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Kotit S, Yacoub MH. The Aswan Rheumatic heart disease reGIstry: rationale and preliminary results of the ARGI database. Front Cardiovasc Med 2023; 10:1230965. [PMID: 37795482 PMCID: PMC10545855 DOI: 10.3389/fcvm.2023.1230965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023] Open
Abstract
Background Rheumatic Heart Disease (RHD) remains a major cause of valvular heart disease related mortality and morbidity in low- and middle-income countries, with significant variation in characteristics and course of the disease across different regions. However, despite the high disease burden, there is sparse region-specific data on demographics, disease characteristics and course in treated and untreated patients to guide policy. Methods The ARGI database is a hospital-based registry in a tertiary referral national centre (Aswan Heart Centre, AHC) in which all patients with the diagnosis of RHD are being included. The mode of presentation, including baseline clinical and echocardiographic characteristics (as well as other imaging modalities), biomarkers and genetics are being documented. Treatment modalities and adherence to treatment is being recorded and patients are followed up regularly every 6 and/or 12 months, or more frequently if needed. Discussion This study shows for the first time an in-depth analysis of the severity and phenotype of disease in Egyptian patients presenting with RHD as well as the progression with time and provides a platform for further comparisons of regional differences in these details as well as their causes. The ARGI database will be of help in achieving the objectives of the Cairo Accord aiming at eradication of RF and RHD.
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Affiliation(s)
| | - Magdi H. Yacoub
- Heart Science Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:pathogens11020179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade’s achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
- Correspondence: or ; Tel.: +256-779010527
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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Gemechu T, Parry EHO, Yacoub MH, Phillips DIW, Kotit S. Community-based prevalence of rheumatic heart disease in rural Ethiopia: Five-year follow-up. PLoS Negl Trop Dis 2021; 15:e0009830. [PMID: 34644305 PMCID: PMC8513824 DOI: 10.1371/journal.pntd.0009830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As little is known about the prevalence and clinical progression of subclinical (latent) rheumatic heart disease (RHD) in sub-Saharan Africa, we report the results of a 5 year follow-up of a community based, echocardiographic study of the disease, originally carried out in a rural area around Jimma, Ethiopia. METHODS Individuals with evidence of RHD detected during the baseline study as well as controls and their family members were screened with a short questionnaire together with transthoracic echocardiography. RESULTS Of 56 individuals with RHD (37 definite and 19 borderline) in the original study, 36 (26 definite and 10 borderline) were successfully located 57.3 (range 44.9-70.7) months later. At follow-up two thirds of the definite cases still had definite disease; while a third had regressed. Approximately equal numbers of the borderline cases had progressed and regressed. Features of RHD had appeared in 5 of the 60 controls. There was an increased risk of RHD in the family relatives of borderline and definite cases (3.8 and 4.0 times respectively), notably among siblings. Compliance with penicillin prophylaxis was very poor. CONCLUSIONS We show the persistence of echocardiographically demonstrable RHD in a rural sub-Saharan population. Both progression and regression of the disease were found; however, the majority of the individuals who had definite features of RHD had evidence of continuing RHD lesions five years later. There was an increased risk of RHD in the family relatives of borderline and definite cases, notably among siblings. The findings highlight the problems faced in addressing the problem of RHD in the rural areas of sub-Saharan Africa. They add to the evidence that community-based interventions for RHD will be required, together with appropriate ways of identifying active disease, achieving adequate penicillin prophylaxis and developing vaccines for primary prevention.
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Affiliation(s)
| | | | - Magdi H. Yacoub
- Aswan Heart Centre, Aswan, Egypt
- NHLI, Heart Science Centre, Imperial College London, London, United Kingdom
| | - David I. W. Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Susy Kotit
- Aswan Heart Centre, Aswan, Egypt
- * E-mail:
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Abdallah AM, Abu-Madi M. The Genetic Control of the Rheumatic Heart: Closing the Genotype-Phenotype Gap. Front Med (Lausanne) 2021; 8:611036. [PMID: 33842495 PMCID: PMC8024521 DOI: 10.3389/fmed.2021.611036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/07/2021] [Indexed: 12/20/2022] Open
Abstract
Rheumatic heart disease (RHD) is a heritable inflammatory condition characterized by carditis, arthritis, and systemic disease. Although remaining neglected, the last 3 years has seen some promising advances in RHD research. Whilst it is clear that RHD can be triggered by recurrent group A streptococcal infections, the mechanisms driving clinical progression are still poorly understood. This review summarizes our current understanding of the genetics implicated in this process and the genetic determinants that predispose some people to RHD. The evidence demonstrating the importance of individual cell types and cellular states in delineating causal genetic variants is discussed, highlighting phenotype/genotype correlations where possible. Genetic fine mapping and functional studies in extreme phenotypes, together with large-scale omics studies including genomics, transcriptomics, epigenomics, and metabolomics, are expected to provide new information not only on RHD but also on the mechanisms of other autoimmune diseases and facilitate future clinical translation.
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Affiliation(s)
- Atiyeh M Abdallah
- Biomedical and Pharmaceutical Research Unit, Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Marawan Abu-Madi
- Biomedical and Pharmaceutical Research Unit, Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
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Poomarimuthu M, Ramasamy T, Govindan R, Andiappan R, Nagarajan G, Kadiam S, Mariakuttikan J. Association of HLA-DRB1 Alleles with Rheumatic Fever and Rheumatic Heart Disease: A Meta-analysis. Immunol Invest 2020; 51:221-232. [PMID: 32967480 DOI: 10.1080/08820139.2020.1822864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rheumatic fever (RF) and its sequel rheumatic heart disease (RHD) is an autoimmune disease caused by an abnormal host immune response to group A streptococcus (GAS) infection. The HLA class II molecules are entailed in immune-mediated infectious, inflammatory, and autoimmune diseases including RHD. However, HLA class II genes are reported to be associated with RF/RHD across different populations with a very little consistency. OBJECTIVE The aim of the study is to investigate the association between HLA class II genes and RF/RHD by meta-analysis. METHODS A comprehensive literature search was conducted to identify all relevant case-control studies published before December 31, 2019. The data were extracted using standardized form and pooled odds ratio (OR) with 95% confidence interval (CI) are calculated to assess the strength of the association between HLA class II genes and RF/RHD. RESULTS Thirteen studies for HLA-DRB1 alleles (1065 patients and 1691 controls) and eight studies for HLA-DQB1 alleles (644 patients and 1088 controls) were finally included. The meta-analysis showed a significantly higher frequency of HLA-DRB1*07 allele (OR = 1.68, P < .0001) in RF/RHD patients when compared to controls, while the frequency of HLA-DRB1*15 allele (OR = 0.60, P = .03) was significantly lower in RF/RHD patients than in controls. However, there were no significant differences in the frequency of HLA-DQB1 alleles between RF/RHD patients and controls. CONCLUSIONS The results of the meta-analysis suggest that the differential presentation of autoimmune peptides by HLA-DRB1*07 (susceptible) and HLA-DRB1*15 (protective) alleles with different affinities may play a crucial role in the pathogenesis of RF/RHD.
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Affiliation(s)
| | - Thirunavukkarasu Ramasamy
- Maternal-Child Health Center, Translational Health Science and Technology Institute, Faridabad, India.,Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, India
| | - Ramajayam Govindan
- Multidisciplinary Research Unit, Madurai Medical College, Madurai, India
| | - Rathinavel Andiappan
- Department of Cardio Vascular Thoracic Surgery, Madurai Medical College & Government Rajaji Hospital, Madurai, India
| | - Gunavathy Nagarajan
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, India
| | - Sony Kadiam
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, India
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Sharma N, Toor D, Baro L, Chaliha MS, Kusre G, Baruah SM, Das S. HLA-DQB genetic susceptibility and rheumatic heart disease: a case-control study. Asian Cardiovasc Thorac Ann 2020; 28:147-151. [DOI: 10.1177/0218492320908988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Rheumatic heart disease is a major global health concern, especially in low- and middle-income countries. The pathogenesis is attributable to an aberrant immune response, host genetic factors, and socioeconomic status. The objective of this study was to screen HLA-DQB1 alleles as genetic susceptibility markers in rheumatic heart disease patients in Assam, North East India, and to correlate the predominant allele with socioeconomic status and clinical profile. Methods A case-control study of 100 echocardiography-confirmed rheumatic heart disease patients and age- and sex-matched healthy controls from Assam Medical College and Hospital was conducted. Human leukocyte antigen typing was performed using HLA-DQ typing kit. A questionnaire was designed to study the socioeconomic status and clinical profile of rheumatic heart disease patients. Results Among the 9 alleles studied, HLA-DRBQ1*03:01 was found to be the statistically significant predominant allele in this population, especially in the Ahom ethnic group. In the HLA-DRBQ1*03:01-positive population, rural dwelling was found to be a significantly increased risk factor for rheumatic heart disease. Among severe cases, 90% of mitral stenosis, 40% of mitral regurgitation, and 33.3% of aortic regurgitation cases were HLA-DRBQ1*03:01-positive. Also, 50% of aortic valve thickening and 36.8% of mitral valve thickening cases were found in this population. Conclusion Our data suggest that HLA-DRBQ1*03:01 is a significant susceptibility marker in this population, and predominant in the rural population. Furthermore, it may play an important role in determining the pattern of valve damage in rheumatic heart disease patients.
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Affiliation(s)
- Neha Sharma
- Amity Institute of Virology and Immunology, Amity University Uttar Pradesh, India
| | - Devinder Toor
- Amity Institute of Virology and Immunology, Amity University Uttar Pradesh, India
| | - Lokajeet Baro
- Assam Medical College and Hospital, Dibrugarh, Assam, India
| | | | - Giriraj Kusre
- Assam Medical College and Hospital, Dibrugarh, Assam, India
| | | | - Sangeeta Das
- Assam Medical College and Hospital, Dibrugarh, Assam, India
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Forcillo J, Watkins DA, Brooks A, Hugo-Hamman C, Chikoya L, Oketcho M, Thourani VH, Zühlke L, du Toit H, Nghaamwa J, Beshir S, Shidhika F, Mwandileya M, Mulendele E, Musuku J, Okello ES, Mwambu TP, Omagino J, Lwabi P, Nyakoojo WB. Making cardiac surgery feasible in African countries: Experience from Namibia, Uganda, and Zambia. J Thorac Cardiovasc Surg 2019; 158:1384-1393. [DOI: 10.1016/j.jtcvs.2019.01.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 12/29/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
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8
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Rheumatic fever and rheumatic heart disease: Facts and research progress in Africa. Int J Cardiol 2019; 295:48-55. [DOI: 10.1016/j.ijcard.2019.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/24/2019] [Indexed: 11/17/2022]
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9
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Sharma N, Toor D. Impact of Socio-Economic Factors on Increased Risk and Progression of Rheumatic Heart Disease in Developing Nations. Curr Infect Dis Rep 2019; 21:21. [DOI: 10.1007/s11908-019-0677-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Rwebembera J, Manyilirah W, Zhu ZW, Nabbaale J, Namuyonga J, Ssinabulya I, Lubega S, Lwabi P, Omagino J, Okello E. Prevalence and characteristics of primary left-sided valve disease in a cohort of 15,000 patients undergoing echocardiography studies in a tertiary hospital in Uganda. BMC Cardiovasc Disord 2018; 18:82. [PMID: 29728065 PMCID: PMC5935941 DOI: 10.1186/s12872-018-0813-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/20/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although rheumatic heart disease remains the leading cause of valve heart disease (VHD) in developing countries, other forms of valve disease have been over shadowed and not regarded as a public health problem. However, several facts suggest that the role of non-rheumatic VHD as a significant cardiovascular disease should be reconsidered. We aimed to assess the prevalence and characteristics of different forms of primary left sided valve diseases from a series of 15,009 echocardiographic studies. METHODS This was a retrospective review of echocardiographic reports for studies performed between January 2012 and December 2013 (24 months) at Uganda Heart Institute. All patients with primary left-sided valve disease were classified into one of five major diagnostic categories and in each diagnostic category; patients were sub-classified into stages A-D of primary valve disease as defined by the American College of Cardiology. RESULTS Three thousand five hundred eighty-two echocardiography reports qualified for final data analysis. The "sclerotic valve changes with normal valve function", a Stage A sub-class of "degenerative valve disease" overwhelmingly overshadowed all the other diagnostic categories in this stage. "Rheumatic Heart Disease", "Degenerative Valve Disease", "Bicuspid Aortic Valve", "Mitral Valve Prolapse" and "Endomyocardial Fibrosis" diagnostic categories accounted for 53.0%, 41.8%, 2.2%, 1.4% and 1.7% respectively in stages B-D of primary VHD. Rheumatic heart disease disproportionately affected the young, productive age groups. It was the major risk factor for infective endocarditis; and was the indication for valve surgery in 44 of 50 patients who had undergone valve replacement procedures. CONCLUSIONS We acknowledge that rheumatic heart disease remains a leading cause of progressive and severe primary left-sided valve disease among young adults in Uganda. But we bring to light the contemporary footprints of other forms of primary valve disease that require coordinated multidisciplinary approach to research, education and clinical management to ensure improved patient outcomes.
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Affiliation(s)
| | | | | | | | - Judith Namuyonga
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | | | - Peter Lwabi
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | | | - Emmy Okello
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
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Streptococcal pharyngitis and rheumatic heart disease: the superantigen hypothesis revisited. INFECTION GENETICS AND EVOLUTION 2018. [PMID: 29530660 DOI: 10.1016/j.meegid.2018.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Streptococcus pyogenes is a human-specific and globally prominent bacterial pathogen that despite causing numerous human infections, this bacterium is normally found in an asymptomatic carrier state. This review provides an overview of both bacterial and human factors that likely play an important role in nasopharyngeal colonization and pharyngitis, as well as the development of acute rheumatic fever and rheumatic heart disease. Here we highlight a recently described role for bacterial superantigens in promoting acute nasopharyngeal infection, and discuss how these immune system activating toxins could be crucial to initiate the autoimmune process in rheumatic heart disease.
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Association of IL-1β +3953 C and HLA-DRB1*15 with Coronary Artery and Rheumatic Heart Diseases in South India. Hum Immunol 2016; 77:1275-1279. [PMID: 27521249 DOI: 10.1016/j.humimm.2016.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 08/02/2016] [Accepted: 08/08/2016] [Indexed: 11/20/2022]
Abstract
Among the various candidate genes predisposing for cardiovascular diseases, HLA-DRB1* and IL-1β +3953C/T alleles have been implicated repeatedly. To test these in South India, we carried out a case control study of 323 Coronary Artery Disease (CAD) patients, 56 Rheumatic Heart Disease (RHD) patients and 254 endemic controls. The polymorphisms were studied by PCR - SSP and ARMS-PCR methods and results analyzed for various clinical and demographic parameters. In CAD, HLA-DRB1*14 allele showed significant predisposition (OR: 2.19; 95% CI: 1.04-4.58; p value=0.023), particularly in male patients (OR: 4.07; 95% CI: 1.20-13.81; p value=0.01) and further in males with Triple Vessel Disease (OR: 5.49; 95% CI: 1.45-20.60; p value=0.007). On the other hand, HLA-DRB1*15 predisposed for RHD (OR: 3.56; 95% CI: 1.87-6.78; p value=0.001) in both the genders. Population stratification showed this higher risk association in Vanniyar caste (OR: 5.00; 95% CI: 1.27-19.59; p value=0.022). Among the IL1-β +3953C/T polymorphism, the ancestral allele 'C' showed a significant high risk association with CAD (OR: 1.83; 95% CI: 1.24-2.70; p value=0.001), particularly in Mudaliar (OR: 6.07; 95% CI: 1.77-20.74; p value=0.003; AF=0.7) and Vanniyar castes (OR: 3.67; 95% CI: 0.92-14.57; p value=0.05; AF=0.660). Two different cardiac ailments studied, RHD & CAD thus showed varied associations in this South Indian cohorts. RHD having an infectious aetiology shared a HLA-DRB1*15 high risk association, while HLA-DRB1*14 and IL-1β +3953C predisposed for CAD, an inflammatory disorder, reiterating the diverse genetic predisposition of the two cardiac ailments studied.
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Aliku T, Sable C, Scheel A, Tompsett A, Lwabi P, Okello E, McCarter R, Summar M, Beaton A. Targeted Echocardiographic Screening for Latent Rheumatic Heart Disease in Northern Uganda: Evaluating Familial Risk Following Identification of an Index Case. PLoS Negl Trop Dis 2016; 10:e0004727. [PMID: 27294545 PMCID: PMC4905680 DOI: 10.1371/journal.pntd.0004727] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/02/2016] [Indexed: 11/19/2022] Open
Abstract
Background Echocardiographic screening for detection of latent RHD has shown potential as a strategy to decrease the burden of disease. However, further research is needed to determine optimal implementation strategies. RHD results from a complex interplay between environment and host susceptibility. Family members share both and relatives of children with latent RHD may represent a high-risk group. The objective of this study was to use echocardiographic family screening to determine the relative risk of RHD among first-degree relatives of children with latent RHD compared to the risk in first-degree relatives of healthy peers. Methodology/Principal Findings Previous school-based screening data were used to identify RHD positive children and RHD negative peers. All first-degree relatives ≥ 5 years were invited for echocardiography screening (2012 World Heart Federation Criteria). Sixty RHD positive cases (30 borderline/30 definite RHD) and 67 RHD negative cases were recruited. A total of 455/667 (68%) family members were screened. Definite RHD was more common in childhood siblings of RHD positive compared to RHD negative (p = 0.05). Children with any RHD were 4.5 times as likely to have a sibling with definite RHD, a risk that increased to 5.6 times when considering only cases with definite RHD. Mothers of RHD positive and RHD negative cases had an unexpectedly high rate of latent RHD (9.3%). Conclusions/Significance Siblings of RHD positive cases with RHD are more likely to have definite RHD and the relative risk is highest if the index case has definite RHD. Future screening programs should consider implementation of sibling screening following detection of an RHD positive child. Larger screening studies of adults are needed, as data on prevalence of latent RHD outside of childhood are sparse. Future studies should prioritize implementation research to answer questions of how RHD screening can best be integrated into existing healthcare structures, ensuring practical and sustainable screening programs. Rheumatic heart disease (RHD) affects at least 33 million people, most of who live in low-resource environments. RHD is a cumulative process and there exists a latent period between early valve damage and presentation with symptoms. Echocardiographic screening (ultrasound of the heart) has proven highly sensitive for latent RHD detection, but implementation research is needed to effectively develop sustainable public health strategies. Critical to this research is determining whom to screen. As family members have both a shared environment and shared genetic susceptibility, they may represent a high-risk group that could be targeted once a case of RHD is identified. We conducted an echocardiographic family screening study to determine the risk of RHD in families with and without an RHD positive child and found that siblings of children with latent RHD are more likely to have latent RHD themselves. Our data suggest that siblings may represent a particularly high-risk group that could be targeted for echocardiographic screening. Future studies are needed to answer questions of how RHD screening can best be integrated into existing healthcare structures, ensuring practical and sustainable RHD screening programs.
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Affiliation(s)
- Twalib Aliku
- School of Medicine, Gulu University, Gulu, Uganda
| | - Craig Sable
- Division of Cardiology, Children’s National Health System, Washington, District of Columbia, United States of America
| | - Amy Scheel
- Division of Cardiology, Children’s National Health System, Washington, District of Columbia, United States of America
| | - Alison Tompsett
- Division of Cardiology, Children’s National Health System, Washington, District of Columbia, United States of America
| | | | - Emmy Okello
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine, Makerere University, Kampala, Uganda
| | - Robert McCarter
- Division of Biostatistics and Informatics, Children’s National Health System, Washington, District of Columbia, United States of America
| | - Marshall Summar
- Division of Genetics and Metabolism, Children’s National Health System, Washington, District of Columbia, United States of America
| | - Andrea Beaton
- Division of Cardiology, Children’s National Health System, Washington, District of Columbia, United States of America
- * E-mail:
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Abstract
Rheumatic heart disease (RHD) constitutes a leading cause of premature death and incapacity in Africa, where it is encountered in younger people, and shows a much faster and more malignant course than that seen in Europe or North America. While it is well established that RHD is a consequence of recurrent, untreated group A β-haemolytic streptococcal infections (GAS), the pathogenesis is incompletely understood, and the variation in natural history and phenotypes are not fully explained. In Africa patients are rarely diagnosed with acute rheumatic fever (ARF). They usually present in the late stages of RHD, with the severe and virulent forms occurring at early ages, therefore leading to high morbidity and mortality in young patients.
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Affiliation(s)
- Ana Olga Mocumbi
- Instituto Nacional de Saüde and Universidade Edurado Mondlane, Maputo, Moçambique.
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15
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Zhang W, Okello E, Nyakoojo W, Lwabi P, Mondo CK. Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions. Afr Health Sci 2015; 15:1182-8. [PMID: 26958019 DOI: 10.4314/ahs.v15i4.17] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy. METHODS We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease. RESULTS Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully. CONCLUSION There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.
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Markham R, Tulloh R. Fifteen-minute consultation: rheumatic fever. Arch Dis Child Educ Pract Ed 2015; 100:176-9. [PMID: 25653243 DOI: 10.1136/archdischild-2014-306545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 01/12/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To present a structured approach for an outpatient consultation or inpatient assessment of a child with possible rheumatic fever. METHOD Review of literature and description of diagnostic and therapeutic approach. CONCLUSIONS A focused history and examination is key to establish the cause and draw a management plan for rheumatic fever.
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Affiliation(s)
- Rebecca Markham
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, Bristol, UK
| | - Robert Tulloh
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, Bristol, UK
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Martin WJ, Steer AC, Smeesters PR, Keeble J, Inouye M, Carapetis J, Wicks IP. Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmun Rev 2015; 14:710-25. [PMID: 25891492 DOI: 10.1016/j.autrev.2015.04.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
Abstract
There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.
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Affiliation(s)
- William John Martin
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Andrew C Steer
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Pierre Robert Smeesters
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Joanne Keeble
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Michael Inouye
- Medical Systems Biology, Department of Pathology and Department of Microbiology and Immunology, University of Melbourne, VIC 3010, Australia
| | | | - Ian P Wicks
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Rheumatology Unit, Royal Melbourne Hospital, Parkville, VIC 3052, Australia.
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Minodier P, Laporte R, Miramont S. Épidémiologie des infections à streptocoque du groupe A dans les pays en développement. Arch Pediatr 2014; 21 Suppl 2:S69-72. [DOI: 10.1016/s0929-693x(14)72263-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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