Rheumatic heart disease in schoolchildren in western district, Saudi Arabia

The Prevalence and Predictors of Atherosclerotic Coronary Artery Disease in Rheumatic and Non-rheumatic Valvular Heart Disease Patients

OBJECTIVES

The paradox of concurrent coronary artery disease (CAD) among patients with rheumatic and non-rheumatic valvular heart disease (RVHD; non-RVHD) is unclear. We aimed to evaluate the impact of the RVHD and non-RVHD on the prevalence of CAD and various risk factors, assess the number of diseased coronaries, clinical profile and the possible predictors of CAD in these patients, which may clarify the paradox and provide an insight for the prevention of CAD.

METHODS

The records of 106 valvular heart disease patients who had undergone valve replacement surgery at the King Faisal Cardiac Centre from January 2014 to October 2019 were evaluated. The clinical data and established risk factors were compared and logistic regression analyses were performed to identify plausible predictors of CAD.

RESULTS

Transthoracic echocardiographic diagnosis of 106 patients confirmed, 43 had RVHD (56.4 ± 8 years), of whom six (13.9%) had CAD with the highest mitral valve regurgitation (p < 0.01), and 63 had non-RVHD (60.0 ± 12 years). Of these, 31 patients showed the highest CAD (49.2%). Single- and triple-vessel disease was most common in RVHD and non-RVHD patients with concurrent CAD (33.3%; 41.9%, respectively), while non-RVHD patients also had quadruple vessel disease. The mean age of the RVHD and non-RVHD patients with coexisting CAD was significantly higher (66.7 ± 5; 66.7 ± 8 years) than those without CAD (46.1 ± 12.0; 54.7 ± 20, respectively). RVHD patients showed a significantly lower prevalence of diabetes, dyslipidaemia, hypertension, inflammatory cells, hepatorenal function markers, ejection fraction, and regional wall motion abnormality compared to RVHD patients with coexisting CAD (p < 0.01). Bivariate analysis indicated white blood cells, monocytes, neutrophils, gamma-glutamyl-transferase (GGT), bilirubin and blood urea nitrogen (BUN) to be significantly lower in RVHD patients. Predictors of high risk of CAD were BUN and hyperlipidaemia for RVHD and BUN, creatinine and GGT for non-RVHD patients.

CONCLUSIONS

The prevalence of CAD in Saudi RVHD patients was significantly lower than in the Western countries, whereas non-RVHD was higher. The low prevalence may partly be attributed to age, reduced mitral regurgitation, and low frequency of risk and inflammatory factors.

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.

Acute rheumatic fever diagnosis and management: Review of the global implications of the new revised diagnostic criteria with a focus on Saudi Arabia

Rheumatic fever (RF) is a common cause of acquired heart disease in children worldwide. It is a delayed, nonsuppurative, autoimmune phenomenon following pharyngitis, impetigo, or scarlet fever caused by group A β-hemolytic streptococcal (GAS) infection. RF diagnosis is clinical and based on revised Jones criteria. The first version of the criteria was developed by T. Duckett Jones in 1944, then subsequently revised by the American Heart Association (AHA) in 1992 and 2015. However, RF remains a diagnostic challenge for clinicians because of the lack of specific clinical or laboratory findings. As a result, it has been difficult for some time to maintain a balance between over- and underdiagnosis of RF cases. The Jones criteria were revised in 2015 by the AHA, and the main modifications were as follows: the population was subdivided into moderate- to high-risk and low risk; the concept of subclinical carditis was introduced; and monoarthritis was included as a feature of musculoskeletal inflammation in the moderate- to high-risk population. This review will highlight the major changes in the AHA 2015 revised Jones criteria for pediatricians and general practitioners.

Anticoagulation in Pregnancy with Mechanical Heart Valves: 10-Year Experience

Anticoagulation in pregnancy was evaluated in 33 women with a mechanical heart valve prosthesis who had 53 pregnancies between 1994 and 2006. Their mean age at valve operation was 24.4 ± 5.4 years, and 22 (67%) had isolated mitral valve disease. Of these patients, 22 had a single pregnancy, 5 had 2 pregnancies, 3 had 3, and 3 had 4. In 43 pregnancies, the patients took warfarin throughout; in the other 10, heparin was used in the first trimester followed by warfarin until the last 15 days. Mean international normalized ratio and warfarin levels before, during, and after pregnancy were similar. Complications occurred in 3 (6%) women who had thrombosed valves: 2 (20%) in the heparin group and 1 (2%) who had warfarin only. Live births resulted from 37 (70%) pregnancies. There were significantly more abortions in the heparin group (6; 60%) than the warfarin group (8; 19%). Hemorrhage requiring transfusion occurred in 2 (5%) patients in the warfarin group. All live births resulted in healthy babies. It was concluded that anticoagulation with warfarin is safe during pregnancy in women with mechanical heart valves.

Impact of MIF Gene Promoter Variations on Risk of Rheumatic Heart Disease and Its Age of Onset in Saudi Arabian Patients

Although macrophage migration inhibitory factor (MIF) has consistently been shown to be an important immune modulator, data on the association between MIF promoter variations and the risk of developing rheumatic heart disease (RHD) remain inconclusive. RHD is an important complication of streptococcal infections in the Middle East, not least in Saudi Arabia, and identifying risk markers is an important priority. Therefore, we investigated the association between two functional MIF promoter variations and RHD susceptibility and severity in Saudi patients: the MIF-173G > C substitution (rs755622) and the MIF-794 CATT5-8 tetranucleotide repeat (rs5844572). Three hundred twenty-six individuals (124 RHD patients and 202 age-, sex-, and ethnically matched healthy controls) were genotyped using allelic discrimination and fragment analysis. Data were analyzed with respect to disease susceptibility, severity, sex, and age of onset. There was a significantly lower frequency of 173C allele carriage in RHD patients compared to controls [odds ratio (OR) = 0.47; 95% confidence intervals (CIs) = 0.28-0.77; p = 0.003]. Interestingly, the 173C allele was associated with late disease onset (p = 0.001). The 794 5-repeat allele was associated with decreased RHD risk (OR = 0.56; 95% CIs = 0.38-0.82; p = 0.003). In contrast, the 794 6-repeat allele was associated with increased risk of RHD (OR = 1.7; 95% CIs = 1.2-2.5; p = 0.002). MIF promoter variations appear to have a dual role in RHD, with 173C allele non-carriers at higher risk of developing RHD at a younger age. These results require further validation in larger multi-ethnic cohorts, and functional studies are necessary to understand the underlying molecular mechanisms driving the at-risk phenotype.

IL10 Promoter Polymorphisms are Associated with Rheumatic Heart Disease in Saudi Arabian Patients

Rheumatic heart disease (RHD) is an inflammatory disease that develops following streptococcal infections. IL10 helps to balance immune responses to pathogens. IL10 polymorphisms have been associated with RHD, although results remain inconclusive. Our aim was to investigate the association between IL10 polymorphisms and RHD in Saudi Arabian patients. IL10 promoter polymorphisms (-1082A/G, -829C/T, and -592C/A) were genotyped in 118 RHD patients and 200 matched controls using the TaqMan allelic discrimination assay. There was a significant difference in IL10-1082 genotype frequency between patients and controls (p = 0.01). -1082G allele carriage (GG+GA vs AA) and the (-1082, -819, -592) GCC haplotype carriage were associated with an increased risk of RHD (p = 0.004, OR 2.1, 95% CIs 1.7-3.4 and p = 0.004, OR 2, 95% CIs 1.3-3.4, respectively). The ACC haplotype was associated with a decrease in RHD risk (p = 0.015, OR 0.6, 95% CIs 0.4-0.9). IL10 promoter polymorphisms may play an important role in the development of RHD and provide an opportunity for therapeutic stratification.

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.

Cutting edge issues in rheumatic fever

Although the incidence of acute rheumatic fever and rheumatic heart disease has decreased significantly in regions of the world where antibiotics are easily accessible, there remains a high incidence in developing nations as well as in certain regions where there is a high incidence of genetic susceptibility. These diseases are a function of poverty, low socioeconomic status, and barriers to healthcare access, and it is in the developing world that a comprehensive prevention program is most critically needed. Development of group A streptococcal vaccines has been under investigation since the 1960s and 50 years later, we still have no vaccine. Factors that contribute to this lack of success include a potential risk for developing vaccine-induced rheumatic heart disease, as well as difficulties in covering the many serological subtypes of M protein, a virulence factor found on the surface of the bacterium. Yet, development of a successful vaccine program for prevention of group A streptococcal infection still offers the best chance for eradication of rheumatic fever in the twenty-first century. Other useful approaches include continuation of primary and secondary prevention with antibiotics and implementation of health care policies that provide patients with easy access to antibiotics. Improved living conditions and better hygiene are also critical to the prevention of the spread of group A streptococcus, especially in impoverished regions of the world. The purpose of this article is to discuss current and recent developments in the diagnosis, pathogenesis, and management of rheumatic fever and rheumatic heart disease.

Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren

BACKGROUND

Historically, sub-Saharan Africa has had the highest prevalence rates of clinically detected rheumatic heart disease (RHD). Echocardiography-based screening improves detection of RHD in endemic regions. The newest screening guidelines (2006 World Health Organization/National Institutes of Health) have been tested across India and the Pacific Islands, but application in sub-Saharan Africa has, thus far, been limited to Mozambique. We used these guidelines to determine RHD prevalence in a large cohort of Ugandan school children, to identify risk factors for occult disease, and to assess the value of laboratory testing.

METHODS AND RESULTS

Auscultation and portable echocardiography were used to screen randomly selected schoolchildren, 5 to 16 years of age, in Kampala, Uganda. Disease likelihood was defined as definite, probable, or possible in accordance with the 2006 National Institutes of Health/World Health Organization guidelines. Ninety-seven percent of eligible students received screening (4869 of 5006). Among them, 130 children (2.7%) had abnormal screening echocardiograms. Of those 130, secondary evaluation showed 72 (55.4%) with possible, probable, or definite RHD; 18 (13.8%) with congenital heart disease; and 40 (30.8%) with no disease. Echocardiography detected 3 times as many cases of RHD as auscultation: 72 (1.5%) versus 23 (0.5%; P<0.001). Children with RHD were older (10.1 versus 9.3 years; P=0.002). Most cases (98%) involved only the mitral valve. Lower socioeconomic groups had more RHD (2.7% versus 1.4%; P=0.036) and more advanced disease (64% versus 26%; P<0.001). Antistreptolysin O titers were elevated in children with definite RHD.

CONCLUSIONS

This is one of the largest single-country childhood RHD prevalence studies and the first to be conducted in sub-Saharan Africa. Our data support inclusion of echocardiography in screening protocols, even in the most resource-constrained settings, and identify lower socioeconomic groups as most vulnerable. Longitudinal follow-up of children with echocardiographically diagnosed subclinical RHD is needed.

Prevalence of rheumatic heart disease among school-children in Aden, Yemen

BACKGROUND

Rheumatic heart disease (RHD) is an important contributor to cardiovascular disease in children and adults in Yemen. This is the first report to determine the prevalence of RHD among school-children in the city of Aden.

METHODS

A cross-sectional case-finding survey of RHD was conducted in 6000 school-children aged 5-16 years. Echocardiography was undertaken in those with clinical signs of organic heart disease.

RESULTS

The prevalence of RHD was 36·5/1000 school-children, which is one of the highest reported among school echocardiography surveys in the world. RHD was more common in 10-16-year-old students. RHD was diagnosed in more than one member of the families of 53 (24·2%) of the children. Mitral regurgitation (MR) was detected in 49·8%, 26·6% had MR with mitral valve prolapse and 17·8% had combined MR and aortic regurgitation. Fifty-eight children were diagnosed with congenital heart disease (CHD), representing a prevalence of 9·7/1000. The main types of CHD were mitral valve prolapse, patent ductus arteriosus, atrial septal defect, pulmonary stenosis and aortic stenosis. Congenital mitral valve prolapse found in 36 children was three times more common in males than females. Children with RHD were more likely to be from low-income families with poor housing and greater overcrowding (49·3%, 39·3% and 64·8%) than children with CHD (44·8%, 32·8% and 48·3%, respectively).

CONCLUSIONS

The high prevalence of RHD is a major public health problem in Yemen. Urgent screening surveys and an RHD prophylactic programme of appropriate management of group A β-haemolytic streptococcal pharyngotonsilitis are required.

The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns around the world. Despite decreasing incidence, there is still a significant disease burden, especially in developing nations. This review provides background on the history of ARF, its pathology and treatment, and the current reported worldwide incidence of ARF and prevalence of RHD.

The primary prevention of rheumatic fever

Rheumatic fever (RF), caused by untreated group A streptococcal (GAS) pharyngitis, is a major cause of morbidity and mortality throughout much of the less developed world and disadvantaged populations (Indigenous and other) in the developed world. Through systematic literature searches, our group has identified potential risk factors for RF and possible interventions for its prevention. The causes can be divided into biological factors, socio-economic, and lifestyle factors and health-care systems and services. Currently, the most promising medical areas look to be improving access to health care and introducing community and school-based sore throat interventions (which aim to diagnose and treat GAS pharyngitis). We could find no convincing support for skin sepsis causing RF. Overall evidence suggests that measures that aim to alleviate poverty and crowding may also reduce the incidence of RF. In comparatively rich countries such as New Zealand and Australia, urgent measures based on available evidence should be undertaken to reduce the very striking health disparity seen with RF and its sequela, rheumatic heart disease in our at-risk populations.

HLA class I and class II HLA DRB profiles in Egyptian children with rheumatic valvular disease

Poststreptococcal sequelae, especially acute rheumatic fever/rheumatic heart disease continues to occur in significant proportions in many parts of the world, especially in less developed countries. An important factor in the study of rheumatic heart disease is the human genetic susceptibility to the disease. The aim of the present study was to detect the most prevalent HLA class I and class II types associated with risk of rheumatic heart disease in Egyptian children. Our study was performed on 100 patients with rheumatic valvular heart diseases and 71 control subjects. Patients were recruited from the Heart Institute, Embaba, Egypt. HLA typing for HLA class I was performed by serotyping and HLDR allele genotyping was performed using INNO-LiPA kits. In the study of HLA class I, there was a statistically significant increase in the B5 allele (P = 0.03; odds ratio, 3.46 [1.12-10.72]) in patients compared to controls, while B49 and B52 alleles (P = 0.004 and P = 0.02) were found in controls only. There was a statistically significant increase in HLA DR* 04-02, 3.46 (1.12-10.72) and HLA DR *10-0101 5.75 (1.27-25.98) in patients. Meanwhile HLA DR*1309120 was found only in controls (P = 0.02). Our study provides further information on the genetic predisposition for rheumatic valvular disease and the protective genotypes in rheumatic heart disease. Further insight into the molecular mechanisms of the disease will be a useful tool for predicting clinical outcome in those patients and, thus, potentially offer new means and approaches to treatment and prophylaxis, including a potential vaccine.

Some of the People, Some of the Time

Acute rheumatic fever is a major cause of heart disease in large parts of the world, but it remains unknown why only a small fraction of those who are infected with rheumatogenic group A streptococci develop an abnormal immune response that leads to acute rheumatic fever. An understanding of the mechanisms underlying host susceptibility can provide important insights into pathogenesis that in turn can inform new treatments. Extensive searches for susceptibility factors have been undertaken, including human leukocyte antigens, B-cell alloantigens, and cytokine genes. Although significant associations have been found between genetic factors and acute rheumatic fever, study results often conflict with each other. This review explores current understanding about host susceptibility to acute rheumatic fever and provides an overall perspective to the number of studies that have recently addressed this subject.

Status of rheumatic heart disease in rural Pakistan

OBJECTIVES

To determine the community based prevalence of rheumatic heart disease (RHD) in the rural population of the district of Rahim Yaar Khan in Pakistan.

SUBJECTS AND METHODS

A representative sample of the rural population of Rahim Yaar Khan district was selected. RHD was screened for by physical examination and the diagnosis was confirmed with echocardiographic Doppler studies. Sociodemographic data on each screened person were collected.

RESULTS

54 cases of RHD were found among the 9430 people screened (prevalence of 5.7 in 1000, 95% confidence interval 4.2 to 7.2). Females were significantly more likely to be affected. There was no significant relation with other factors studied (education, crowding, and socioeconomic status). Less than 20% of those found to have RHD were aware of their diagnosis before participation in this study and only three affected people (8%) were taking rheumatic prophylaxis.

CONCLUSIONS

There is a high prevalence of RHD among the rural population of Pakistan. The prevalence has not declined over the past three decades. Nearly all people with RHD, including most of those who know their diagnosis, do not receive the benefit of potentially life saving secondary prevention measures.

Acute rheumatic fever: a chink in the chain that links the heart to the throat?

Acute rheumatic fever (ARF) remains a major problem in tropical regions, resource-poor countries, and minority indigenous communities. It has long been thought that group A streptococcal (GAS) pharyngitis alone was responsible for acute rheumatic fever; this belief has been supported by laboratory and epidemiological evidence gathered over more than 60 years, mainly in temperate climates where GAS skin infection is uncommon. GAS strains have been characterised as either rheumatogenic or nephritogenic based on phenotypic and genotypic properties. Primary prevention strategies and vaccine development have long been based on these concepts. The epidemiology of ARF in Aboriginal communities of central and northern Australia challenges this view with reported rates of ARF and rheumatic heart disease (RHD) that are among the highest in the world. GAS throat colonisation is uncommon, however, and symptomatic GAS pharyngitis is rare; pyoderma is the major manifestation of GAS infection. Typical rheumatogenic strains do not occur. Moreover, group C and G streptococci have been shown to exchange key virulence determinants with GAS and are more commonly isolated from the throats of Aboriginal children. We suggest that GAS pyoderma and/or non-GAS infections are driving forces behind ARF in these communities and other high-incidence settings. The question needs to be resolved as a matter of urgency because current approaches to controlling ARF/RHD in Aboriginal communities have clearly been ineffective. New understanding of the pathogenesis of ARF would have an immediate effect on primary prevention strategies and vaccine development.

Systematic review of rheumatic heart disease prevalence in children in developing countries: the role of environmental factors

OBJECTIVES

To consider the worldwide prevalence of rheumatic heart disease in children in developing countries using surveys with uniform methodologies, and to consider the effect of environmental factors including socio-economic status, overcrowding, urbanization, nutrition and access to medical services on the distribution of rheumatic heart disease in developing countries.

METHODS

Sixty-one surveys of the prevalence of rheumatic heart disease in developing countries were found using a systematic review of MEDLINE from January 1976 to July 1999. Twenty-four studies were selected for comparison based on their uniform methodological and diagnostic techniques.

RESULTS

There is a high prevalence of rheumatic heart disease in the Pacific region with a lower prevalence in the Indian subcontinent, Asian, sub-Saharan African, Mediterranean, Latin American and Caribbean regions. However, aside from the Indian subcontinent, these regions have not been well studied, and it may be that the true prevalence is actually higher.

CONCLUSIONS

There is a lack of good quality prevalence surveys of rheumatic heart disease in developing countries. It appears that a threshold level where higher socio-economic status is associated with reduced prevalence of rheumatic heart disease is not reached in developing countries. Therefore, differences in prevalence between socio-economic groups in the one area cannot be detected. A similar case can be made for overcrowding. Many regions need well-designed studies of rheumatic heart disease that incorporate assessment of environmental factors as well as the study of the microbiological epidemiology of rheumatic heart disease and group A streptococci.

Epidemiological survey of rheumatic heart disease among school children in the Shimla Hills of northern India: prevalence and risk factors

STUDY OBJECTIVE

To determine the prevalence of rheumatic heart disease (RHD) and study the relationship of this disease to factors such as age, sex, housing, and socioeconomic status in Shimla town and the adjoining rural area.

DESIGN

A cross sectional survey, carried out by a specially trained examiner in cardiology.

SETTING

The study involved high risk school children (5-16 years of age) from Shimla town and the adjoining rural area of Kasumpti-Suni Block in the period 1992-93.

SUBJECTS

A total of 15,080 children on the school register (8120 boys and 6960 girls) were examined generally and specifically for evidence of RHD.

MAIN RESULTS

Of the 15,080 children screened, the prevalence of rheumatic fever (RF)/RHD was 2.98 per thousand with no significant difference between the age groups of 5-10 and 11-16 years or in either sex (p > 0.05). The prevalence was significantly greater in rural schools (4.8/1000) than in urban schools (1.98/1000) (p < 0.05). There was overcrowding and poor housing in most cases. There were fewer cases of RHD with severe valvular lesions in the younger age group than in the older children. The mitral valve was the valve most commonly affected by RF/RHD.

CONCLUSIONS

RHD continues to be a serious health problem. Regular surveys are needed to identify cases early and to ensure secondary prophylaxis with penicillin is given thereby preventing recurrence of RF and progression of the severity of the valvular lesion. Echocardiography is necessary to identify cases of RF/RHD. Strategies for preventing RHD should involve primary prevention to avert the first attack of carditis and strengthening of secondary prophylaxis through improved education and motivation of patients, parents, and physicians.

Acute rheumatic fever in Saudi Arabia: mild pattern of initial attack

Fifty-one children with the initial attack of acute rheumatic fever (ARF) were studied prospectively to verify the sociodemographic and clinical profile and to compare results with those from other countries. Most children belonged to large families who lived in an urban setting with ready access to medical care. Unlike reports from many developing countries, the clinical manifestations in this study paralleled data from the West and included arthritis in 76% of the cases, carditis in 43%, and chorea in 8%. Among the 22 cases with carditis, 18 had mitral regurgitation, three developed combined mitral and aortic regurgitation, and one had aortic regurgitation. This study demonstrates the mild nature of ARF in Saudi Arabia and supports the concept that climate and geography appear to bear little relationship to the incidence and severity of ARF.