified between the left atrium diameter and the P-wave dispersion and interatrial electromechanical delay (r = 0.524 and p < 0.001, and r = 0.351 and p = 0.014, respectively). Furthermore, an important correlation was also identified between the P-wave dispersion and the interatrial electromechanical delay (r = 0.494 and p < 0.001).

CONCLUSION

This study shows the prolongation of P-wave dispersion and interatrial electromechanical delay in acute rheumatic fever. Left atrial enlargement can be one of the underlying reasons for the increase in P-wave dispersion and interatrial electromechanical delay.

Clinical, laboratory and echocardiographic profile of acute rheumatic fever in Nepali children

BACKGROUND

Acute rheumatic fever (RF) is a common, preventable health problem in developing countries. Sporadic outbreaks and the prevalence in some indigenous populations have renewed interest in RF in developed countries also.

AIMS

To describe the clinical, laboratory and echocardiographic features, outcome and value of echocardiography in detecting valvular disease in RF.

METHODS

A prospective, cross-sectional study was conducted over 2 years. Patients under 14 years admitted to the cardiology unit of Kanti Children's Hospital, Kathmandu with RF using the Jones criteria were recruited consecutively.

RESULTS

The median age (range) of the 51 patients was 11 (5-14) years, the male:female ratio was 1.6:1 and 39% had a history of a sore throat. Clinical and laboratory features detected were as follows: carditis 92%, arthritis 33%, chorea 8%, subcutaneous nodules 4%, fever 51%, arthralgia 37%, elevated antistreptolysin O titre 94%, elevated CRP 78%, prolonged PR interval 45%, pericardial effusion 22% and cardiac failure 28%. In total, 36 patients (71%) complained of joint pains. A murmur on auscultation was significantly associated with underlying diseased valves confirmed by echocardiography (p=0.001). A murmur was audible in 78.4% and diseased valves were confirmed by echocardiography in 88.2%. The mitral valve was the most commonly involved valve (82%) and mitral regurgitation the commonest lesion (24%). A thickened mitral valve predicted carditis (p=0.007). Five (10%) patients died.

CONCLUSION

Inclusion of echocardiographic evidence of carditis and possibly arthralgia as major criteria would improve case detection.

Use of Doppler echocardiography to support the decision to discontinue secondary prophylaxis for patients with rheumatic fever and normal cardiac auscultation

Secondary prophylaxis remains the safest way to prevent or minimize heart valve damage in patients with rheumatic fever. However, criteria to determine the duration of prophylaxis have not been well established. This study aimed to evaluate the clinical and Doppler echocardiographic profile of patients with rheumatic fever and a normal clinical examination at least 5 years after the first episode and to discuss the contribution of Doppler echocardiography in supporting the decision to discontinue secondary prophylaxis. An observational longitudinal study analyzing 183 patients with rheumatic fever and a normal clinical examination 5 years or more after the initial attack was conducted. The patients underwent Doppler echocardiography to study the severity of mitral or aortic valvular disease. Of the 183 patients, 77 (42 %) had clinical carditis. Subclinical chronic heart disease occurred for 79 % of the patients with previous clinical carditis and for 25 % of the patients without clinical carditis. Of the 35 patients with previous clinical carditis who were in the period of discontinued prophylaxis, residual valvular heart disease was observed in all, whereas of the 62 patients without clinical carditis, only 27 % showed residual valvular heart disease. Considering Doppler echocardiographic criteria, prophylaxis would be continued for 13 (34 %) of the patients with previous clinical carditis and for only 2 (3 %) of those without clinical carditis. Return of cardiac auscultation to normal is not always accompanied by return of Doppler echocardiographic findings to normal. Criteria regarding Doppler echocardiographic findings and valve morphology should be evaluated by the time secondary prophylaxis is discontinued. However, further studies are needed to demonstrate whether prolonged prophylaxis provides any benefit to patients with persistent echocardiographic findings.

Mean platelet volume in acute rheumatic fever

Acute rheumatic fever (ARF) is still an endemic disease, especially among school-aged children in developing countries. Mean platelet volume (MPV), which is commonly used as a measure of platelet size, indicates the rate of platelet production and platelet activation. We aimed to investigate MPV in children with ARF. The study population consisted of 40 children with ARF (32 patients with carditis and 8 patients without carditis) and 40 healthy control subjects. White blood cell (WBC) and platelet counts were significantly higher and MPV values were significantly lower in patients with ARF during the acute stage when compared to controls. Erythrocyte sedimentation rate (ESR) and C-reactive protein values significantly decreased in patients with ARF after the treatment when compared to baseline, whereas MPV values increased. MPV values were negatively correlated with ESR and WBC, and platelet counts. In conclusion, during the acute stage of ARF, MPV values were lower when compared to controls.

P-wave dispersion in children with acute rheumatic fever

As a new and simple electrocardiographic marker, P-wave dispersion is reported to be associated with inhomogeneous and discontinuous propagation of sinus impulses. The current study aimed to investigate P-wave dispersion in children with acute rheumatic fever. The study population consisted of 47 children with acute rheumatic fever (29 patients with carditis and 18 patients without carditis) and 31 healthy control subjects. Maximum and minimum P-wave durations were measured from the 12-lead surface electrocardiogram. The P-wave dispersion was calculated as the difference between maximum and minimum P-wave durations. The maximum P-wave duration and the P-wave dispersion of the patients with and without carditis were significantly greater than those of the control subjects. The P-wave dispersion of the patients with carditis was significantly greater than that of the patients without carditis. In conclusion, the P-wave dispersion was higher in the children with acute rheumatic fever than in the healthy control subjects.

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.

Cardiac troponin T in children with acute rheumatic carditis

The existence of cardiac damage in active rheumatic carditis patients is unknown, especially in those without pericarditis. The aim of this study was to determine cardiac myocyte damage using cardiac troponin T (cTnT) measurements in active rheumatic carditis. The levels of creatine kinase MB isoenzyme (CK-MB), cTnT, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), cardiothoracic ratio (CTR), and fractional shortening (FS) were compared using Mann-Whitney U test between 28 patients with active rheumatic carditis and 32 controls (healthy children). Association of cTnT levels with ESR, CRP, and CTR was evaluated with Spearman correlation analysis. ESR, CRP, cTnT levels, and CTR were statistically higher in the patients than in the controls. There were no differences between the groups for CK-MB levels and FS. No relationships were found between cTnT levels and ESR, CRP, and CTR in the patient group. The results of the study suggest that when cTnT levels are within non-pathological range, there is no serious cardiac damage; however, statistically significant increases in cTnT levels may indicate minor damages in patients with active carditis due to acute rheumatic fever.

QT Dispersion predicting acute rheumatic carditis

OBJECTIVE

To investigate QT dispersion in the surface electrocardiogram of children with rheumatic carditis.

METHODS

QT dispersion was quantitatively evaluated in 33 children with acute rheumatic carditis. As a control group, we studied 33 healthy children free of any disease. The children were eligible for participation if the following criteria were met: diagnosis of acute rheumatic fever based on the revised Jone's criteria and suffering from their first attack of carditis. The echo Doppler cardiogram was performed in all children, within 48-72 hours of hospitalisation.

RESULTS

Patients with carditis had a greater QT dispersion than the control group. When we analyse the QT dispersion according to the severity of the carditis, we observed that the dispersion tended to be greater in those with more severe valvar lesion. The sensitivity and specificity of the measurements of the QT dispersion in predicting acute carditis were estimated by using receiver operating characteristic curves. A QT dispersion greater than 40 milliseconds had a sensitivity of 63.6% and a specificity of 93.9% in predicting acute rheumatic carditis.

CONCLUSION

The lengthening of QT dispersion may reflect on cardiac involvement in rheumatic fever and be a new important parameter in the diagnosis and therapeutic decision for rheumatic carditis.

Prevalence of rheumatic heart disease in children and young adults in Nicaragua

Rheumatic heart disease (RHD) results in morbidity and mortality that is disproportionate among individuals in developing countries compared to those living in economically developed countries. The global burden of disease is uncertain because most previous studies to determine the prevalence of RHD in children relied on clinical screening criteria that lacked the sensitivity to detect most cases. The present study was performed to determine the prevalence of RHD in children and young adults in León, Nicaragua, an area previously thought to have a high prevalence of RHD. This was an observational study of 3,150 children aged 5 to 15 years and 489 adults aged 20 to 35 years randomly selected from urban and rural areas of León. Cardiopulmonary examinations and Doppler echocardiographic studies were performed on all subjects. Doppler echocardiographic diagnosis of RHD was based on predefined consensus criteria that were developed by a working group of the World Health Organization and the National Institutes of Health. The overall prevalence of RHD in children was 48 in 1,000 (95% confidence interval 35 in 1,000 to 60 in 1,000). The prevalence in urban children was 34 in 1,000, and in rural children it was 80 in 1,000. Using more stringent Doppler echocardiographic criteria designed to diagnose definite RHD in adults, the prevalence was 22 in 1,000 (95% confidence interval 8 in 1,000 to 37 in 1,000). In conclusion, the prevalence of RHD among children and adults in this economically disadvantaged population far exceeds previously predicted rates. The findings underscore the potential health and economic burden of acute rheumatic fever and RHD and support the need for more effective measures of prevention, which may include safe, effective, and affordable vaccines to prevent the streptococcal infections that trigger the disease.

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

BACKGROUND

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

AIM

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

MATERIALS AND METHODS

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

CONCLUSION

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

What is the true frequency of carditis in acute rheumatic fever? A prospective clinical and Doppler blind study of 56 children with up to 60 months of follow-up evaluation

BACKGROUND

This study aimed to evaluate prospectively clinical and echocardiographic findings of patients who had rheumatic fever with and without clinical features of cardiac involvement.

METHODS

For this study, 56 consecutive patients (mean age, 11.4 years) with acute rheumatic fever diagnosed according to the 1992 modified Jones criteria were evaluated at diagnosis, after 3 and 6 months, then at 2 and 5 years. All assessments were performed blindly and included physical and cardiac examination, electrocardiogram, chest X-ray, and two-dimensional color-flow Doppler echocardiography.

RESULTS

Initial clinical carditis was observed for 27 patients (48.2%), all of whom had positive echocardiographic abnormalities. Echocardiographic abnormalities were observed in 11 patients who had arthritis or chorea presentation without initial clinical carditis. Persistence of the abnormalities was observed at a late follow-up evaluation in 72.7% of the cases. Sydenham's chorea was present in 8 patients with clinical carditis and in 10 without this disorder, 8 of whom had echocardiographic abnormalities.

CONCLUSION

Patients who had acute rheumatic fever without clinical signs of carditis showed acute and late follow-up echocardiographic abnormalities suggestive of cardiac involvement. Clinicians should be attentive for the presence of cardiac involvement among patients with chorea.

Use of the Jones Criteria in the diagnosis of acute rheumatic fever in an Australian rural setting

OBJECTIVE

To answer the question, are the Jones Criteria being used appropriately in the diagnosis of acute rheumatic fever (ARF) by non-specialist medical staff in a remote Australian setting?

METHODS

The medical records of all patients discharged from Katherine Hospital (Northern Territory) with a diagnosis of ARF between January 2000 and April 2004 were retrospectively reviewed for adherence to the Jones Criteria. Data were also collected on specialist follow-up and need for transfer to a tertiary hospital.

RESULTS

Twenty-five patients had a diagnosis of ARF and all were Aboriginal or Torres Strait Islander. Thirty-two per cent did not fulfil the Jones Criteria and of these 63% were recurrent cases. Eighty-eight per cent received specialist follow-up and of those who did not fulfil the Jones Criteria, all were diagnosed as ARF by the specialist. Only 20% required transfer to a tertiary hospital for higher-level care.

CONCLUSION

The Jones Criteria are being used appropriately to diagnose initial episodes of ARF but less successfully in recurrent episodes. Specialist follow-up is essential but acute episodes can be managed in remote settings, reducing the need to transfer patients to tertiary care with resultant patient dislocation and social isolation.

IMPLICATIONS

The diagnosis of ARF results in long-term penicillin prophylaxis. This is a major public health undertaking that requires correct diagnosis. This study demonstrates that the Jones Criteria are being used appropriately to diagnose ARF in a remote setting. The ability to diagnose and treat Indigenous patients within their local region reduces social isolation and creates a more positive health care experience.

Jones criteria and underdiagnosis of rheumatic fever

OBJECTIVE

The authors attempt to determine whether typical clinical and laboratory manifestations of acute rheumatic fever (ARF) are in accordance to what has been traditionally described and how useful the Jones criteria are for diagnosis.

METHODS

Data from 81 cases of ARF were retrospectively collected.

INCLUSION CRITERIA

5 to 15 years of age and diagnosis of ARF confirmed by 2 or more rheumatologists, sustained for at least 6 months and two or more visits.

RESULTS

Girls had more chorea (23/50.0% vs. 5/14.3%)(p< 0.0001). Cardiovascular (65/80.2%) and joint involvements (63 / 77.8%) were the most frequent manifestations. Fever was noted in roughly half of the patients. Arthritis was more frequent than arthralgia (47/58.0% vs. 16/19.8%, respectively) (p< 0.0001); however, no specific pattern of joint involvement was found to be more prevalent. Mitral insufficiency was the most frequently detected echocardiographic sign (53 / 93.0%) and its association with aortic insufficiency was noted in 27 / 47.4% patients. Only 24 / 29.6% patients fulfilled Jones criteria for ARF requiring an evidence of previous group-A streptococcal infection (GASI). When compulsory GASI was disregarded, this number rose to 71/87.7% patients (p< 0.0001).

CONCLUSION

Girls were more affected by chorea; heart valves and joints were equally affected and represented the major clinical features; no specific pattern of joint involvement (eg.: migratory arthritis) could be labeled as typical; and strict adherence to Jones criteria, with compulsory documentation of a previous GASI, may lead to underdiagnosis of ARF.

The Challenge of Acute Rheumatic Fever Diagnosis in a High-Incidence Population: A Prospective Study and Proposed Guidelines for Diagnosis in Australia's Northern Territory

BACKGROUND

Accurate diagnosis of acute rheumatic fever (ARF) remains problematic in high-incidence settings and especially in the Aboriginal population of Australia's Northern Territory. Previous investigators have demonstrated that strict application of the 1992 Updated Jones Criteria results in under-diagnosis. This study's objectives were to review use of the Jones Criteria (1992 Update) in diagnosing ARF in Australian Aboriginal patients presenting with suspected rheumatic fever, and formulate a locally relevant algorithm to improve diagnosis.

METHODS

Patients presenting to Royal Darwin Hospital with suspected ARF were prospectively assessed during a 15-month period. Demographic information, clinical history, examination, laboratory and echocardiographic findings were documented in order to determine whether the Jones Criteria were fulfilled, and to identify alternative diagnoses. The hospital discharge diagnosis was recorded and patients were followed up 18-33 months later.

RESULTS

Out of 35 patients with suspected ARF, all were Aboriginal Australians, 17 (49%) had a discharge diagnosis of definite ARF, 7 (20%) had definite non-rheumatic fever diagnoses (disseminated gonococcal infection, systemic lupus erythematosis, buttock abscess and other febrile illnesses in children with cardiac murmur due to previously undiagnosed RHD). The remaining 11 (31%) posed diagnostic difficulties because of mild symptoms that failed to fulfil Jones Criteria (attracting diagnoses such as 'unexplained arthralgia') or atypical features such as older age. Two patients whose illness initially failed to fulfil the Jones Criteria, who were neither diagnosed with ARF nor commenced on secondary benzathine penicillin prophylaxis, were found on follow-up to have definite and probable ARF, respectively. At least 29% (8/28) of patients without prior recognised ARF/RHD had echocardiographic evidence of established RHD, indicating that previous episodes were missed.

CONCLUSIONS

Individual mild episodes of ARF may be overlooked, with patients missing out on the timely institution of secondary prophylaxis. The Jones Criteria should be supplemented by active exclusion of differential diagnoses and vigilant follow-up including echocardiography. 'Probable' and 'possible ARF' should be recognised as diagnostic categories applying to patients not fulfilling the Jones Criteria but who nevertheless should be offered prophylactic penicillin at least until further follow-up. A set of diagnostic guidelines is proposed.

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

OBJECTIVES

Acute rheumatic fever and its sequel, rheumatic heart disease, is a major problem in children, adolescents and young adults. Despite the widespread application of the Jones criterions, carditis is either underdiagnosed or overdiagnosed. Echocardiography is rarely used optimally for precise diagnosis. The objective of our study, therefore, was to define the potential role of echocardiography in detecting carditis in the setting of acute rheumatic fever.

MATERIALS AND METHODS

We performed echocardiography in 452 consecutive patients with acute rheumatic fever, clinically diagnosed by the strict Jones criterions, using the patients as part of a multi-centric and double blinded prospective study.

RESULTS

Of our 452 patients, 230 were males, and 222 were females. The youngest was aged 1 year 11 months, while the oldest was a 51-year-old female. Out of the 452 cases of acute rheumatic fever, 239 patients (52.8%) had arthritis. Out of 164 cases of clinically diagnosed carditis, only 141 cases had echocardiographic evidence of carditis (85.97%). The remaining 23 patients (14%) had functional murmurs, tachycardia, or anaemia. Of the patients, 2 also had congenitally malformed hearts. Of 40 patients with rheumatic chorea, 28 (70%) had echocardiographic evidence of carditis or valvitis. Polyarthralgia was seen in 213 cases (47.12%), from which only 38 patients (17.8%) had carditis clinically, albeit that 88 patients (41.3%) showed echocardiographic evidence of subclinical carditis or valvitis.

CONCLUSION

Echocardiography, when carried out in patients with acute rheumatic fever diagnosed strictly according to the Jones criterion, can avoid both overdiagnosis and underdiagnosis of carditis. A high incidence of carditis, or subclinical carditis, is detected by echocardiography when performed in patients with rheumatic chorea or arthralgia.

Akutes rheumatisches Fieber (ARF) und Poststreptokokken reaktive Arthritis (PSRA)—

Betahemolytic strains of streptococcus A are able to induce a spectrum of immunologically induced diseases, depending on the immunogenic M structure of the bacteria as well as on the genetic determined reaction of the host. In acute rheumatic fever (ARF) the Jones criteria, revised and modified several times and updated in 1992, remain the diagnostic standard. Echocardiography, still not included in the Jones criteria, has become a very important diagnostic tool, especially as half of the ARF induced carditis cases are clinically inapparent. Diagnosis may be very difficult if arthritis is the only major sign, especially if not occurring in the typical migrating pattern, a fact frequently reported from countries with a high risk of ARF. Poststreptococcal reactive arthritis (PSRA) has been described as a different entity as well as a part of rheumatic fever. There is a lack of validated diagnostic criteria to establish a reliable diagnosis. There are no accepted recommendations for antibiotic prophylaxis in PSRA.

Rheumatic fever in children younger than 5 years: is the presentation different?

OBJECTIVE

To review our experience with children who presented with rheumatic fever (RF) before 5 years of age and to compare their presentation with that of older children.

METHODS

The cardiology database was reviewed to identify patients who were younger than 5 years and had a diagnosis RF using the Jones criteria from January 1985 through March 2000. Patient age, sex, date and age at presentation, and the major Jones criteria fulfilled were noted. When carditis was present, its severity was judged to be moderate to severe when there was radiographic cardiomegaly and/or clinical congestive heart failure. The clinical presentation of patients who presented in the first 5 years of life were compared with the presentation of those whose RF was diagnosed after 5 years of age. Clinical findings at follow-up evaluation and echocardiographic findings both at presentation and at follow-up were noted for the children who were younger than 5 years at presentation.

RESULTS

Of 541 cases of RF seen from January 1985 through March 20000, 27 (5%) were in children who were younger than 5 years (median: 4.0 years; range: 1.9-4.9 years). Major Jones criteria at presentation were arthritis in 17, carditis in 14, chorea in 3, and erythema marginatum in 3. The carditis was mild in 4 and moderate to severe in 10 patients. Compared with older children, younger children were more likely to present with moderate to severe carditis, arthritis without carditis or chorea, or the rash of erythema marginatum and were less likely to have chorea. The incidence of carditis was similar in the 2 groups as was the ratio of boys to girls. At follow-up (9.6 +/- 5.6 years), 69% of younger children who presented with carditis have clinical rheumatic heart disease. Subclinical, echocardiographically detected valvular abnormalities were detected both at presentation (33% of all children with RF before 5 years of age) and at follow-up (55% of those who initially had carditis).

CONCLUSIONS

Approximately 5% of children with RF were younger than 5 years at diagnosis. Compared with older patients, children who presented before 5 years of age were more likely to have moderate to severe carditis and to present with arthritis or the rash of erythema marginatum and were less likely to have chorea. Chronic rheumatic heart disease was common in young children who presented with carditis. Long-term follow-up is necessary to determine the outcome for young children with subclinical echocardiographic evidence of valvular disease.

A case of acute rheumatic fever accompanied by transient aortic regurgitation

Though acute rheumatic fever (RF) is now rare in Japan, it continues to be an important disease condition that physicians should be prepared to diagnose and treat. We describe a patient with acute RF accompanied by transient aortic regurgitation (AR). The AR was detected only by echocardiography. There were no other indications, and it disappeared after treatment with prednisolone. The changes in cardiac valves in the early phase of RF have been the subject of only a few case studies. Echocardiography is quite valuable in the workup of patients with acute RF and should be performed even if there are no signs of cardiac involvement.

What is new in pediatric cardiology

Enormous advances in the diagnosis and management of heart disease in pediatric patient have taken place during the last-four decades. In this review the authors will concentrate on the developments within the last five to ten years. It will deal with what may be called medical advances. Recent advances in molecular genetics and defining the familial patterns have led to finding that certain genetic and molecular factors are linked to congenital heart disease and arrythmia, thus providing opportunity for improved genetic counseling and future gene therapy. Medical treatment of congenital heart disease targets not only the augmentation of ventricular contractility (positive inotropy) but also addresses the neuro-humoral derangement associated with it. The ultrasound technology for the evaluation of the heart has come a long way from the early A-mode and M-mode capabilities to color Doppler, 2-dimentional and 3-dimentional capabilities.

Rheumatic fever

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

Rheumatic fever in the 21st century

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

Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease

OBJECTIVE

To determine the frequency of occurrence and long term evolution of subclinical carditis in patients with acute rheumatic fever.

DESIGN

Valvar incompetence was detected by clinical examination and Doppler echocardiographic imaging during the acute and quiescent phases of rheumatic fever. Patients were followed prospectively and submitted to repeat examinations at one and five years after the acute attack. Persistence of acute mitral and aortic lesions detected solely by echocardiography (subclinical disease) was compared with that of disease detected by clinical examination as well (thereby fulfilling the latest 1992 Jones criteria for rheumatic carditis).

SETTING

Three general hospitals with a university affiliation in Chile.

PATIENTS

35 consecutive patients fulfilling the revised Jones criteria for rheumatic fever. Clinical and echocardiographic examination was repeated in 32 patients after one year and in 17 after five years. Ten patients had subclinical carditis on admission, six of whom were followed for five years.

MAIN OUTCOME MEASURES

Auscultatory and echocardiographic evidence of mitral or aortic regurgitation during the acute attack or at follow up.

RESULTS

Mitral or aortic regurgitation was detected by Doppler echocardiographic imaging in 25/35 rheumatic fever patients as opposed to 5/35 by clinical examination (p = 0.03). Doppler echocardiography revealed acute valvar lesions in 10 of 20 rheumatic fever patients who had no auscultatory evidence of rheumatic carditis (subclinical carditis). Three of these subclinical lesions and three of the clinical or auscultatory lesions detected on admission were still present after five years of follow up, emphasising that subclinical lesions are not necessarily transient.

CONCLUSIONS

Doppler echocardiographic imaging improves the detection of rheumatic carditis. Subclinical valve lesions, detected only by Doppler imaging, can persist. Echocardiographic findings should be accepted as a major criterion for the diagnosis of rheumatic fever.

Bedside cardiac examination: constancy in a sea of change

The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. Although not proven, it is likely that individual training with computer technology, audiotape instruction, or simulator technology such as described in the following paragraphs would be effective at improving bedside clinical diagnosis and cost-effective patient care in the postgraduate, continuing medical education setting. The advances in auscultation during the last few years have been more incremental than fundamental. There is ongoing research into the mechanism of production of S3 and S4, and mathematical modeling techniques have recently been used with some success in evaluating the vibrations of S3 and S4 as forced, damped oscillations of a viscoelastic system. Analysis of sound energy with the technique of spectral waveform analysis, which investigates the frequency content of sound signals, has been used for many years in the study of cardiovascular sound. By the use of various methods of mathematical analysis, investigators have found potentially useful information in spectral sound patterns of prosthetic valves, murmur characteristics, and even potentially hemodynamic information from heart sounds. Despite the mathematical advances, there are still disturbing drawbacks to some of the analytic techniques, such as the production of mathematical terms containing "negative energy." Although the potential of obtaining significant clinical information from spectral analysis of heart sound recordings is attractive, the clinical usefulness of such techniques remains virtually nonexistent. Similar to the recent advances in auscultation, the technical advances in the design of the stethoscope have also been more incremental than fundamental. There are at least 3 recently introduced electronic stethoscopes that have the capability of amplification and filtration and that claim noise reduction. Because their introduction is recent, no information is available in the peer-review literature regarding their clinical performance; therefore their place in the clinical arena remains to be elucidated--perhaps a boon for patient care providers with specific hearing defects and perhaps useful in noisy clinical environments. Peer-review literature has not shown clear superiority of one type of acoustic stethoscope over another. The teaching of auscultation has been an area of recognized importance in patient care since the inception of auscultation as a medical art. Attempts to facilitate practitioner learning in the performance and interpretation of auscultation have advanced through the decades limited only by the technical infrastructure of the day. The availability of recorded heart sounds and murmurs appeared shortly after the availability of recording and playback devices, with first vinyl and later tape recordings. In 1974, technology was employed to create a virtual patient named "Harvey," an engineered cardiology patient simulator that reproduces many of the physical findings of the cardiology examination. Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)

Usefulness of antimyosin antibody imaging for the detection of active rheumatic myocarditis

Myocarditis constitutes an important component of rheumatic carditis. Antimyosin scintigraphy, which allows noninvasive assessment of myocyte damage, can be used for documentation of cardiac involvement in patients with rheumatic fever where clinical diagnosis is not unequivocal.