Attack Of Acute Rheumatic Fever Research Articles

Acute rheumatic fever in adult patients.

Acute rheumatic fever (ARF) is considered as a disorder of children, and attacks in adults are usually a recurrence of disease acquired in the child’s life. Although the incidence of ARF in children has a decreasing trend in developed countries, resurgent and sporadic epidemics still occur in adults. The first attacks of ARF in adult patients without a childhood history can lead to a diagnostic dilemma.A medical record review in adults at least 18 years of age with an arthralgia complaint fulfilling 2015 revised Jones criteria was performed from January 1, 2000 to December 31, 2019.Eleven ARF patients were identified, including 8 with initial attacks (6 females aged 26–42 years, 33.9 ± 5.3) and 3 pre-existing valvular heart disease with recurrent attacks (2 females aged 38–52 years, 45.0 ± 7.0). In addition to febrile pharyngitis and migratory polyarthritis in initial attacks, pericarditis was encountered in 1, valvulitis in 2, prolong PR interval in 3 and skin involvement in 2 patients with erythema marginatum and IgA vasculitis. All responded to antibiotics and nonsteroidal anti-inflammatory drugs therapy with normalized clinical and laboratory abnormalities, no new-onset carditis, and no recurrent disease during a long-term follow-up (3.8–19.8 years, 12.7 ± 5.4).A sporadic occurrence of adult ARF is observed in southern Taiwan. This disease should be considered by physicians for the differential diagnosis of febrile pharyngitis with arthritis and/or carditis in adults, even in areas with a low incidence of ARF.

Detecting sub-clinical disease activity in patients with chronic rheumatic valvular heart disease

ObjectiveValve disease progression in rheumatic heart disease(RHD) is generally attributed to recurrent attacks of acute rheumatic fever(ARF). However, persistence of chronic sub-clinical inflammation remains a plausible but unproven cause. Non-invasive means to identify sub-clinical inflammation may facilitate research efforts towards understanding its contribution to disease progression. MethodsPatients with chronic RHD, without clinical evidence of ARF, undergoing elective valve surgery were enrolled. Sub-clinical inflammation was ascertained by histological evaluation of left atrial appendage and valve tissue excised during surgery. We assessed the diagnostic utility of Gallium-67 scintigraphy imaging, and inflammatory biomarkers, hsCRP, IL-2, IL-6, Tumor Necrosis Factor-Alpha(TNF-α), Interferon-gamma(IFN-γ), and Serum Amyloid A(SAA), in identifying patients with sub-clinical inflammation. ResultsOf the 93 RHD patients enrolled(mean age 34 ± 11 years, 45% females), 86 were included in final analysis. Sub-clinical inflammation was present in 27 patients(31.4%). Patients with dominant regurgitant lesions were more likely to have sub-clinical inflammation compared to those with stenotic lesions, though this association was not statistically significant(dominant regurgitant lesions vs isolated mitral stenosis: OR 3.5, 95%CI 0.68–17.96, p = 0.133). Inflammatory biomarkers were elevated in the majority of patients: hsCRP, IL-2, IL-6, TNF-α, and IFN-γ in 44%, 89%, 90%, 79%, and 81% patients, respectively. However, there was no significant association between biomarker elevation and histologically ascertained sub-clinical inflammation. Ga-67 imaging was unable to identify inflammation in the 15 patients in whom it was performed. ConclusionSub-clinical inflammation is common in RHD patients. Conventional inflammatory markers are elevated in the majority, but aren’t discriminatory enough to identify the presence of histologic inflammation.

Acute rheumatic fever - A pathological analysis of clinically missed cases.

Acute rheumatic fever (ARF) and its post-inflammatory sequel chronic rheumatic heart disease (RHD) are endemic in the Indian setting. Despite the updated Jones criteria, many cases of ARF remain undiagnosed or are missed. This study aims to analyze pathological profiles of such cases and their importance in context of clinical presentation and Jones criteria. A 22-year retrospective observational study of ARF was conducted in the Department of Pathology in a tertiary care institute. The cases were categorized as 1. Those fulfilling and 2. those partially or not fulfilling the Jones Criteria. Based on the autopsy findings, the lesions were classified as categorized mitral stenosis and/or regurgitation (MS ± MR) and pure mitral regurgitation (MR). Nil. In 22 years, among 697 cases of autopsied cases of RHD, there were 59 cases (8.5%) of ARF. Among them, seven cases fulfilled the Jones criteria; five of them were clinically diagnosed. The remaining 52 cases (88.1%, 34 with MS ± MR and 18 with MR) did not fulfill or partially fulfilled the Jones criteria and were not diagnosed. A total of 18 patients (30.5%) had the first attack of ARF, whereas recurrences were noted in the remaining patients (69.5%). The study indicates that the typical manifestations of ARF under Jones criteria may not be present, especially in cases with recurrence. Hence, a presumptive or possible diagnosis of ARF can be made with presence of minor criteria or strong clinical suspicion in such cases.

Throat Colonization and Antibiotic Susceptibility of Group a β-Hemolytic Streptococci Among Rheumatic Heart Disease Patients Attending a Cardiac Referral Hospital in Tanzania, a Descriptive Cross-Sectional Study.

Background: Secondary prophylaxis against repeated attacks of acute rheumatic fever is an important intervention in patients with rheumatic heart disease (RHD), and it aims to prevent throat infection by group A β-hemolytic streptococcus (GAS); however, its implementation faces many challenges. This study aimed to assess throat colonization, antibiotic susceptibility, and factors associated with GAS colonization among patients with RHD attending care at Jakaya Kikwete Cardiac Institute in Dar-es-Salaam, Tanzania.Methods: A descriptive cross-sectional study of RHD patients attending the Jakaya Kikwete Cardiac Institute was conducted from March to May 2018, where we consecutively enrolled all patients known to have RHD and coming for their regular clinic follow-up. A structured questionnaire was used to obtain patients' sociodemographic information, factors associated with GAS colonization, and status of secondary prophylaxis use and adherence. Throat swabs were taken and cultured to determine the presence of GAS, and isolates of GAS were tested for antibiotic susceptibility using Kirby–Bauer disk diffusion method according to the Clinical and Laboratory Standards Institute version 2015. Antibiotics of interest were chosen according to the Tanzanian Treatment Guidelines.Results: In total, 194 patients with RHD were enrolled, their mean age was 28.4 ± 16.5 years, and 58.2% were females. Only 58 (29.9%) patients were on regular prophylaxis, 39 (20.1%) had stopped taking prophylaxis, whereas 97 (50.0%) had never been on prophylaxis. Throat cultures were positive for GAS in 25 (12.9%) patients. Patients who stopped prophylaxis were 3.26 times more likely to be colonized by GAS when compared to patients on regular prophylaxis. Majority (96%) of GAS isolates were susceptible to penicillin, ceftriaxone, and ciprofloxacin, whereas the highest resistance (20%) was observed with vancomycin. No GAS resistance was observed against penicillin.Conclusion: The prevalence of GAS throat colonization is high among this population and is associated with stopping prophylaxis. The proportion of patients on regular secondary prophylaxis is unacceptably low, and interventions should target both patients' and physicians' barriers to effective secondary prophylaxis.

Changes in valvular regurgitation in mid-term follow-up of children with first attack acute rheumatic fever: first evaluation after the updated Jones criteria

In present study, we aimed to evaluate the changes in valvular regurgitations in mid-term follow-up of children with first attack acute rheumatic fever diagnosed after updated Jones criteria. The medical records of the children diagnosed with acute rheumatic fever between June 2015 and November 2018 were evaluated retrospectively. When compared to the findings during diagnosis, the changes in the degree of valvular regurgitation in the last visit were coded as same, regressed, or disappeared. A total of 50 children were diagnosed with the first attack of acute rheumatic fever between the noted dates. Nine patients (18%) could be diagnosed depending on the new criteria. Eight patients did not have carditis, and 35 patients (49 valves) could be followed for a median follow-up period of 11.7 ± 3.3 months. In our study, the valvar lesions continued in 82% of patients with clinical carditis at the end of the first year and the degree of valvular regurgitation decreased in 39% of them. Despite this, in a significantly higher (p = 0.031) ratio of patients with silent carditis (41%), valvar lesions disappeared in the same follow-up period. In 18.4% of the involved valves, regurgitation regressed to physiological level. Updated Jones criteria make it possible to diagnose a significant number of patients, and the ratio of complete recovery among patients with silent carditis is significantly higher. Also, it can be speculated that the normal children in whom a physiological mitral regurgitation is detected should be followed in terms of rheumatic heart disease.

The consequence of the first attack of acute rheumatic fever with subclinical carditis

Background: Immune mediated damage of RF occurs most prominently in the heart, joints, brain, skin and subcutaneous tissues, however RF leaves no lasting damage to the brain, joint or skin, it is the leading cause of acquired heart disease in children and adolescents worldwide, therefore carditis is the most important manifestation of RF. Echocardiography along with color; Doppler imaging is now worldwide used for early detection of cardiac involvement even in the absence of clinical evidence, which in this case is called subclinical carditis (SCC) and was reported to cause similar consequences to clinically evident carditis.Methods: A retrospective study carried out on 35 patients already diagnosed to have RF and subclinical RHD and attending the cardiology clinic at Alexandria University Children’s Hospital (AUCH) from December 2015 to November 2016. Data collected from patients' files and then appropriately updated during subsequent follow-up visits.Results: 35 children already diagnosed to have RF and subclinical RHD were included in the current study, 22 patients (66.6%) improved completely with no residual cardiac lesion, 10 patients (30.3%) had persistent lesion and one patient (3.1%) had worsened condition.Conclusions: The most important predictors of poor prognosis according to the current study were recurrence and lack of regular compliance to long acting penicillin (LAP). Furthermore the outcome was not influenced by the treatment given in the initial attack.

Echocardiographic Stigmata in the First Attack of Acute Rheumatic Fever as a Major Criterion for the Diagnosis of Rheumatic Carditis in Misan, Iraq

Echocardiographic Stigmata in the First Attack of Acute Rheumatic Fever as a Major Criterion for the Diagnosis of Rheumatic Carditis in Misan, Iraq

PO601 New Zealand’s Ongoing Success In Preventing First Attacks of Acute Rheumatic Fever

PO601 New Zealand’s Ongoing Success In Preventing First Attacks of Acute Rheumatic Fever

Echocardiographic and Laboratory Findings of Turkish Children during the First Attack of Acute Rheumatic Fever

Echocardiographic and Laboratory Findings of Turkish Children during the First Attack of Acute Rheumatic Fever

Recurrent rheumaticactivity in rheumatic heart disease

Introduction:Acute rheumatic fever (ARF) is caused by autoimmune effect of group A streptococcal infection (GAS). Cardiac involvement is typically pancarditis. Valvular damage persists after the improvement of acute episode of ARF, the persistent valvular defect and its sequel is called rheumatic heart disease (RHD). People with previous episode of ARF are at increased risk of developing newer episodes of ARF and it increases the severity of valvular damage. Thus RHD gradually worsens in patients with recurrent attacks of ARF. Frequent episodes of ARF can be prevented by secondary prophylaxis.Methods and Materials:All diagnosed cases of RHD were includedand non RHD patients were excluded from this study. Proper history, detailed physical examination, routine laboratory test, ECG and echocardiography were done in all patients. Recurrent rheumatic activity was diagnosed on the basis of modified Jones criteria’1992 and who criteria of 2004.Results:Among 100 patients studied, 45 cases were hospitalised because of heart failure due to poor compliance of medications, 38 had acute attack of rheumatic fever, and 17 cases were having lower respiratory tract infection. Thus the incidence of acute rheumatic activity in established RHD was 38%. 50% patients were on penicillin prophylaxis and 10% were on oral tablets of penicillin or azithromycin for secondary prophylaxis. It means 60% of the patient population was on secondary prophylaxis. Conclusion: Recurrent rheumatic activity is a hidden cause of morbidity and mortality in established cases of RHD as penicillin prophylaxis is not adequate because of poor compliance to the drug.

Utility of Left Atrial Stiffness in Children with Acute Rheumatic Fever: A Speckle Tracking Echocardiography

Objective: We aimed to investigate the changes in left atrial stiffness (LASt) in children with acute rheumatic fever (ARF) and its impact on clinical outcome. Patients and methods: 64 children presented with first attack of ARF, were enrolled and studied, using standard, tissue Doppler and speckle tracking echocardiography. They were compared with 36 matched controls. Left atrial (LA) volumes, mitral annular velocities, and global longitudinal LA strain were measured. The ratio of E/e′ to LA strain was used as an index of LA stiffness. Results: LA maximal, minimal and pre-A volume indexes were significantly higher in children with ARF compared to controls (P<0.001). The E/e“ ratio was significantly elevated (P<0.001), whilst the global LA strain was significantly decreased (P<0.001). LASt was greater in children with ARF than in the controls (p<0.001). Follow-up data showed that children with adverse clinical outcomes had a significantly greater LASt (P<0.003). ROC analysis showed that the predictive value of LASt in predicting adverse clinical outcome in children with ARF is corresponding to a good test with a cut off value ≥ 0.63 with area under the curve = 0.91 (P<0.0001), with a sensitivity of 81.5% and a specificity of 94.7%. Conclusions: Children with first attack ARF have increased LASt in comparison with that of the matched controls. Meanwhile LASt is a good predictor adverse events of children of first attack of ARF. LASt could be a valuable parameter of subclinical carditis and ARF risk stratification.

Erythema marginatum rheumaticum

A 12-year-old boy presented with high grade intermittent fever for 15 days with polyarthralgia involving the large joints of his extremities for last 5 days. His parents also noticed appearance of a pinkish coloured non-pruritic rash on the back of the trunk about a week after the onset of fever which resolved spontaneously only to reappear on the extensor surface of his right leg in the morning of the day of presentation. On examination, the patient was febrile with an oral temperature of 102 °F. The large joints of his extremities were not swollen but were tender on palpation. The rash was non-tender and non-pruritic, having elevated and reddened edges with a flat and clear centre (Fig. 1). Rest of the systemic examination was normal except sinus tachycardia. Complete blood count was normal except for raised ESR (90 mm), C-reactive protein (53 mg/L) and Anti-streptolysin O titre (754 IU). EKG was done and it revealed sinus tachycardia only. Trans-thoracic echocardiography documented thickened mitral valve leaflets with mild mitral regurgitation. Throat culture grew Streptococcus pyogenes. The patient was diagnosed to have acute rheumatic fever (ARF) based on the revised Jones criteria, treated symptomatically and was advised prophylactic benzathine penicillin G for secondary prevention until adulthood. Fig. 1 Erythematous annular papule over right lower limb with central clearing and serpentines spreading edges. Erythema marginatum, a form of annular erythema, is very uncommon in children experiencing the first attack of ARF [1]. The typical lesions have central clearing and serpenginous spreading edges and often are unnoticed by the patient or parent because they are painless and non-pruritic. It becomes even more difficult to detect the rash in dark-skinned people, explaining its rare occurrence (less than 1%) in ARF patients in non-white populations [2], [3]. Fever triggers the development of this rash, which perhaps explains the evanescent nature of the rash. Physicians should be careful not to overlook this rare but useful clinical manifestation of ARF, particularly in patients with subclinical valvular involvement to avoid potential late cardiac complications.

Heart lesion after the first attack of the rheumatic Fever 22 years experience in single centre.

Background:Acute rheumatic fever and its sequels, rheumatic heart diseases, remain major unsolved preventable health problems in Kosovo population, particularly among the disadvantages indigenous Albanian and Egyptians people. In Kosovo, despite of performing secondary prophylaxis with benzathine penicillin, acute rheumatic fever hospitalization rates have remained essentially unchanged for the last 20 years. The role of echocardiography in the diagnosis of acute rheumatic carditis was established over the last 20 years.Aims:In this study we aimed to determine the prevalence of rheumatic heart disease in children from Kosovo population with first attack of acute rheumatic fever. Also, we presented that echocardiography examination detects a greater prevalence of rheumatic heart disease than other diagnostic procedures. We aimed to compare the sensitivity and specificity of cardiac auscultation, ECG record, lab analysis to echocardiography and to determine the feasibility of specific age in this setting.Methods:To optimize accurate diagnosis of rheumatic fever and rheumatic heart disease, we utilized two group models. In the first group of 388 children, hospitalized and treated before 1999, diagnosis of rheumatic fever was decided basing on the clinical and laboratory findings whereas in second group (221 children treated from1999 to 2010) clinical and lab diagnosis were amplified also on the detection by echocardiography.Conclusion:In second group, using echocardiography as a method of diagnosis and assessment children with rheumatic fever, we found high rates of undetected rheumatic heart disease in this high-risk group population. Echocardiographic examination of children with rheumatic fever for rheumatic heart disease may over diagnose rheumatic heart disease unless congenital mitral valve anomalies and physiological regurgitation are excluded.

Jaccoud's Arthropathy with Radial Shaft Deformity in a Patient with a History of Mild Carditis and Sydenham's Chorea

Background: Jaccoud’s arthropathy was first described in 1869 in a patient with recurrent attacks of acute rheumatic fever and recurrent migratory polyarthritis. The typical features include characteristic joint deviation with metacarpophalangeal subluxation, ulnar deviation, swan neck deformity of the fingers, and Z deformity of both thumbs and hook formation and alignment disorders without noticeable erosions on radiographs. In this report, Jaccoud’s arthropathy presenting with deformity of shaft of the radius is described. Case presentation: A 12-year-old-girl was diagnosed to have chorea at the age of 8 years after she presented with irregular, jerky, rapid and involuntary movements that involved the face, the trunk and the distal extremities. She was treated with haloperidol. The chorea resolved after 3 months of treatment. Echocardiogram showed thickening of the mitral valve leaflets and mild mitral regurgitation. Three years later, the child presented with progressive symmetric deformity of the wrist joints. She reported no pain or limitation of movement. On physical examination, there was no cardiac murmur. There was varus deformity of both wrist joints. There was no tenderness or limitation of movement. Anti-streptolysin O was negative at the first presentation and on this visit. Rheumatoid factor was negative but antinuclear antibody test was positive. Echocardiogram showed complete resolution of the mitral regurgitation. X-ray of the wrists showed marked symmetric curving of the distal radius and varus deformity of the wrists. There was joint deviation with metacarpophalangeal subluxation and ulnar deviation of the hand. There was no Z deformity of the thumbs. Conclusion: The common presentation of Jaccould’s arthropathy is involvement of the wrist, metacarpophalangeal joints and joints of the feet. The metacarpal and metatarsal bones are the ones, which are commonly affected. Our patient has an unusual presentation of deformity of the distal radial bone. This has not been described, at least to our knowledge.

Incidence of acute rheumatic fever in the world: a systematic review of population-based studies

Background:There is no systematic overview of prospective studies of incidence of acute rheumatic fever (ARF) in the world.Aim:To summarise all population-based studies of the incidence of ARF world wide.Method:A systematic...

Natural history of mitral stenosis and echocardiographic criteria and pitfalls in selecting patients for balloon valvuloplasty.

In summary, MS is a progressive disease characterized by a long latent period between the initial attack of acute rheumatic fever and the development of symptoms. For patients with MS who require mechanical relief of obstruction PMV is the preferred treatment and gives results comparable to surgical commissurotomy. Two-dimensional echocardiographic assessment of mitral valve morphology is the most important predictor of outcome. An echocardiographic score <8 predicts good immediate and long-term results. In patients undergoing PMV, TEE is useful for detecting left atrial and left atrial appendage thrombi, guiding transseptal puncture, assessing results and detecting complications.

Advanced atrioventricular conduction block in acute rheumatic fever

We carried out a retrospective case control analysis to evaluate the outcome, and the need for treatment, of problems with atrioventricular conduction occurring during an acute attack of rheumatic fever, assessing the occurrence of second and third atrioventricular block versus first degree block. We reviewed and analysed the clinical, electrocardiographic and echocardiographic records of all children diagnosed in a single institute as having acute rheumatic fever during a period of seven consecutive years. During the period from October, 1994, through October, 2001, 65 children meeting the modified Jones criterions for acute rheumatic fever were hospitalized in the Soroka University Medical Center, Israel. First-degree atrioventricular block was identified in 72.3% of the children, and resolved with no specific treatment other than non-steroidal anti-inflammatory medications. Second-degree atrioventricular block of Mobitz type I, was observed in one child (1.5%), which progressed from first-degree block, and subsequently resolved. Complete atrioventricuar block was found in 3 children (4.6%), one progressing from Mobitz type I second-degree block, and two being seen as the first presentation. Of the three children with complete atrioventricular block, one patient was not treated, the second was treated with aspirin, and the final one with combined aspirin and steroids. The disturbances of conduction resolved in all three. We conclude that advanced atrioventricular block is rare during acute rheumatic fever. If occurring, block appears to be temporary, and resolves with conventional anti-inflammatory treatment. Specific treatment, such as insertion of a temporary pacemaker, should be considered only when syncope or clinical symptoms persist.

The changing incidence of juvenile mitral stenosis and natural history of rheumatic mitral valvulitis in Al Baha, Saudi Arabia.

This study aimed to evaluate the impact of improved socio-economic conditions and health care on chronic mitral valve complications of rheumatic heart disease in Al Baha in the Kingdom of Saudi Arabia. Altogether, 190 cases of acute rheumatic fever (ARF) seen between 1982 and 1996 and 146 cases of symptomatic mitral stenosis seen between 1984 and 1996 were analysed. 2-D/Doppler echocardiography was used to evaluate the severity and progression of mitral regurgitation (MR)/mitral stenosis (MS). Of 90 cases of ARF who presented initially with MR, the murmur remained unchanged in 40%, increased in 30% and had decreased or disappeared in 30%. In cases with recurrence of ARF, mitral incompetence deteriorated in 16 of 26 cases (61.5%) and remained stable in ten (38%). Severe MS developed during follow-up in three cases of ARF, all aged less than 20 years. Seven of 50 cases (14%) of severe MS studied were aged 20 years or less. The 43% (25 of 58 cases) of severe cases of MS aged 20 years or less reported from King Faisal Hospital, Riyadh in 1981 compared with 14% of severe cases aged 20 years or less in this study indicates a significant slowing down of the rate of progression of MS following an attack of ARF in this region. Among individuals with MR during an ARF attack who reliably take their antibiotic prophylaxis, 70% will lose that murmur within 5 years of follow-up. In this series, only 30% showed a decrease or loss of MR and this probably reflects the degree of non-compliance with secondary antibiotic prophylaxis in our cases. The rate of default from antibiotic prophylaxis was 32.6%.

Rheumatic Fever—A Half-Century Perspective

Rheumatic Fever—A Half-Century Perspective

Identification of Cardiac Autoantigens in Human Heart CDNA Libraries Using Acute Rheumatic Fever Sera

Antigenic mimicry or cross-reactivity between Group A streptococcal antigens and cardiac autoantigens may initiate an autoimmune response resulting in cardiovascular damage in acute rheumatic fever. This study describes a molecular biological approach to the identification of such cross-reactive cardiac antigens. Two human heart cDNA libraries were constructed in the expression vector lambda gt11 and screened with patient sera, monoclonal antibodies and rabbit immune sera cross-reactive with streptococcal and cardiac antigens. Using the serum of a patient with a recurrent acute attack of rheumatic fever containing high titres of antibodies cross-reactive with both sets of antigens, we were able to identify three positive clones with insert sizes of 1.0 kb, 1.4 kb and 0.9 kb in these libraries. Acute rheumatic fever (ARF) sera reacted more strongly with these autoantigen clones than did normal sera. Autoantibodies eluted from the purified plaques of all three clones displayed different patterns of cross-reactivity against immunoblots of streptococcal M5, M6, M19 and M24 protein extracts. The cDNA inserts were sequenced and compared with known sequences in the EMBL and Genbank databases. One clone was 98% homologous with human cytokeratin 8 and showed homologies of 40 to 50% with human cardiac heavy chain myosin, tropomyosin and streptococcal M5 protein--all members of the alpha-helical coiled-coil family of proteins. Another clone was completely homologous to the G-protein alpha-subunit of adenyl cyclase, whilst the sequence of the third clone was not found in any of the data banks.