On the gravity of the acute rheumatic fever in children from Pernambuco, Brazil.

Abstract

In an anatomopathological study dated 1970, Lira et al1 showed the severity of Acute Rheumatic Disease (ARD) in Pernambuco, describing 43% of the 52 cases studied in childhood and highlighting the importance of cardiomegaly and the high level of adhesive pericarditis. This study contradicted the idea that the ARD was a condition inherent in cold climates. Although in almost all regions of the world the reduced incidence and increased prevalence of the disease vis-a-vis the application of Doppler echocardiogram are described in the study of populations2, in our field, despite parallels with this universal finding, severe forms of ARD arise, requiring early surgical management of heart valve lesions in children with high surgical risk. Why Pernambuco still presents such severe forms of a disease nearly extinct in developed countries? The analysis of the clinical condition of 13 severely ill children, studied in detail for a short period - 18 months - at a single hospital in Recife, out of 54 children, thus revealing high prevalence, should partly answer this question. Clinical characteristics of a sample of 13 patients From January 2011 to June 2012, 54 children with acute rheumatic heart disease, with diagnosis based on the modified Jones criteria, assisted at the IMIP, 13 of which were hospitalized with a severe clinical picture, accounting for 24.2% of this series, with active ARD. In a recent hospital study conducted in Auckland, New Zealand3, over a 12-year period, 44 patients were described, which shows the representativeness of the sample, obtained in a short period of 18 months. Table 1 shows clinical and laboratory data that caught our attention. In the analysis, we can see that: Table 1 Clinical and laboratory findings in 13 children with severe acute rheumatic fever. Recife, 2013 a) The picture of rheumatic heart disease was preceded by tonsillitis in at least half of the cases, with fever and arthritis in nearly 70% of them; b) Congestive Heart Failure (CHF), including Acute Pulmonary Edema (APE), occurred in 100% of patients with Mitral Insufficiency (MI) diagnosed in the same 100%, accompanied by Aortic Regurgitation (AR) in about one third of the cases - in the genesis of IM, the rupture of the mitral valve chordae tendineae in 1/4 of the series was relevant. Despite the CHF, the left ventricular ejection fraction (LVEF) remained normal or exaggerated, except in 2 patients with MI with ruptured chordae tendineae and AR - normal LVEF is consistent with the literature, a fact that comes in disfavor of a myocardial factor in the genesis of the CHF, which would be due primarily to the valvular involvement4; c) Only one case of chorea (case 2 - 7.7%) was observed; d) There was severe cardiomegaly with average cardiothoracic index (CTI) of 57.7%, reaching as much as 71.7%; e) On three occasions, very high values were found for the number of leukocytes in peripheral blood, and, on four occasions, there were high levels of Anti-streptolysin O (ASO), contradicting what is put by Decourt5, who recognizes a slight increase in these variables, arguing marked bacterial aggressiveness and long-lasting antigenic stimulation; f) The QTc value - a potential indicator of severity in ARD5 - proved to be increased in three patients (cases 4, 6 and 8 - 23.0%), according to Decourt values. On the ECG, we saw in a patient with extreme generalized edema (!) - an old condition described by Bouillaud, in France, in 1836, in a 30-year-old man6 - fragmented QRS complex, in extrasystoles originating from the right ventricle, suggestive of the possibility of sudden death7, as well as the presence of inverted U waves in the left precordial leads, emerged shortly, indicating severity of ventricular overload, almost always present in sick patients (first-degree AV block was seen on two occasions - 15.3%); g) Of the 13 patients, 10 (76.9%) underwent implantation of bioprosthetic valves in valves mutilated by rheumatism.