Lesson topic №29 Острая ревматическая лихорадка (Rheumatic fever)

Prednisone 1 mg/kg orally 2 times a day (up to 60 mg/day) is recommended instead of aspirin for patients with moderate to severe carditis (as judged by a combination of clinical findings, presence of cardiac enlargement, and possibly by severely abnormal echocardiography results). If inflammation is not suppressed after 2 days or for severe heart failure, an IV corticosteroid pulse of methylprednisolone succinate (30 mg/kg IV once a day, maximum 1 g/day, for 3 successive days) may be given. Oral corticosteroids typically are given for 2 to 4 weeks and then tapered over another 2 to 3 weeks. Aspirin should be started during the corticosteroid taper and continued for 2 to 4 weeks after the corticosteroid has been stopped. Aspirin dose is the same as above. Inflammatory markers such as Erythrocyte sedimentation rate and C-reactive protein may be used to monitor disease activity and response to treatment.

Recurrences of mild cardiac inflammation (indicated by fever or chest pain) may subside

spontaneously; aspirin or corticosteroids should be resumed if recurrent symptoms last longer than a few days or if heart failure is uncontrolled by standard management (eg, diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, inotropic agents).

Antibiotic prophylaxis

Antistreptococcal prophylaxis should be maintained continuously after the initial episode of acute rheumatic fever to prevent recurrences ( see Table: Recommended Prophylaxis Against Recurrent Group A Streptococcal Infection). Antibiotics taken orally are slightly less effective as those given by injection. However, with the oral route, painful injections are avoided, and clinic visits and observation for postinjection reactions are not needed.

The optimal duration of antistreptococcal prophylaxis is uncertain. Children without carditis should receive prophylaxis for 5 years or until age 21 (whichever is longer). The American Academy of Pediatrics recommends that patients with carditis without evidence of residual heart damage receive prophylaxis for 10 years or until age 21 (whichever is longer). Children wi th carditis and evidence of residual heart damage should receive prophylaxis for > 10 years; many experts recommend that such patients continue prophylaxis indefinitely or, alternatively, until age 40. Prophylaxis should be life long in all patients w ith severe valvular disease who have close contact with young children because young children have a high rate of GAS carriage.

Recommended Prophylaxis Against Recurrent Group A Streptococcal Infection

* In parts of the world with high acute rheumatic fever endemicity, IM prophylaxis every 3 weeks is superior to every 4 weeks.

Key Points

Rheumatic fever is a nonsuppurative, acute, inflammatory complication of group A streptococcal (GAS) pharyngeal infection occurring most often initially between ages 5 years and 15 years.

Symptoms and signs may include migratory polyarthritis, carditis, subcutaneous nodules, erythema marginatum, and chorea.

Chronic rheumatic heart disease, particularly involving the mitral and/or aortic valves, may progress over decades and is a major cause of heart disease in the developing world.

Diagnosis of acute rheumatic fever (ARF) requires 2 major or 1 major and 2 minor manifestations (modified Jones criteria for a first episode of ARF) and evidence of GAS infection.

Give antibiotics to eliminate GAS infection, aspirin to control fever and pain caused by arthritis and mild carditis, and corticosteroids for patients with moderate to severe carditis.

Give prophylactic antistreptococcal antibiotics after the initial episode of ARF to prevent recurrences.

Poststreptococcal Reactive Arthritis

Poststreptococcal reactive arthritis is development of arthritis after group A streptococcal infection in patients who do not meet the criteria for acute rheumatic fever.

Poststreptococcal reactive arthritis may or may not represent an attenuated variant of acute rheumatic fever (ARF). Patients do not have symptoms or signs of the carditis common in ARF.

Compared with the arthritis of ARF, poststreptococcal reactive arthritis typically involves only 1 or 2 joints, is less migratory but more protracted, and does not respond as well or as quickly to aspirin.

Other, nonrheumatic disorders causing similar symptoms (eg, Lyme arthritis, juvenile idiopathic arthritis) should be excluded.

It can be treated with other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.

Although clinical practice for secondary prevention of cardiac involvement varies greatly, it is reasonable to give antistreptococcal prophylaxis for several months to 1 year and then to reevaluate the patient.

If cardiac lesions are detected by echocardiography, long-term prophylaxis is indicated.

Thank you for your attention.