Silent Acute Rheumatic Fever Unmasked by Using Handheld Echocardiography for Febrile Children Presenting in a Rheumatic Heart Disease–Endemic Area

Abstract

ObjectiveTo understand the burden of acute rheumatic fever (ARF) among children living in low-income countries who presenting to the hospital with febrile illness and to determine the role of handheld echocardiography (HHE) in uncovering sub-clinical carditis as a major manifestation of ARF. Study designA cross-sectional study carried at the Pediatric Hospital in Al Obeid, North Kordofan, Sudan, from September 2022 to January 2023 and including febrile children 3 through 18 years of age with or without clinical features of ARF and without another cause for their fever (not excluding malaria). History, examination, blood investigations and HHE were done. ARF was diagnosed according to the Jones Criteria (JC). Clinical ARF was diagnosed if there is a major clinical JC and silent ARF if the only major JR is subclinical carditis. ResultsThe study cohort included 400 children with a mean age of 9 years. Clinical ARF was diagnosed in 95 patients (95/400, 24%), most of whom presented with a joint major manifestation (88/95, 93%). Among the 281 children who did not present with a clinical manifestation of ARF, HHE revealed RHD in 44 patients (44/281, 16%); 31 of them fulfilled criteria for silent ARF (31/281, 11%). HHE increased the detection of ARF by 24%. HHE revealed mild RHD in 41/66 (62%) and moderate or severe RHD in 25/66 (38%) patients. Both sensitivity and specificity of HHE compared with standard echocardiography were 88%. ConclusionsThere is a significant burden of ARF among febrile children in Sudan. HHE increased the sensitivity of diagnosis, with 11% of children having sub-clinical carditis as their only major manifestation (ie, silent ARF). RHD prevention policies need to prioritize decentralization of echocardiography to improve ARF detection.