Subclinical Carditis Research Articles

The efficacy of echocardiographic criterions for the diagnosis of carditis in acute rheumatic fever

There is a great need for echocardiographic criterions for accurate diagnosis of carditis in acute rheumatic fever. To test the efficacy of proposed echocardiographic criterions for the diagnosis of carditis. We studied 333 patients suspected of having acute rheumatic fever, undertaking detailed clinical examination, laboratory tests and meticulous echocardiography in each case. We used previously established echocardiographic criterions for the diagnosis of carditis and subclinical valvitis. In 220 cases (66.06%), both the echo criterions, and the Jones' criterions, gave positive results. In 52 cases (15.61%), we found evidence of subclinical carditis, in that clinically no murmur was heard, meaning the Jones' criterions were negative, but the echocardiographic evaluation was positive. In 4 patients clinically diagnosed as having carditis, the Jones' criterions were positive, but echocardiographic evaluation showed them to have congenitally malformed hearts. In another 57 cases (17.11%), the Jones' criterions were negative, as were the results of echocardiographic evaluation. These patients were taken as control subjects. On this basis, the echocardiographic criterions had sensitivity of 81% and specificity of 93%. Using our echocardiographic criterions, it is possible to make a precise diagnosis of carditis or subclinical valvitis. Hence, echocardiography should, in future, be included as a major criterion in the Jones' system.

RHEUMATIC FEVER IN THE NEW MILLENNIUM

INTRODUCTION: During the past 2 decades the presentation of rheumatic fever (RF) has changed markedly from that of an acute florid illness to a more subtle subacute form that is frequently missed. OBJECTIVE: With this work we attempted to describe the changing face of RF with its different patterns and time of presentation, particularly subclinical carditis. METHODS: This work included 1732 patients with RF followed up in the pediatric department and pediatric cardiology clinic at Pediatric Hospital, Ain Shams University. Every patient was subjected to a thorough clinical examination, measurement of erythrocyte sedimentation rate and antistreptolysin O titer and C-reactive protein levels, a chest radiograph, electrocardiography, and echocardiography Doppler. Echocardiography was performed at the time of admission and repeated after 2, 4, and 6 weeks and 1 year after the attack. Diagnosis of RF was based on the revised Jones criteria. RESULTS: Age at the first attack was <5 years for 10% of the patients, 5 to 10 years for 51%, 11 to 15 for 36%, and >15 for 3%; the male/female ratio was 1:1.34. Major clinical RF manifestations were carditis (60%), polyarthritis (56%), chorea (15%), erythema marginatum (0.12%), and subcutaneous nodules (0.12%). Seventy-two percent had carditis, after we combined clinical and echocardiographic criteria of cardiac affection 6 weeks after the attack. Pure arthritis was present in 41% of the patients, arthritis and carditis in 29%, and arthritis and subclinical carditis in 30%. One year after the initial attack the number of patients with echocardiographic features of valve affection remained the same. Pure chorea was present in 55% of the patients, chorea and carditis in 30%, and chorea and subclinical carditis in 25%. One year after the initial attack, 70% of the patients with chorea had echocardiographic features of valve affection. Chronicity of chorea is common with multiple relapses. CONCLUSIONS: RF is not uncommon in children <5 years of age. Subclinical carditis should be anticipated and looked for at the right time in susceptible patients, particularly those with rheumatic arthritis and chorea. Multicenter studies should be carried out for the addition of the echocardiographic features of carditis to Jones' minor criteria for the diagnosis of RF. Diagnosis of carditis requires a high index of suspicion in at least 1 of 3 cases.

The case for utilizing more strict quantitative Doppler echocardiographic criterions for diagnosis of subclinical rheumatic carditis

Our aim was to perform a comparative, quantitative and qualitative, analysis of valvar echocardiographic findings in patients with acute rheumatic fever, with or without clinical manifestations of carditis, as compared to healthy controls. We analyzed cross-sectional Doppler echocardiographic images of 31 patients with acute rheumatic fever diagnosed according to the Jones criterions as modified in 1992. Of 31 patients, 22 presented with clinical carditis, while 9 had subclinical carditis. The patients, and a control group of 20 healthy individuals, underwent cardiac examination and echocardiographic assessment, assessing quantitative and qualitative findings of mitral and aortic valvar abnormalities. The leaflets of the mitral valve were statistically thicker in those with clinical and subclinical carditis when compared to controls (p less than 0.001). We observed a greater frequency of mitral variance, convergence of mitral flow, and aortic regurgitation for those with clinical and subclinical carditis when compared to controls (p less than 0.001, p less than 0.001 and p equal to 0.003, respectively). Patients with clinical and subclinical carditis had more quantitative and qualitative changes in the parameters than did the controls. Echocardiography is a sensitive method to detect valvar abnormalities in patients with acute rheumatic fever and carditis. Additionally, by using regular standardized criterions, abnormalities that lead to a diagnosis of subclinical carditis are found in those patients with acute rheumatic fever in the apparent absence of cardiac involvement.

Subclinical carditis in rheumatic fever: A systematic review

Objective Subclinical carditis (SCC) – pathological valvular regurgitation detected on echocardiography that is not evident clinically – has been reported in acute rheumatic fever (ARF), but its significance is unknown. We aimed to review the existing literature on the prevalence and outcome of SCC in ARF. Methods We conducted a systematic literature review using MEDLINE. Results Prevalences of SCC in ARF ranged from 0% (in one study only) to 53% in 23 articles. The weighted pooled prevalence of SCC in ARF was 16.8% (95%CI 11.9 to 21.6). This increased slightly to 18.1% (95%CI 11.1 to 25.2) by analysing only the 10 studies that applied full World Health Organization criteria for SCC diagnosis. The weighted pooled prevalence of persistence or deterioration of SCC 3 to 23 months after ARF diagnosis was 44.7% (95%CI 19.3 to 70.2) from 11 articles. Conclusion SCC is relatively common in ARF. Although some studies suggest that SCC lesions may persist or deteriorate, the available data are insufficient and of poor quality, so no confident conclusions can be drawn about the prognosis of SCC. Until better studies are conducted, clinicians will have to make management decisions that are not evidence-based. These decisions will have important practical implications for the use of echocardiography acutely and during follow-up, diagnosis of ARF, and duration of secondary prophylaxis in patients with SCC.

The role of echocardiography in diagnosing carditis in the setting of acute rheumatic fever

Acute rheumatic fever and its sequel, rheumatic heart disease, is a major problem in children, adolescents and young adults. Despite the widespread application of the Jones criterions, carditis is either underdiagnosed or overdiagnosed. Echocardiography is rarely used optimally for precise diagnosis. The objective of our study, therefore, was to define the potential role of echocardiography in detecting carditis in the setting of acute rheumatic fever. We performed echocardiography in 452 consecutive patients with acute rheumatic fever, clinically diagnosed by the strict Jones criterions, using the patients as part of a multi-centric and double blinded prospective study. Of our 452 patients, 230 were males, and 222 were females. The youngest was aged 1 year 11 months, while the oldest was a 51-year-old female. Out of the 452 cases of acute rheumatic fever, 239 patients (52.8%) had arthritis. Out of 164 cases of clinically diagnosed carditis, only 141 cases had echocardiographic evidence of carditis (85.97%). The remaining 23 patients (14%) had functional murmurs, tachycardia, or anaemia. Of the patients, 2 also had congenitally malformed hearts. Of 40 patients with rheumatic chorea, 28 (70%) had echocardiographic evidence of carditis or valvitis. Polyarthralgia was seen in 213 cases (47.12%), from which only 38 patients (17.8%) had carditis clinically, albeit that 88 patients (41.3%) showed echocardiographic evidence of subclinical carditis or valvitis. Echocardiography, when carried out in patients with acute rheumatic fever diagnosed strictly according to the Jones criterion, can avoid both overdiagnosis and underdiagnosis of carditis. A high incidence of carditis, or subclinical carditis, is detected by echocardiography when performed in patients with rheumatic chorea or arthralgia.

Evaluation of subclinical valvar disease in patients with rheumatic fever

Carditis is the only manifestation of acute rheumatic fever that leads to permanent disability. Hence, its diagnosis is of paramount importance. Recently, it has been reported that Doppler echocardiography has disclosed subclinical valvar regurgitation in some patients with acute rheumatic fever manifested as isolated arthritis or pure chorea. The prognosis of such patients with acute rheumatic fever and subclinical valvitis is not clear. We aimed, therefore, prospectively to investigate the potential to diagnose patients with subclinical carditis. We examined 40 patients, aged from 7 to 16 years, with Doppler evidence of mitral and aortic regurgitation, but in the absence of any pathologic murmur. The major findings satisfying the Jones criterions were arthritis in 29 patients, chorea in 10 patients, and arthritis and erythema marginatum in one patient. Of the patients, 33 had mitral regurgitation, 6 patients had combined mitral and aortic regurgitation, and one patient had aortic regurgitation. The patients were followed over a mean period of 18.1 +/- 13.9 months, the valvar regurgitation disappearing in 23 (57.5%). No significant differences were observed in the resolution of the valvitis between those treated with acetylsalicylic acid, steroids, or those receiving no treatment. It is noteworthy, nonetheless, that patients treated with steroids were the fastest to recover from valvitis (p < 0.05). Based on our study, we suggest that subclinical valvitis demonstrated by echocardiography should now be accepted as adequate evidence for the diagnosis of carditis, and become a major diagnostic criterion for acute rheumatic fever. When managing this group of patients with subclinical disease, treatment with steroids seems to have a role in promoting early resolution of the valvitis.

Immunohistochemical characterisation of Aschoff nodules and endomyocardial inflammatory infiltrates in left atrial appendages from patients with chronic rheumatic heart disease

Fifty left atrial appendages collected fresh during closed mitral valvotomy in patients with chronic rheumatic heart disease, were analysed to determine the frequency of Aschoff nodules and characteristics of mononuclear inflammatory infiltration. Fifty-six percent of specimens demonstrated Aschoff nodules with no clinical or laboratory evidence of acute rheumatic activity in the patients undergoing surgery. Endomyocardial infiltration contained predominantly T cells and occasionally B cells. The relative proportions of T helper-inducer, T suppressor-cytotoxic lymphocytes and macrophages were 45.1 ± 7.6, 23.5 ± 4.8 and 29.3 ± 9.6%, respectively. Frequent presence of Aschoff nodules and heavy mononuclear infiltrates in chronic rheumatic heart disease suggests a possibility of subclinical ongoing carditis.

Acute Rheumatic Fever-Reply

In Reply .—Data from our study 1 strongly supported concept 2 that if host escapes carditis in initial attack, he or she will continue to do so in subsequent recurrences. After reviewing these data 1,2 we suggested that the regimen [for secondary prophylaxis] should be selective patients who escape carditis in initial attack should maintain prophylaxis for five years. The duration of five years is admittedly arbitrary but is based on earlier observations that recurrences are most common during first few years after index attack. 1,3 The statement by Professor Sanyal that some children with polyarthritis may have subclinical carditis that makes them unduly susceptible to cardiac involvement during subsequent attacks of ARF lacks evidence; furthermore, we have already highlighted our reservations on retrospective study of Kuttner and Mayer. 4 It is very interesting that experience of Professor Sanyal with recurrences ... where

STUDIES OF AUSTRALIAN ABORIGINAL CHILDREN: STREPTOCOCCAL INFECTION, HEART REACTIVE ANTIBODY AND SUBCLINICAL RHEUMATIC CARDITIS

SYNOPSISElevated erythrocyte sedimentation rates in Australian Aboriginal school children in Queensland indicated a significant incidence of chronic active inflammation. The characteristics of the abnormal group, when compared with suitable controls, were relative retardation of growth, enteric parasites, respiratory infections, elevated serum immunoglobulins G and M, and high carrier rates of group A steptococci. Associated findings suggest that subclinical chronic rheumatic carditis is present in a large number of Aboriginal school children.