Recurrent Acute Rheumatic Fever Research Articles

Outcomes of rheumatic fever in Uganda: a prospective cohort study

Rheumatic heart disease is the largest contributor to cardiac-related mortality in children worldwide. Outcomes in endemic settings after its antecedent illness, acute rheumatic fever, are not well understood. We aimed to describe 3-5 year mortality, acute rheumatic fever recurrence, changes in carditis, and correlates of mortality after acute rheumatic fever. We conducted a prospective cohort study of Ugandan patients aged 4-23 years who were diagnosed with definite acute rheumatic fever using the modified 2015 Jones criteria from July 1, 2017, to March 31, 2020, enrolled at three rheumatic heart disease registry sites in Uganda (in Mbarara, Mulago, or Lira), and followed up for at least 1 year after diagnosis. Patients with congenital heart disease were excluded. Patients underwent annual review, most recently in August, 2022. We calculated rates of mortality and acute rheumatic fever recurrence, tabulated changes in carditis, performed Kaplan-Meier survival analyses, and used Cox regression models to identify correlates of mortality. Data were collected between Sept 1 and Sept 30, 2022. Of 182 patients diagnosed with definite acute rheumatic fever, 156 patients were included in the analysis. Of these 156 patients (77 [49%] male and 79 (51%) female; data on ethnicity not collected), 25 (16%) died, 21 (13%) had a cardiac-related death, and 17 (11%) had recurrent acute rheumatic fever over a median of 4·3 (IQR 3·0-4·8) years. 16 (24%) of the 25 deaths occurred within 1 year. Among 131 (84%) of 156 survivors, one had carditis progression by echo. Moderate-to-severe carditis (hazard ratio 12·7 [95% CI 3·9-40·9]) and prolonged PR interval (hazard ratio 4·4 [95% CI 1·7-11·2]) at acute rheumatic fever diagnosis were associated with increased cardiac-related mortality. These are the first contemporary data from sub-Saharan Africa on medium-term acute rheumatic fever outcomes. Mortality rates exceeded those reported elsewhere. Most decedents already had chronic carditis at initial acute rheumatic fever diagnosis, suggesting previous undiagnosed episodes that had already compounded into rheumatic heart disease. Our data highlight the large burden of undetected acute rheumatic fever in these settings and the need for improved awareness of and diagnostics for acute rheumatic fever to allow earlier detection. Strauss Award at Cincinnati Children's Hospital, American Heart Association, and Wellcome Trust.

Outcomes of possible and probable rheumatic fever: A cohort study using northern Australian register data, 2013-2019.

In Australia, there is a high burden of acute rheumatic fever (ARF) among Aboriginal and Torres Strait Islander peoples. Clinical diagnostic criteria can result in a diagnosis of 'definite', 'probable' or 'possible' ARF and outcomes range from recovery to severe rheumatic heart disease (RHD). We compared outcomes by ARF diagnosis, where the main outcome was defined as disease progression from: possible to probable ARF, definite ARF or RHD; probable to definite ARF or RHD; or definite ARF to definite ARF recurrence or RHD. Data were extracted from the Northern Territory RHD register for Indigenous Australians with an initial diagnosis of ARF during the 5.5-year study period (01/01/2013-30/06/2019). Descriptive statistics were used to describe cohort characteristics, probability of survival, and cumulative incidence risk of disease progression. Cox proportional hazards regression was used to determine whether time to disease progression differed according to ARF diagnosis. Sub-analyses on RHD outcome, clinical manifestations, and antibiotic adherence were also performed. In total there were 913 cases with an initial ARF diagnosis. Of these, 92 (13%) experienced disease progression. The probability of disease progression significantly differed between ARF diagnoses (p = 0.0043; log rank test). Cumulative incidence risk of disease progression at 5.5 years was 33.6% (95% CI 23.6-46.2) for definite, 13.5% (95% CI 8.8-20.6) for probable and 11.4% (95% CI 6.0-21.3) for possible ARF. Disease progression was 2.19 times more likely in those with definite ARF than those with possible ARF (p = 0.026). Progression to RHD was reported in 52/732 (7%) of ARF cases with normal baseline echocardiography. There was a significantly higher risk of progression from no RHD to RHD if the initial diagnosis was definite compared to possible ARF (p<0.001). These data provide a useful way to stratify risk and guide prognosis for people diagnosed with ARF and can help inform practice.

Echocardiographic Screening of Rheumatic Heart Disease: Current Concepts and Challenges.

The incidence of acute rheumatic fever (ARF), which most commonly affects children aged 5-15 years after group A Streptococcus (GAS) infection, ranges from 8 to 51 per 100 000 people worldwide. Rheumatic heart disease (RHD), which occurs when patients with ARF are inappropriately treated or not given regular prophylaxis, is the most common cause of non-congenital heart disease in children and young adults in low-income countries. Timely treatment of GAS infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is a key aspect of RHD control. The most important factor determining the prognosis of RHD is the severity of cardiac involvement. Although approximately 70% of patients with carditis in the acute phase of the disease recover without sequelae, carditis is important because it is the only complication of ARF that causes sequelae. One-third of patients with ARF are asymptomatic. Patients with mild symptoms of recurrent ARF and silent RHD will develop severe morbidities within 5-10 years if they do not receive secondary preventive treatments. A new screening program should be established to prevent cardiac morbidities of ARF in moderate- and highrisk populations. In the present study, we examined the applicability of echocardiographic screening programs for RHD. Cite this article as: Topçu S, Uçar T. Echocardiographic screening of rheumatic heart disease: Current concepts and challenges. Turk Arch Pediatr. 2024;59(1):3-12.

Current Clinical Profile of Acute Rheumatic Fever and Recurrent Acute Rheumatic Fever in Pakistan.

Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

Abstract 12362: High Rates of Mortality in Uganda Following Acute Rheumatic Fever: Findings From a Community-Based Prospective Cohort Study

Introduction: Rheumatic heart disease (RHD) is the largest contributor to cardiac mortality in children worldwide. Little contemporary data exist on its antecedent illness, acute rheumatic fever (ARF). There is an urgent need to understand outcomes following ARF in RHD-endemic settings. We aimed to describe medium-term mortality, disease recurrence, and change in carditis among Ugandan children following ARF diagnosis, and to identify correlates of mortality. Methods: We conducted a prospective cohort study of children diagnosed with definite ARF in 2017-2020 during a community-based incidence study. Patients were enrolled in a national registry and followed with annual review, most recently in August 2022. Kaplan-Meier (KM) survival analysis was used to describe all-cause mortality and individual Cox proportional hazards regression models were used to identify correlates of death. Descriptive statistics were used to characterize changes in carditis. Results: Among 135 children with definite ARF, 22/135 (16.3%) experienced death, 19/135 (14.1%) cardiac death, 5/135 (3.7%) ARF recurrence, and 5/135 (3.7%) surgery over a median (interquartile range) of 4.25 (3.4, 5.1) years. KM analysis saw 14/22 (63.6%) of deaths occur by one year, 16/22 (72.7%) by two years, and 20/22 (90.9%) by three years. The presence of moderate/severe carditis (HR 14.1, 95% CI 4.2, 47.7) and PR prolongation (HR 3.9, 95% CI 1.5, 9.9) at diagnosis was associated with increased cardiac mortality. Among 107 survivors included in echocardiographic sub-analysis, 27/107 (25.2%) had improvement in carditis, 70/107 (65.4%) no change, and 10/107 (9.4%) progression. Conclusions: These are the first contemporary data from sub-Saharan Africa reviewing medium-term outcomes following ARF. Adverse outcome rates exceeded those reported elsewhere. Most decedents already had advanced cardiac involvement upon first ARF diagnosis, as evidenced by PR prolongation and high-grade carditis, suggesting a history of prior undiagnosed ARF recurrences that had already compounded into RHD. These data indicate that a high burden of ARF exists in the community that is undetected by current methods, emphasizing the need for better point-of-care diagnostics to improve early ARF detection.

An outbreak of acute rheumatic fever in a remote Aboriginal community

ObjectivesWe describe the public health response to an outbreak of acute rheumatic fever (ARF) in a remote Aboriginal community. MethodsIn August 2021, the Northern Territory Rheumatic Heart Disease Control Program identified an outbreak of acute rheumatic fever in a remote Aboriginal community. A public health response was developed using a modified acute poststreptococcal glomerulonephritis protocol and the National Acute Rheumatic Fever Guideline for Public Health Units. Results12 cases were diagnosed during the outbreak; six-times the average number of cases in the same period in the five years prior (n=1.8). Half (n=6) of the outbreak cases were classified as recurrent episodes with overdue secondary prophylaxis. Contact tracing and screening of 11 households identified 86 close contacts. ConclusionsThis outbreak represented an increase in both first episodes and recurrences of acute rheumatic fever and highlights the critical need for strengthened delivery of acute rheumatic fever secondary prophylaxis, and for improvements to the social determinants of health in the region. Implications for Public HealthOutbreaks of acute rheumatic fever are rare despite continuing high rates of acute rheumatic fever experienced by remote Aboriginal communities. Nevertheless, there can be improvements in the current national public health guidance relating to acute rheumatic fever cluster and outbreak management.

Clinical profile of acute rheumatic fever in children in Pakistan: A study at a tertiary care hospital.

Objective: To determine the clinical profile of children presenting with acute rheumatic fever (ARF) at a tertiary care healthcare facility. Study Design: Cross-sectional study. Setting: Department of Pediatrics, Rai Medical College Teaching Hospital, Sargodha Pakistan. Period: January 2021 to December 2022. Material &amp; Methods: We analyzed children of both genders aged between 1 month to 18 years and presenting with ARF. At the time of enrollment, medical history was obtained and physical as well as clinical examinations were performed. The demographical and clinical information were recorded. ARF was labeled as per “Modified Jones Criteria”. A special proforma was formed to record study data. Results: In a total of 154 children, 96 (62.3%) were female while the mean age was 9.3±4.6 years. Forty four (28.6%) patients were having first episode of ARF while 110 (71.4%) had recurrence of ARF. Fever was noted to be the most common presentation noted in 121 (78.6%) patients of ARF. Arthritis was significantly more common among patients with first episode of ARF when compared to recurrence of ARF (70.5% vs. 29.1%, p&lt;0.0001). Degree of carditis was significantly more severe among patients with recurrence of ARF (p&lt;0.0001). Conclusion: Majority of the acute rheumatic fever patients present with recurrence of acute rheumatic fever. Fever was the commonest clinical presentation while arthritis was significantly more prevalent among patients with first episode of acute rheumatic fever.

Positive impact of training rural health workers in identification and prevention of acute rheumatic fever in eastern Uganda.

Diagnosis of acute rheumatic fever (ARF) is mainly clinical. Delayed or missed diagnosis and failure to administer appropriate and timely treatment of ARF leads to rheumatic heart disease (RHD), which could necessitate expensive treatments such as open-heart surgery. Implementation of preventative guidelines depends on availability of trained healthcare workers. As part of the routine support supervision, the Uganda Heart Institute sent out a team to rural eastern Uganda to evaluate health workers' knowledge level regarding management of ARF. Health workers from selected health facilities in Tororo district, eastern Uganda, were assessed for their knowledge on the clinical features and role of benzathine penicillin G (BPG) in the treatment and prevention of ARF recurrence. Using the RHD Action Needs assessment tool, we generated and administered a pre-test, then conducted training and re-administered a post-test. Eight months later, health workers were again assessed for knowledge retention and change in practices. Statistical analysis was done using Stata version 15. During the initial phase, 34 of the 109 (31%) health workers passed the pre-test, indicating familiarity with clinical features of ARF. The level of knowledge of BPG use in ARF was very poor in all the health units [25/109 (22.6%)] but improved after training to 80%, as shown by the chi-squared test ( χ2 = 0.000). However, retention of this knowledge waned after eight months and was not significantly different compared to pre-training (χ2 ≥ 0.2). A critical knowledge gap is evident among health workers, both in awareness and treatment of ARF, and calls for repetitive training as a priority strategy in prevention.

The evidence that rheumatic heart disease control programs in Australia are making an impact

ObjectiveRheumatic heart disease (RHD) comprises heart-valve damage caused by acute rheumatic fever (ARF). The Australian Government Rheumatic Fever Strategy funds RHD Control Programs to support detection and management of ARF and RHD. We assessed epidemiological changes during the years of RHD Control Program operation. MethodsLinked RHD register, hospital and death data from four Australian jurisdictions were used to measure ARF/RHD outcomes between 2010 and 2017, including: 2-year progression to severe RHD/death; ARF recurrence; secondary prophylaxis delivery and earlier disease detection. ResultsDelivery of secondary prophylaxis improved from 53% median proportion of days covered (95%CI: 46-61%, 2010) to 70% (95%CI: 71-68%, 2017). Secondary prophylaxis adherence protected against progression to severe RHD/death (hazard ratio 0.2, 95% CI 0.1-0.8). Other measures of program effectiveness (ARF recurrences, progression to severe RHD/death) remained stable. ARF case numbers and concurrent ARF/RHD diagnoses increased. ConclusionsRHD Control Programs have contributed to major success in the management of ARF/RHD through increased delivery of secondary prevention yet ARF case numbers, not impacted by secondary prophylaxis and sensitive to increased awareness/surveillance, increased. Implications for public healthRHD Control Programs have a major role in delivering cost-effective RHD prevention. Sustained investment is needed but with greatly strengthened primordial and primary prevention.

Secondary Prevention of Rheumatic Heart Disease in Nepal: Are We Going Backward?

A secondary level of prophylaxis has proven to be the most successful in Nepal, a country with an endemic rate of rheumatic heart disease, in combating the severe issues associated with rheumatic heart disease. The use of benzathine penicillin G in secondary prophylaxis of rheumatic heart disease, recommended by several guidelines, has been increasingly abandoned in Nepal due to a lack of national guidelines and the termination of the prior programs. The use of oral penicillin and alternative oral antibiotics, which are less effective in preventing the recurrence of acute rheumatic fever, is on the rise. Nepal urgently needs to develop new national guidelines and ensure their effective implementation in order to slow the increase in the number of rheumatic heart disease patients. In this article, we explore the limitations, challenges, and advantages of using the consensus-supported intramuscular benzathine penicillin G as the first-line drug for the secondary prevention of rheumatic heart disease.

An Uncommon Association of Ebstein’s Anomaly and Acute Rhumatic Fever

Background: Ebstein’s anomaly is a relatively rare congenital heart disease (atrialisation of the right ventricle). Anomalies of left side of the heart have been described with this condition. We however present a case of Ebstein's anomaly with recurrent acute rheumatic fever (ARF) and mitral stenosis. Case report: A 13-year-old boy with not followed for heart disease and with a history of notion of repetitive angina, is admitted to the pediatric emergency room for fever and polyarthritis. General examination not showed subcutaneous nodules and laboratory investigations revealed leucocytosis, elevated erythrocyte sedimentation rate (ESR) and antistreptolysin O (ASO) titre. Echocardiography revealed Ebstein anomaly with moderate mitral stenosis. A diagnosis of recurrent ARF was made based on the carditis, arthritis, history of recurrence of sore throat and evidence of recent streptococcal infection. He was transferred to the cardiology department and initially put on medical treatment. Its clinical course was marked by the appearance of unresolved ventricular tachycardia despite drug cardioversion. His prognosis was unfavorable with death after 10 days of hospitalization under antiarrhythmic treatment. Conclusion: Ebstein's disease is a rare disease. Cardiac arrhythmias are deleterious and the association of rheumatic fever with co-morbidity increases its lethality.

Secondary prevention of rheumatic heart disease in Ethiopia: a multicenter study

BackgroundEthiopia has a high acute rheumatic fever (ARF) and rheumatic heart disease (RHD) prevalence, and to our knowledge, there are no data on the status of secondary prevention in children with RHD. This study describes the status of secondary RHD prevention.MethodsA multicenter, prospective study was performed on children aged 5–17 years with RHD in Ethiopia. Good adherence was defined as at least 80% completion of benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Socio-demographics, severity of RHD, and ARF recurrence were evaluated.ResultsA total of 337 children with a mean age of 12.9 ± 2.6 years were included. The majority (73%) had severe aortic/mitral disease. Participants were on BPG (80%) or Amoxicillin (20%) prophylaxis. Female sex (P = 0.04) use of BPG (0.03) and shorter mean duration of prophylaxis in months (48.5 ± 31.5 vs. 60.7 ± 33, respectively, P < 0.008) predicted good adherence. Running out of medications (35%), interrupted follow-up (27%), and the COVID-19 pandemic (26%) were the most common reasons for missing prophylaxis. Recurrence of ARF was higher in participants on Amoxicillin compared with BPG (40% vs. 16%, P < 0.001) and in those with poor adherence compared with good adherence (36.8% vs. 17.9%, respectively, P = 0.005). Type and duration of prophylaxis (OR 0.5, CI = 0.24, 0.9, P = 0.02; OR = 1.1, CI = 1.1, 1.2, P = 0.04, respectively), and sex (OR = 1.9, CI = 1.1, 3.4, P = 0.03) were independent predictors of poor adherence.ConclusionPoor adherence is prevalent in Ethiopian children living with RHD. Amoxicillin is a suboptimal option for prophylaxis as its use is associated with lower adherence and a higher rate of ARF recurrence.

Evaluation of Children with Acute Rheumatic Fever: A Single-Center Experience.

Objective:The epidemiological characteristics, risk factors, complications, recurrence status, clinical and laboratory features, and treatment methods of the patients who admitted to our Pediatric Cardiology Outpatient Clinic with a pre-diagnosis of acute rheumatic fever (ARF) were evaluated.Materials and Methods:The data of 166 patients who admitted with a pre-diagnosis of ARF and were diagnosed with ARF, and the data of 51 patients who were not diagnosed with ARF, were retrospectively analyzed.Results:The patients with ARF were between the ages of 5 and 18. Most of the patients with ARF attack admitted in December (15.6%), January (13.8%), and February (13.2%). The most common complaints of the patients diagnosed with ARF were isolated joint pain and/or swelling, at 50.6%. While 91.5% of the patients were diagnosed for the first time, 8.5% had ARF recurrence. It was seen that the most common major criterion was carditis (94.6%). The severity of valve regurgitation and the rates of monoarthritis were significantly higher in patients with recurrence (P < .05). Non-compliance with prophylaxis was observed in 10 (71.4%) of 14 patients with recurrence, and in 43 (28.2%) of 152 patients without recurrence. Anti-streptolysin O was lower (P = .021) and alanine transaminase (ALT) was higher (P = .019) in the recurrence group.Conclusion:Our study showed that in patients with a pre-diagnosis of ARF, a differential diagnosis should be made with other diseases. Especially in patients with joint complaints as the only major symptom, a differential diagnosis should be made. ARF recurrence is associated with non-compliance with prophylaxis, and both the severity of valve regurgitation and monoarthritis rates are higher in patients who develop recurrence. Alanine aminotransferase is significantly higher in patients with ARF recurrence.

Subjective wellbeing among rheumatic heart disease patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: observational cross-sectional study

BackgroundSubjective wellbeing (SWB) is a self-reported positive life judgment and good feeling. RHD, rheumatic heart disease, is a long-term sequel of single or recurrent acute rheumatic fever. There are no studies that assessed SWB in RHD patients. We aimed to assess SWB among RHD subjects enrolled in chronic care at Tikur Anbessa Specialized Hospital (TASH), Ethiopia.MethodsThis observational cross-sectional study employed a validated Amharic WHO-5 wellbeing index to assess SWB. Sociodemographic and clinical data were collected using structured questionnaire. RHD subjects aged 9 years and above were included. Factors associated with SWB were assessed using logistic regression models.ResultsThe study included 384 subjects, females 68.2% (262). Children, < 18 years, constituted one third of study subjects, 32.8% (126). Moderate and severe echocardiographic RHD dominated, 85.9% (330) with no associated comorbidity, 84.4% (324). Only 17.2% (66) had surgical or device intervention. Poor SWB was documented in 9.6% of study subjects (95% CI: 6.88–13.04). On multivariable regression, those with younger age RHD diagnosis, < 20 years, had almost three times higher odds of poor SWB, adjusted odds ratio (aOR) 2.69(95% CI: 1.30–5.58, P 0.008). Those with monthly family income of < 1000 Ethiopian Birr had three times higher odds of poor SWB, aOR 2.97(95% CI: 1.24–7.1, P 0.014). Study subjects who had good medication adherence had reduced odds of poor SWB, aOR 0.37(95% CI: 0.18–0.77, P 0.028). Those who received psychologic support from their families also had reduced odds of poor SWB, aOR 0.26(95% CI: 0.11–0.64, P 0.003).ConclusionPoor SWB was documented in one-tenth of RHD patients. Family income, younger age at RHD diagnosis, medication adherence and psychological support predicted poor SWB. Poor SWB has to be considered and assessed among RHD patients particularly among those with younger age at RHD diagnosis and poor family income. Further mixed studies are recommended to assess how medication adherence and psychological supports associate with positive SWB among RHD patients.

Abstract 13547: Secondary Prevention of Rheumatic Heart Disease in Ethiopia

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant causes of morbidity and mortality. Ethiopia has a high RHD prevalence but has no national strategic guidelines for preventing RHD and no data on the status of secondary prevention in children with RHD. Generating local information is essential to designing effective prevention and control strategies. This study describes the status of secondary RHD prevention in Ethiopian children. Methods: A multicenter, cross-sectional study was performed in children aged 5-17 years with an echocardiogram-based RHD diagnosis. Participants with congenital heart disease and a recent RHD diagnosis (&lt;1 year) were excluded. Good adherence was defined as at least 80% completion of intramuscular benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Covariates included socio-demographics, type and severity of RHD, and ARF recurrence. Chi-square test and Student’s t-test were used to assess differences. Multivariate logistic regression was performed. Results: We included 337 participants with a mean age (±standard deviation) of 12.9±2.6 years. The majority were females (54%) and 73% had severe aortic/mitral disease. BPG (80%) and Amoxicillin (20%) were the prophylaxis of choice. Predictors of good adherence were female sex (P=0.04), use of BPG (0.03), and shorter mean duration of prophylaxis in months (48.5±31.5 vs. 60.7±33, P&lt;0.008). Running out of medicines (35%), interrupted follow-up (27%), and the COVID pandemic (26%) were the three most common reasons for missing prophylaxis. Recurrence of ARF was higher in participants on Amoxicillin (40% vs. 16%, P&lt;0.001) and in those with poor adherence (36.8% vs. 17.9%, P=0.005). Type and duration of prophylaxis (OR 0.5, P =0.02; OR=1.1, P =0.04, respectively), and sex (OR=1.9, P =0.03) were independent predictors of poor adherence. Conclusion: Poor adherence is prevalent in Ethiopian children with RHD. Amoxicillin is a suboptimal option for prophylaxis associated with lower adherence and a higher rate of ARF recurrence.

Postabaltive Pericarditis in Patient with a Prior History of Rheumatic Disease: a Case Report

A 60 year-old male with a previous (40 years ago) history of rheumatic carditis without valve involvement and 5 years history of paroxysmal atrial fibrillation underwent ablation (PV isolation with roof and mitral isthmus lines). The following day patient developed AF episode with severe mid-sternal chest pain with widespread concave ST elevation throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6). Serum troponin I was 87.2 ng/ml with a creatinine concentration of 0.88 mg/dl and hemoglobin level of 15 g/dl. 2D transthoracic echocardiogram excluded wall motion abnormalities, or significant pericardial effusions. Recurrence of acute rheumatic fever was excluded based on revised Jones criteria. Careful analysis of ECG allowed us to recognize the ECG criteria of pericarditis and to avoid unnecessary emergent coronary angiography. Ultimately, the patient was diagnosed with pericarditis. After diagnosis, the patients presenting symptoms resolved with treatment including sotalol 160 mg per day, nonsteroidal anti-inflammatory agents.&#x0D; Conclusions: This is the first reported case study of post-cardiac ablation pericarditis in patient with prior history of rheumatic carditis.

Acute Rheumatic Fever.

The incidence of acute rheumatic fever (ARF) is 8 to 51 per 100,000 people worldwide. It most commonly affects children 5 to 15 years of age after a group A streptococcal infection. Overcrowding and poor socioeconomic conditions are directly proportional to the incidence of ARF. Rheumatic carditis is a manifestation of ARF that may lead to rheumatic heart disease (RHD). Timely treatment of group A streptococcal infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Prevention of recurrent ARF is the most effective way to prevent RHD. ARF is diagnosed using the 2015 modified Jones criteria. There is no gold standard laboratory test. Therefore, clinicians need to be aware of the clinical signs and symptoms of ARF to include in their differential diagnosis when seeing such patients. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is key to RHD control. Clinicians need to understand the implications of secondary prophylaxis for ARF. There is also a need to improve ARF diagnosis, to find novel therapies to reduce the incidence of ARF, and to reduce the prevalence of RHD. RHD research is neglected and underfunded. Thus, there is also a need for RHD advocacy and public health awareness to increase research on RHD.

Recurrent attacks of rheumatic fever among school-age children (6–12 years)

ObjectiveTo assess factors related to recurrence of rheumatic fever attacks among school-age children (6–12 years) in El-Mahala El-Kobra City, Gharbiya Governorate.BackgroundRecurrent episodes of acute rheumatic fever (ARF) can lead to rheumatic heart disease with considerable morbidity and mortality in children.Patients and methodsA cross-sectional study was conducted in a center for follow-up of patients with rheumatic fever and rheumatic heart diseases in El-Mahala El-Kobra City, Gharbiya Governorate. There were 237 cases aged 6–12 years attending the selected center during the years of the study (first of November 2015 to end of October 2017). All cases that attended the center for follow-up (after either single attack or recurrent attacks of rheumatic fever) were recruited in the study. Participants were interviewed using a self-designed questionnaire filled by the researcher to assess socioeconomic characteristics and family and dietary history. Laboratory investigations included erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O titer, and hemoglobin percent, and also ECG and echocardiography were collected from patients' files.ConclusionThere was a significant association between recurrence of rheumatic fever attacks and age of the patient, tonsillectomy, regimen of taking long-acting penicillin, and lack of adherence to treatment.ResultsThe study revealed that among 237 studied rheumatic cases, 104 (43.9%) had recurrent attacks of ARF. The most significant factor associated with recurrent ARF was the age of the patient, negative history for tonsillectomy, a regimen of taking long-acting penicillin, and lack of adherence to its use.

Changing face of acute rheumatic fever in childhood and our clinical results.

This study aims to evaluate the demographic and clinical findings of acute rheumatic fever (ARF) patients followed up in our clinic, their responses to treatment, and prognoses and to determine the clinical utility of echocardiography (ECHO) in the diagnosis of ARF. We retrospectively evaluated the data of 160 patients with ARF (6-17, mean 11.7±2.3 years, F/M: 88/72) that was diagnosed according to the Jones criteria and followed up in the pediatric cardiology clinic between January 2010 and January 2017. About 29.4% (n=47) of 104 patients with rheumatic heart disease (RHD) had subclinical carditis. It was observed that subclinical carditis was most common in patients with polyarthralgia (52.2%); in contrast, clinical carditis was most commonly observed together with chorea (39%) and polyarthritis (37.1%). It was found that 60% (n=96) of the patients with rheumatic fever were between the ages of 10-13 and 31.3% (n=50) presented arthralgia most frequently in the winter months. The most common concomitant major symptoms were carditis + arthritis (35%) and carditis + chorea (19.4%). In patients with carditis, the most affected valves were mitral (63.8%) and aortic (50.6%) valves, respectively. The prevalence of monoarthritis, polyarthralgia, and subclinical carditis increased in cases diagnosed during and after 2015. The cardiac valve involvement findings of 71 of 104 patients (68.2%) with carditis improved during the approximately 7 years of follow-up. The regression of heart valve symptoms was significantly higher in patients with clinical carditis and those that complied with prophylaxis compared to patients with subclinical carditis and those that did not comply with prophylaxis. We conclude that ECHO results should be included in the diagnostic criteria of ARF, and that subclinical carditis is associated with a risk of developing permanent RHD. Secondary prophylaxis non-compliance is significantly associated with recurrent ARF, and early prophylaxis can reduce the prevalence of RHD in adults and potential associated complications.

Retrospective Study Assessing Compliance of Secondary Prophylaxis in Paediatric Patients at Risk of Recurrent Acute Rheumatic Fever in a Western Australian Metropolitan Hospital Setting

Bicillin prophylaxis is critical in the prevention of recurrent acute rheumatic fever (ARF) in patients with prior ARF or RHD. In the Perth metropolitan area, bicillin prophylaxis is administered by the nurse-led Hospital in the Home (HiTH) service. The aim of this study was to audit compliance with secondary antibiotic prophylaxis and clinical outpatient reviews in paediatric patients diagnosed with ARF and RHD in the Perth metropolitan area.