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PubMed1987

Antibodies to penicillin in children receiving long-term secondary prophylaxis for rheumatic fever.

The occurrence of IgE and IgG antibodies to penicillin G and V in children on long-term treatment with penicillin as secondary prophylaxis for rheumatic fever was studied using Phadebas RAST (Pharmacia Diagnostics, Uppsala, Sweden) and ELISA respectively. The duration of the prophylaxis ranged between 1.5 months and 5 years (mean 1.8 years). Of 18 patients who had been given penicillin for more than 1.5 months, two had IgE antibodies and 12 had IgG antibodies to penicillin. Patients with acute rheumatic fever who had not yet received long-term treatment with penicillin had antibodies of the IgG class in two out of 12 cases. The patients gave no history of adverse reactions to the penicillin injections and there were no signs of immune complex-mediated disease. The two children who had IgE antibodies were switched to oral erythromycin instead of the penicillin injections. Penicillin is the drug of choice in the prophylaxis of rheumatic fever and can apparently be safely given as intramuscular injections of depot-penicillin to prevent recurrences of the disease and ensuing cardiac damage.

Child↗
PubMed1991

Acute rheumatic fever during childhood in Saudi Arabia.

During a 5-year period ending in December 1989, 73 episodes of acute rheumatic fever in 67 children aged 4-14 years were prospectively studied to ascertain the clinical profile of the disease in initial attacks and recurrences, and to compare the findings with those from other countries. Among 51 children with a first episode of acute rheumatic fever, 76% had arthritis and 43% had carditis. In 22 children with recurrences, arthritis was present in 45% and carditis in 91%. Carditis was more severe among the cases with recurrences. Mitral insufficiency was the most common valvular lesion, but no case of mitral stenosis was detected. Chorea, subcutaneous nodules, and Erythema marginatum were relatively rare. The demographic, clinical and laboratory findings of this study resemble those from Western countries, in contrast with data from tropical countries. Efforts aimed at prompt recognition and adequate treatment of streptococcal pharyngitis and maintenance of anti-streptococcal chemoprophylaxis would be rewarding in reducing the incidence of this disease and its sequelae.

Acute Disease↗
PubMed1998

Acute rheumatic fever in southern Saudi Arabia.

Forty six attacks of acute rheumatic fever (ARF) in forty patients were diagnosed between November 1987 and August 1995. Thirty four were initial attacks and 12 were recurrences. Arthritis was the commonest feature, 84.8%. Carditis occurred in 65.2% of the group, 67.6% of the initial attacks and 58.3% of the recurrences; however, the frequency of moderate/severe carditis was higher in recurrences, 25% versus 11.8%. Of those with carditis, mitral regurgitation occurred in 93.3%, aortic regurgitation in 16.7% and significant tricuspid regurgitation in 6.7%. Mitral stenosis was not encountered. No mortality occurred during ARF. Chorea, erythema marginatum and subcutaneous nodules were infrequent. These data are similar with those from a previous study which demonstrated the mild nature of ARF in Saudi Arabia, but showed higher frequency of carditis and suggested the frequency of carditis was not significantly higher during recurrences as compared to frequency of moderate/severe carditis.

Acute Disease↗
PubMed2005

The challenge of acute rheumatic fever diagnosis in a high-incidence population: a prospective study and proposed guidelines for diagnosis in Australia's Northern Territory.

BACKGROUND: Accurate diagnosis of acute rheumatic fever (ARF) remains problematic in high-incidence settings and especially in the Aboriginal population of Australia's Northern Territory. Previous investigators have demonstrated that strict application of the 1992 Updated Jones Criteria results in under-diagnosis. This study's objectives were to review use of the Jones Criteria (1992 Update) in diagnosing ARF in Australian Aboriginal patients presenting with suspected rheumatic fever, and formulate a locally relevant algorithm to improve diagnosis. METHODS: Patients presenting to Royal Darwin Hospital with suspected ARF were prospectively assessed during a 15-month period. Demographic information, clinical history, examination, laboratory and echocardiographic findings were documented in order to determine whether the Jones Criteria were fulfilled, and to identify alternative diagnoses. The hospital discharge diagnosis was recorded and patients were followed up 18-33 months later. RESULTS: Out of 35 patients with suspected ARF, all were Aboriginal Australians, 17 (49%) had a discharge diagnosis of definite ARF, 7 (20%) had definite non-rheumatic fever diagnoses (disseminated gonococcal infection, systemic lupus erythematosis, buttock abscess and other febrile illnesses in children with cardiac murmur due to previously undiagnosed RHD). The remaining 11 (31%) posed diagnostic difficulties because of mild symptoms that failed to fulfil Jones Criteria (attracting diagnoses such as 'unexplained arthralgia') or atypical features such as older age. Two patients whose illness initially failed to fulfil the Jones Criteria, who were neither diagnosed with ARF nor commenced on secondary benzathine penicillin prophylaxis, were found on follow-up to have definite and probable ARF, respectively. At least 29% (8/28) of patients without prior recognised ARF/RHD had echocardiographic evidence of established RHD, indicating that previous episodes were missed. CONCLUSIONS: Individual mild episodes of ARF may be overlooked, with patients missing out on the timely institution of secondary prophylaxis. The Jones Criteria should be supplemented by active exclusion of differential diagnoses and vigilant follow-up including echocardiography. 'Probable' and 'possible ARF' should be recognised as diagnostic categories applying to patients not fulfilling the Jones Criteria but who nevertheless should be offered prophylactic penicillin at least until further follow-up. A set of diagnostic guidelines is proposed.

Acute Disease↗
PubMed1994

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.

Amino Acid Sequence↗
PubMed1992

[Rheumatic fever. Its current status based on 4 cases].

We report on 4 patients with rheumatic fever hospitalized and investigated in our clinics within a 12 month period between 1990 and 1991. In each case a clinically non-severe sore throat preceded the outbreak of rheumatic fever. In three cases diagnosis was according to the revised Jones criteria. Polyarthritis was the only major symptom in these cases. One patient suffered from monarthritis. Minor symptoms were fever, arthralgia, elevated blood sedimentation rates and elevated values for CRP and for antistreptolysin O. The joint symptoms were treated with nonsteroidal drugs and subsided. One of the patients had a recurrence 9 months after the first attack even though correct secondary prophylaxis with a 4-weekly intramuscular regimen of 1.2 million units of benzathine penicillin was carried out. We discuss some epidemiological aspects and diagnostic difficulties resulting from a changing clinical pattern of the disease, and emphasize the need for streptococcal sore throat treatment and continuous secondary prophylaxis to prevent recurrences.

Adult↗
PubMed1981

Acute rheumatic fever in Mississippi: a survey of hospitalized cases, 1964 to 1973.

The incidence of acute rheumatic fever in Mississippi was estimated by reviewing the hospital charts of Mississippi residents with a discharge diagnosis of acute rheumatic fever from 1964 through 1973. The average annual incidence was 1.5 cases/100,000 population for primary attacks and 0.4 cases/100,000 population for recurrent attacks. The annual incidence was highest for the group aged 19 to 14 years, with 4.8 cases/100,000 population for primary attacks and 1.4 cases/100,000 population for recurrences. These rates are significantly lower than rates reported from similar surveys in Nashville, Baltimore, New York City, and the Navajo reservation. Age-adjusted rates of primary and recurrent attacks were higher for blacks than for whites, but the proportion of attacks that were recurrences did not differ by race. The proportion of attacks that were severe (cardiomegaly, pericarditis, or congestive heart failure) was significantly greater for blacks than for whites. No significant change in incidence was detected in the ten-year period. Among persons with primary attacks, only 18% are known to have had an antecedent pharyngitis and consulted a physician. Only 21% of persons with secondary attacks are known to have been receiving chemoprophylaxis.

Acute Disease↗
PubMed1986

[Acute rheumatic fever in Martinique. Epidemiological, clinical and biological study].

An epidemiological and clinical survey of rheumatic fever was carried out in Martinique. The clinical manifestations, portal of entry and socio-economic facilitating factors appeared to be the same as those observed in metropolitan France when the disease occurred with a similar frequency. The prevalence and severity of rheumatic fever in Martinique are still high (in 1982, 49 new cases in a population of 300,000, including 12 with severe carditis), but they tend to diminish as the eradication campaign goes on. The reasons for the persistence of the disease and the problems encountered in the eradication campaign are discussed in the light of epidemiological data collected during the last 3 years.

Adolescent↗
PubMed1963

RHEUMATIC FEVER.

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Adolescent↗
PubMed1973

Studies in rheumatic fever. VI. Ultrastructure of chronic rheumatic heart disease.

The fine structure alterations in the atrium and atrial appendage, mitral valve and papillary muscle are described in 11 matched patients with chronic rheumatic heart disease. The muscle changes consisted of loss of myofilaments and accumulation of lipid and osmiophilic dense bodies. The connective tissue stroma of the atrium and the mitral valve showed extensive deposition of collagen and elastic fibers. There were numerous foci of collagen degeneration, characterized by fraying of the collagen fibers and accumulation of homogeneous granular material at these sites. Although the muscle changes were more striking, the connective tissue alterations appear important in the evolution of the chronic disease. The extent of collagen degeneration appeared to parallel the degree of collagen formation. The muscle fiber degeneration and connective tissue alterations did not correlate with the clinical findings. At the resolution of the electron microscope, the continuing process in the rheumatic heart appears to be primarily collagen formation and degradation rather than primary degeneration of the muscle fibers. It is the balance of these processes which determine the clinical state of the patient. Acute muscle damage along with evidence of inflammation do not seem to be associated with progressive, chronic rheumatic heart disease.

Adult↗
PubMed1991

[The clinical observation and follow-up of acute rheumatic fever].

There were 15 patients under 15 years of age with cases of acute rheumatic fever diagnosed by revised Jones criteria admitted to pediatric department, Chang Gung Memorial Hospital of Kaohsiung from Jan. 1986 through Dec. 1989. There were 11 boys and 4 girls. The age of onset was more commonly between 13 and 15 years old. Carditis was the most common clinical presentation, noted in 13 cases. Eleven cases had valvular involvement: mitral regurgitation (MR) and mitral valve prolapse (MVP), 5 cases; MR and aortic regurgitation (AR), 4 cases; MR, 1 case; and MVP, 1 case. One case with MR + AR also suffered transient acute glomerulonephritis, which presented with gross hematuria but improved one week later. And one case with severe MR expired due to severe congestive heart failure. Eleven of the 14 survivors had regular follow-up at our clinic with an interval of 3 months to 38 months, and received parenteral benzathine penicillin for prophylaxis. During follow-up, the murmur in 4 cases with MR + MVP and 2 cases with MR + AR disappeared within 2 months. One of the three cases who had not received secondary prophylaxis had recurrence of rheumatic fever 3 years later after the initial diagnosis.

Acute Disease↗
PubMed1994

Persistence of acute rheumatic fever in the intermountain area of the United States.

We report our 8-year experience with the resurgence of acute rheumatic fever during the years 1985 through 1992. The records of 274 confirmed cases referred to Primary Children's Medical Center were reviewed. The clinical features including the presence of the Jones criteria, demographic data, preceding streptococcal infection, and the use of echocardiographic studies were tabulated and assessed. Patients came predominantly (84%) from middle-class families with access to medical care. Only 46 patients (17%) sought medical attention for a preceding sore throat. Carditis evident by auscultation was the dominant major manifestation in 68% of the cases. Echocardiography demonstrated mitral regurgitation that was not audible in 15 (47%) of 32 patients who had only polyarthritis at onset and in 30 (57%) of the 53 who had pure chorea. The incidence of acute rheumatic fever has been declining since the peak of the outbreak in 1985 but is continuing in the intermountain area at rates comparable to those of the 1960s.

Acute Disease↗
PubMed1990

Acute rheumatic fever in New York City (1969 to 1988): a comparative study of two decades.

One hundred fifteen attacks of acute rheumatic fever were observed during the past two decades (1969 to 1988) at the Columbia-Presbyterian Medical Center; 104 were initial attacks and 11 were recurrences. The maximum number of cases (18) occurred during the first year of this period, 1969; thereafter the annual incidence decreased until a resurgence was apparent in 1985 to 1986, with 25 cases. There were no differences in the frequency of major manifestations nor the severity of carditis in the 1970s compared with the 1980s. Polyarthritis alone was present in 51 cases, carditis alone in 31, and combined carditis and polyarthritis in 28; chorea was diagnosed in 5. Congestive heart failure occurred in 17 attacks of carditis, including one death from fulminant disease in 1982. In contrast to recent reports, the majority of the affected population was urban, low income, and from crowded communities: more than half were Hispanic, predominantly from Dominican Republic families. The prevalence of acute rheumatic fever underscores the need for early detection and treatment of streptococcal pharyngitis. The observation that 9.5% of the attacks were recurrent reflects failure to comply with antimicrobial prophylaxis and reaffirms the need for more effective secondary prevention programs.

Acute Disease↗
PubMed1988

Rheumatic fever in an urban community.

Forty-six children with acute rheumatic fever were admitted to Coronation Hospital, Johannesburg, between April 1981 and December 1984; 4 of them were admitted twice during this period. Their ages ranged from 4.5 years to 12.4 years. Carditis was present in 26 patients, arthritis in 22, chorea in 14, subcutaneous nodules in 3 and erythema marginatum in 2. Three patients died and a further 3 had to undergo emergency valve replacement for intractable cardiac failure. Thirty-five developed rheumatic heart disease; they all had mitral regurgitation. Compliance with prophylaxis was acceptable in only 22 cases.

Acute Disease↗