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PubMed1974

Cellular reactivity studies to streptococcal antigens. Migration inhibition studies in patients with streptococcal infections and rheumatic fever.

The question of whether hypersensitivity to streptococcal antigens plays a role in the pathogenesis of the nonsuppurative sequelae of streptococcal infections remains at present unclear. As a first step in the approach to this question, the degree of cellular reactivity of peripheral blood leucocytes to streptococcal antigens was investigated in a number of rheumatic fever patients, patients with uncomplicated streptococcal infections, as well as normal healthy subjects. Using the in vitro technique for the inhibition of capillary migration of peripheral blood leucocytes as an index of the degree of sensitivity to streptococcal antigens, the results indicate that patients with acute rheumatic fever exhibit an exaggerated cellular reactivity to these antigens and in particular to streptococcal cell membrane antigens. This abnormal response to streptococcal membrane antigens appears to persist in rheumatic subjects for at least 5 yr after the initial attack of rheumatic fever. Only Group A streptococcal membrane antigens elicited this unusual response in rheumatic subjects, since the cellular reactivity to Group C and D streptococcal membranes was the same in all groups. Patients with evidence of valvular disease exhibited the same degree of cellular reactivity to these antigens as did patients without clinical evidence of rheumatic heart disease. The nature of the antigens responsible for the observed cellular response remains unknown. Enzymatic treatment of streptococcal cell walls and membranes designed to remove type-specific M proteins did not alter the observed cellular reactivity to the streptococcal antigens. The finding that an abnormal cellular response to certain streptococcal antigens is present only in rheumatic patients suggests that cell-mediated factors may play an important role in the disease process.

Animals↗
PubMed1997

The co-occurrence of acute rheumatic fever and AIDS.

We describe a patient with advanced acquired immunodeficiency syndrome (AIDS) who presented with evidence of carditis, arthritis, and chorea in the setting of fever, and serologic evidence for recent streptococcal infection. Several features atypical for rheumatic fever were present and included persistently high titer of antistreptolysin O, the simultaneous occurrence of chorea and arthritis, and the presence of chorea in a sexually mature adult man. The differential diagnosis of arthritis in a host at risk for human immunodeficiency virus should be expanded to include acute rheumatic fever, which may manifest atypical features.

Acquired Immunodeficiency Syndrome↗
PubMed2001

[Rheumatic fever behind acute chorea in a young girl. A case report].

This article presents the case of a 13-year old girl who was admitted to the emergency department because of rapidly evolving, seriously disabling impairments in movement and speech. Investigation led to the conclusion that her problems were caused by Sydenham's chorea as a manifestation of rheumatic fever. A neuropsychiatric examination performed one year after the onset of disease revealed a hitherto unknown mild mental retardation. The case description is followed by a clinical update on rheumatic fever focusing on cerebral manifestations. The theories concerning the existence of PANDAS--an autoimmune neuropsychiatric disorder following streptococcal infections, distinct from rheumatic fever--are presented.

Acute Disease↗
PubMed1980

Acute rheumatic fever in adults over the age of 45 years: an analysis of 23 patients together with a review of the literature.

The natural history of acute rheumatic fever (ARF) in adults has been studied from an analysis of 23 patients together with a review of a further 466 published cases. In contrast to the picture in juvenile ARF, in our patients (average age 55 yr), only arthritis (83%) and carditis (35%) were major criteria for the diagnosis. All patients had at least 3 minor criteria. To summarize, 39% of the patients, average age 56 yr were seen in their initial attack of ARF. In those patients with a previous history of rheumatic fever, the mean interval between the index attack and the first illness was 20.5 yr. Contact with young children appeared to be an important predisposing factor. None had an ESR of less than 50 mm in the first hour, even in the presence of cardiac failure. Findings in the acute illness included anemia (70%), hyperglobulinemia (70%), urinary sediment (66%), and hypercalcemia in 7 out of 12 cases. The response to treatment was good and only 1 patient of 13 followed-up developed a new valvular lesion. A survey of the literature shows that attacks of ARF may occur at any age; death in the acute episode is rare and occurs only in patients with severe preexisting valvular disease with congestive failure. The problem of diagnosing active carditis in the presence of rheumatic heart disease (RHD) is discussed. While juvenile ARF may be overdiagnosed, the diagnosis may be missed in the adult rheumatic patient whose cardiac state inexplicably deteriorates. In such patients evidence for a preceding streptococcal infection should be sought. Patients with a high risk of developing ARF include those with carditis in previous attacks, with preexistent RHD, and with several children in the family. These factors should be considered when advising on the duration of antibiotic prophylaxis.

Acute Disease↗
PubMed1979

Peripheral retinal neovascularization in rheumatic fever.

During a two-year period, a 15-year-old boy had three major manifestations of rheumatic fever, ie, chorea, rash, and carditis. Following the acute carditis, peripheral retinal neovascularization appeared in the left eye. Associated transient hemiparesis suggests that emboli may account for the retinal vascular occlusion. Rheumatic fever should be considered in the medical survey of patients who have retinal new vessels of obscure origin.

Adolescent↗
PubMed1977

Recurrences and sequelae of rheumatic fever in Nashville. A follow-up study.

A follow-up study of 311 patients who acquired rheumatic fever in Nashville, Tenn, during the period from 1963 to 1969 showed that 53% took penicillin prophylaxis regularly, 36% did not take it as recommended, and 11% did not take it at all. There were no recurrences among those who received prophylaxis by injection regularly, six recurrences among those who took oral prophylaxis regularly, and no recurrences among 45 subjects who did not take prophylaxis. Among these 45, however, were 29 for whom prophylaxis was not recommended by their physicians. The original study indicated that the incidence of acute rheumatic fever among blacks was twice as high as among whites. In the present study, incidence of rheumatic heart disease and recurrences was substantially higher among blacks than among whites.

Administration, Oral↗
PubMed1986

Experience on follow-up of registered rheumatic fever patients in the Zimbabwean Midlands.

A total of 75 patients with rheumatic fever, 49 acute (ARF) and 26 acute-on-chronic (A-C-RF), registered in the Zimbabwean Midlands during a 7 year period [1973-1980], followed up for 1-12 years where each one had a potential of follow-up of at least 5 years, were reviewed. Their mean age at diagnosis was 13.2 +/- 7.9 (range 3-39) years and 5 of them were over thirty years old. Thirty five percent were followed up regularly although only 20% realised the full potential. 12% of ARF who initially had no carditis, developed it on a recurrence. The disease was more florid among defaulters than among regulars; chronic valvular lesions being clinically established in 2.8 +/- 1.8 (range 1-6) years; chronic heart failure developing in 5.2 years and death occurring in relatively young patients aged 10.9 +/- 3.0 years old. There were more recurrences among defaulters than among regulars (p less than 0.001). The follow-up was better in those with clinically established valvular lesions, worse in the asymptomatic ones and it was unrelated to age or residence. In addition to improving social-economic conditions, parenteral penicillin prophylaxis should be continued until one is at least 40 years old.

Acute Disease↗
PubMed1992

Resurgence of acute rheumatic fever in west Alabama.

This study was done to ascertain whether there was an increased incidence of acute rheumatic fever (ARF) in west Alabama, similar to that reported elsewhere within the United States. Hospital records for the previous 10 years were reviewed and 5-year intervals were compared (1980 through 1984 vs 1985 through 1989). A sevenfold increase was noted in the later period. Possible explanations for this increase are discussed. Close surveillance, appropriate testing, and adequate complete treatment must be continued to eradicate streptococcal disease leading to acute rheumatic fever.

Acute Disease↗
PubMedDate not supplied

[The echocardiogram in the first attack of rheumatic fever in childhood].

In order to evaluate the contribution of echocardiography (echo) in the first episode of rheumatic fever, 18 children (mean age: 8.5 +/- 2.9 years) observed between 1987 and 1992 have been retrospectively studied. In 11 of them the echo has been done in the first month after the initial episode. By M-Mode echo the most constant finding was a high left atrium: aorta ratio in all cases with clinical carditis. By 2D-echo, hyperechogenicity of mitral valve leaflets and subvalvular apparatus was a common finding, three patients having mitral valve prolapse, one with dilatation of the mitral ring and the other with leaflets not able to coapt. Doppler-echo displayed in 17 patients mitral valve regurgitation, and in three aortic regurgitation. In three children the diagnosis of carditis was made by echo in the absence of murmur. During follow-up mitral valve regurgitation disappeared in four children. The authors conclude that early echo is very important in all children suspected to have rheumatic fever, specially because mitral valve regurgitation can be demonstrated by color flow mapping even in the absence of cardiac murmur.

Adolescent↗
PubMed1982

Skin infections and immunoglobulin A in serum, sweat, and saliva of patients recovered from poststreptococcal acute glomerulonephritis or acute rheumatic fever and their siblings.

Differences in hygienic habits and base-line secretory immunoglobulin (Ig) A which might have contributed to the prevalence of skin infections and/or absence of increased serum IgA values were sought in patients with poststreptococcal acute glomerulonephritis (nephritis) in contrast to patients with acute rheumatic fever in Trinidad by studying patients and their siblings after the patients had recovered from these diseases. The overall history of skin infections was similar at this time in all groups, although they had been much more common in patients with nephritis and their families at the time of acute illness. The recovered nephritis patients bathed slightly less often than the other individuals, used a cream or lotion after bathing rather than coconut oil, and tended to sweat less than the others, but none of these differences was statistically significant. Neither were significant differences demonstrated in amounts of IgA and IgG in serum and saliva of recovered nephritis patients and their siblings compared to recovered rheumatic fever patients and their siblings, while only small amounts of IgA and IgG were present in any sweat, and probably had been transuded rather than secreted. These studies suggest that the lower serum IgA titers in patients with nephritis compared to patients with rheumatic fever in Trinidad do not reflect basic differences in serum IgA or secretory IgA as measured in saliva, and that IgA is not secreted by the eccrine glands.

Adolescent↗
PubMed1993

Various rheumatic syndromes in adult patients associated with high antistreptolysin O titres and their differential diagnosis with rheumatic fever.

OBJECTIVES: The purpose of this study was to analyse retrospectively adult patients with acute joint or muscle symptoms and a high antistreptolysin O (ASO) titre to find out which syndromes of clinical arthritis are associated with serological evidence of streptococcal infection. METHODS: Seventy six adult patients with an acute arthritis syndrome or an exacerbation in their chronic rheumatic disease and simultaneously a high ASO titre (> or = 500 Todd units) were examined in two time periods in the 1980s. RESULTS: Twenty six patients had arthritis associated with a known rheumatic disease, 25 had non-specific arthralgia/myalgia, 20 had reactive arthritis, and five had septic arthritis. No case of classic rheumatic fever classified by two major criteria was found. Six patients fulfilled one major and at least two minor criteria. The frequency of HLA-B27 was significantly higher in the whole patient group than in the healthy Finnish population (30 v 14%). CONCLUSIONS: It is concluded that classic rheumatic fever is now rare, even in patients with arthritis with a high ASO titre. These results support the suggestion that beta haemolytic streptococci may trigger reactive arthritis as well as rheumatic fever.

Acute Disease↗
PubMed2003

An immunological marker (D8/17) associated with rheumatic fever as a predictor of childhood psychiatric disorders in a community sample.

BACKGROUND: Previous studies have documented that various behavioral disturbances accompany Sydenham's chorea, a neurologic variant of rheumatic fever. Further, an immunological marker associated with rheumatic fever (monoclonal antibody D8/17) has been reported to be elevated in several neuropsychiatric disorders, most frequently tics and obsessive-compulsive disorder. We examined this association in a community sample of children previously identified as being D8/17 positive or negative. It was hypothesized that D8/17 positivity would predict increased rates of tics and obsessive-compulsive disorder, even in the absence of Sydenham's chorea. Possible associations with other disorders accompanying Sydenham's chorea--hyperactivity, anxiety, and depression, also were explored. METHOD: From 1991 to 1995, 2631 children (mean age = 9.6 +/- 1.6 years) from a low socioeconomic area of Mexico City were screened for the D8/17 marker. In a 2- to 5-year follow-up of 240 of these children (108 positive and 132 negative), structured psychiatric interviews and rating scales were administered to the child and main caretaker. Assessments were conducted and scored blind to the child's D8/17 status. RESULTS: No association was seen between D8/17 positivity and tics or OCD. CONCLUSION: This study failed to provide support for the generalized use of D8/17 as a marker of susceptibility to tics and OCD in a community sample.

Antibodies, Monoclonal↗
PubMed2004

Involvement of immunoglobulin FcgammaRIIA and FcgammaRIIIB gene polymorphisms in susceptibility to rheumatic fever.

OBJECTIVES: To assess the impact of the human FcgammaRIIA and FcgammaRIIIB gene polymorphisms on the risk of rheumatic fever (RF). DESIGNS AND METHODS: FcgammaRIIA-R/H-131 and FcgammaRIIIB-NA1/NA2 genotypes were determined using polymerase chain reaction in 66 RF cases and 117 healthy controls in this case control study. RESULTS: Compared with healthy controls, the RR genotype was enriched in the entire group of RF cases (odds ratio [OR] 4.98, 95% confidence interval [95% CI] 1.81-13.70). RF patients were more frequently HR heterozygotes rather than HH homozygotes (OR 3.09 vs. 0.11). The results of this study show that patients who have RF are more likely to have the RR and HR genotypes than control children. These probabilities show that RR is associated with the greatest risk for rheumatic fever and HR is associated with an intermediate risk. For the distribution of FcgammaRIIIB NA2 genotypes, a nonsignificant increase was found in RF patients (39.31% vs. 51.51%; OR 1.64, P = 0.1226). CONCLUSION: The FcgammaRIIA-R/H-131 polymorphism may be an important marker in determining predisposition to RF.

Adult↗
PubMedDate not supplied

Reversibility of mitral regurgitation following rheumatic fever: clinical profile and echocardiographic evaluation.

The clinical disappearance of the murmur of rheumatic mitral regurgitation after period of time has been documented by many researchers. However no studies have related the disappearance of the murmur with the functional or anatomical state of the mitral valve. This study was done to elucidate the mitral valve status using doppler and color coded echocardiography among those children who have lost their apical pansystolic murmur on auscultation following a documented attack of rheumatic fever. The study sample consisted of 51 patients including 31 patients in whom the murmur has disappeared (group I), and 20 patients with persistent isolated mitral regurgitation (group II). Patients of group I had significantly lower grades of murmur intensity, lower incidence of cardiomegaly, and had no heart failure in the initial attack. They were more compliant with prophylaxis and had less recurrences than patients of group II. The murmur disappeared in patients of group I from 1/2 to 14 years after the initial attack. Echocardiography revealed that such patients had a normal mitral valve apparatus, and a normal heart size and function. Only 5 patients of this group had a significant regurgitant jet demonstrated by colour doppler. We concluded that recovery of the mitral valve and return of cardiac functions to normal is possible in patients who had mitral regurgitation following rheumatic fever. Some of them may still have an inaudible mild regurgitation. Patients who have lost their murmur may be allowed to exercise freely, yet penicillin prophylaxis should not be discontinued.

Adolescent↗
PubMed2006

Temporal changes in streptococcal M protein types and the near-disappearance of acute rheumatic fever in the United States.

BACKGROUND: The explanation for the very substantial decrease in the incidence of acute rheumatic fever in the United States, particularly over the past 50 years, is unclear. It has been proposed that certain M types of group A streptococci (GAS) include strains that are particularly rheumatogenic and that others are nonrheumatogenic. METHODS: We compared the M type distribution of GAS recovered from children from Chicago, Illinois, with acute pharyngitis during 1961-1968 to that of GAS recovered from Chicago children and children from across the United States in 2000-2004, with attention to changes in M types that previously were associated with rheumatogenic strains. RESULTS: The rheumatogenic types 3, 5, 6, 14, 18, 19, and 29 comprised 49.7% of 468 pharyngeal isolates during 1961-1968 but only 10.6% of 450 Chicago isolates during 2000-2004 (P < .001) and 17.9% of 3969 isolates nationwide during 2000-2004 (P < .001). Significant decreases in types 3, 5, and 6 and virtual disappearance of types 14, 18, 19, and 29 occurred between the 2 study periods. No change in the proportion of type 1 isolates, a highly heterogeneous group that includes some rheumatogenic strains, was observed. The nonrheumatogenic GAS types 2, 4, 22, and 28 increased from 4.9% to approximately 28% of pharyngeal isolates in Chicago and nationwide between the 2 study periods (P < .001). CONCLUSIONS: These data support the concept of rheumatogenic strains of GAS and indicate that the marked decrease in the incidence of acute rheumatic fever in the United States over the past 4 decades is correlated with the replacement of rheumatogenic types by nonrheumatogenic types in cases of acute streptococcal pharyngitis in children. The reasons underlying the observed change in distribution of M types remain to be elucidated.

Acute Disease↗
PubMed1991

Ultrastructure of naturally occurring subcutaneous nodule in acute rheumatic fever.

Electron microscopic evaluation of subcutaneous nodules excised from two cases of acute rheumatic fever showed an electron dense and smudgy material which had a distinct filamentous appearance in places. The latter was recognized as collagen. This corresponded to the fibrinoid necrosis seen under the light microscope. In addition, several histiomonocytic cells and fibroblasts were seen. A large number of cells were degenerated. A fair degree of resemblance of the nodule both by light and electron microscopy to the rheumatoid nodule was noted.

Collagen↗
PubMed1987

Atlanto-axial dislocation in acute rheumatic fever. Case report.

A 10-year-old boy had a sore throat, followed in 4 weeks by acute rheumatic fever and in 6 weeks by atlanto-axial dislocation. Reduction of the dislocation by means of a halo vest relieved his pain, but the cervical spine remained unstable after 3 months of immobilization and required an occiput-C1-2 fusion and rib graft to stabilize the atlanto-axial joint. This is the eighth reported case of atlanto-axial dislocation associated with acute rheumatic fever. The features of previous cases are summarized and the clinical aspects, mechanisms, diagnosis, and treatment of atlanto-axial dislocation are reviewed.

Acute Disease↗