Can subclinical valvitis detected by echocardiography be accepted as evidence of carditis in the diagnosis of acute rheumatic fever?

Aim: Subclinical valvar insufficiency, or valvitis, has recently been identified using Doppler echocardiography in cases of acute rheumatic fever with isolated arthritis or chorea. The prognosis of such patients with acute rheumatic fever and subclinical valvitis is critical when determining the duration of antibiotic prophylaxis. We aimed, therefore, prospectively to investigate the association of silent valvitis in patients having rheumatic fever in the absence of clinical evidence of cardiac involvement, and to evaluate its prognosis. Methods and Results: Between November 1998 and September 1999, we identified 26 consecutive patients with silent valvitis in presence of rheumatic fever but in the absence of clinical signs of carditis. The patients, eight female and 18 male, were aged from 6 to 16 years, with a mean of 9.9± 2.7 years. Major findings were arthritis in 16, chorea in 7, and arthritis and erythema marginatum in 1 patient. Two cases had arthralgia with equivocal arthritic signs and Doppler echocardiographic findings of pathologic mitral regurgitation. Silent pathologic mitral regurgitation was found in 12 cases, and aortic regurgitation in 2 cases. All patients with arthritic findings were treated with acetylsalicylic acid with one exception, this patient receiving both prednisone and acetylsalicylic acid. No antiinflammatory treatment was given to patients with chorea. After a mean follow-up of 4.52 months, valvar regurgitation disappeared in 4 patients, including the one with migratory arthralgia and no other major criterions. All six patients with chorea and silent carditis still have mitral insufficiency. Conclusion: Acute rheumatic fever without clinical carditis is not a benign entity. Doppler echocardiographic findings of subclinical valvar insufficiency, therefore, should be considered as carditis when seeking to establish the diagnosis of acute rheumatic fever.

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A case of acute rheumatic fever: Echocardiographic findings for mitral regurgitation in acute rheumatic carditis.

Japanese Circulation Journal ◽

10.1253/jcj.51.1393 ◽

1987 ◽

Vol 51 (12) ◽

pp. 1393-1396 ◽

Cited By ~ 4

Author(s):

YASUHISA KAJINO ◽

HAJIME IWAYANI ◽

NORIYUKI HANEDA ◽

MASAKAZU SAITO ◽

TOSHIKAZU NISHIO ◽

...

Keyword(s):

Mitral Regurgitation ◽

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Rheumatic Carditis ◽

Echocardiographic Findings

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Criteria for judging the improvement in subclinical rheumatic valvitis

Cardiology in the Young ◽

10.1017/s1047951103001070 ◽

2003 ◽

Vol 13 (6) ◽

pp. 500-505 ◽

Cited By ~ 11

Author(s):

Sevim Karaaslan ◽

Saadet Demirören ◽

Bülent Oran ◽

Tamer Baysal ◽

Osman Başpinar ◽

...

Keyword(s):

Mitral Regurgitation ◽

Rheumatic Fever ◽

Aortic Regurgitation ◽

Short Duration ◽

Acute Rheumatic Fever ◽

Aortic Valves ◽

Cross Sectional

Recent technical improvements in cross-sectional echocardiography have made it possible to detect even mild organic regurgitation of the mitral and aortic valves in patients with acute rheumatic fever. To determine the prevalence and prognosis of subclinical valvitis, we have analyzed 104 patients with acute rheumatic fever referred to our institution. Of 53 patients who had no murmur, 22 of them with polyarthritis, 29 with chorea, and 2 with polyarthritis and chorea, 23 (43.4%) had subclinical valvitis. Isolated mitral regurgitation was the most common valvar lesion, seen in 82.6% of the patients. Isolated aortic regurgitation was detected in 4.4% of the cases, and combined mitral and aortic regurgitation in the remaining 13%. During follow-up, the degree of mitral regurgitation improved in 59.1%, decreased in 18.2%, and increased or remained unchanged in 22.7% according to the length of colour jet. According to criterions of velocity, mitral regurgitation improved in 86.4% of the patients, and increased or unchanged in the remaining 13.6%. Mitral regurgitation disappeared completely in 6 of the patients (27.3%) as judged according to both the length of colour jet and the velocity of regurgitation. Aortic regurgitation improved in all the patients with this problem, disappearing completely in two of the four.Based on this experience, we suggest that not only the disappearance of regurgitation, but also improvements in the echocardiographic diagnostic criterions of regurgitation, such as the length of the colour jet less than 1 cm, or velocity less than 2.5 m/s, or indicative of regurgitation that is either intermittent or of short duration, should also be considered as criterions indicating improvement in valvar regurgitation in patients with subclinical rheumatic valvitis.

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THERAPY OF ACUTE RHEUMATIC FEVER

PEDIATRICS ◽

10.1542/peds.15.5.522 ◽

1955 ◽

Vol 15 (5) ◽

pp. 522-536

Author(s):

Alan K. Done ◽

Robert S. Ely ◽

Lorin E. Ainger ◽

J. Rodman Seely ◽

Vincent C. Kelley

Keyword(s):

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Clinical Evidence ◽

Bed Rest ◽

Erythrocyte Sedimentation ◽

Adequate Dosage ◽

Almost All ◽

Withdrawal Of Therapy ◽

Erythrocyte Sedimentation Rates

Sixty-two children with acute rheumatic fever were treated with either ACTH, cortisone, salicylates or bed rest alone. Data concerning the effect on acute symptoms and follow-up observations of residual cardiac murmurs are presented. In addition, similar follow-up data on 18 previously-reported patients treated with ACTH are presented. Joint symptoms responded somewhat more rapidly to ACTH or cortisone than to salicylates, but an impressive response occurred to all of the drugs. Fever subsided within a few hours to 2 days in almost all individuals treated with any of these drugs. Elevated erythrocyte sedimentation rates returned to normal much more rapidly in the ACTH (mean 16 days) and cortisone (mean, 12 days) groups than in the salicylate (mean, 43 days) or bed-rest (mean, 48 days) groups. Although laboratory evidence of "rebound" in the form of an elevation of erythrocyte sedimentation rate occurred in 52 per cent of patients in the hormone-treated groups upon reduction or withdrawal of therapy, clinical evidence of "rebound" was rare in these groups but relatively common among the salicylate-treated patients. After follow-up periods as long as 3 9/12 years, residual cardiac murmurs were rare in the hormone-treated patients as compared to those treated with salicylates or with bed rest alone. Three years after discharge from the hospital, 6 per cent of the hormone-treated patients and 82 per cent of those not treated with hormones had residual cardiac murmurs. Moreover, the appearance of new murmurs following discharge was rare in the hormone groups and the murmurs which appeared were not persistent. New, persistent murmurs were noted relatively commonly following treatment with salicylates or bed rest alone. The importance of adequate dosage and individualization in therapy of rheumatic fever with ACTH and cortisone is stressed. The conclusions drawn are: the optimal initial doses of ACTH and cortisone are at least 1 I.U. and 3 mg. per pound per day, respectively; the initial daily dose should be continued until all laboratory and clinical evidence of rheumatic activity has disappeared; and then therapy should be decreased gradually but only if the patient shows no evidence of reactivation of rheumatic fever.

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Suspected acute rheumatic fever in a young man in England

BMJ Case Reports ◽

10.1136/bcr-2021-244469 ◽

2021 ◽

Vol 14 (11) ◽

pp. e244469

Author(s):

Zak Michael Wilson ◽

Katie Craster

Keyword(s):

Chest Pain ◽

General Practitioner ◽

Mitral Regurgitation ◽

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Supportive Therapy ◽

Acute Hospital ◽

Shortness Of Breath ◽

Pleural Effusions ◽

Pericardial Thickening

A 24-year-old fit and well Caucasian man was referred to acute hospital via his General Practitioner with chest pain, palpitations, shortness of breath and an antecedent sore throat. Investigations revealed pericardial and pleural effusions, pericardial thickening on MRI, mild mitral regurgitation on echocardiogram and a raised Antistreptolysin O (ASO) titre.He was treated as acute rheumatic fever (ARF) with a prolonged course of penicillin, supportive therapy with bisoprolol and colchicine with lansoprazole cover. The patient made a full recovery and subsequent cardiac MRI showed resolution of all changes.

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Clinical features and diagnosis of acute rheumatic fever

ESC CardioMed ◽

10.1093/med/9780198784906.003.0281 ◽

2018 ◽

pp. 1138-1140

Author(s):

Antoinette Cilliers

Keyword(s):

High Risk ◽

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Clinical Signs ◽

Clinical Manifestations ◽

Heart Association ◽

Risk Groups ◽

Group A ◽

High Risk Populations ◽

Minor Criteria

The diagnosis of acute rheumatic fever cannot be made using a single test. The diagnosis requires the recognition of a complex of clinical signs divided into major and minor manifestations as well as laboratory investigations aided by application of the Jones criteria, originally devised in 1944. The clinical manifestations are secondary to the effects of antibodies produced against the group A Streptococcus organism which cross-react against cardiac, skin, synovial, and neurological tissue associated with signs of inflammation. Several adjustments to the Jones criteria have been published over the last 70 years. The latest 2015 American Heart Association modification includes echocardiography/Doppler studies to diagnose subclinical carditis and also incorporates risk stratification whereby at-risk populations are divided into low- and moderate-to-high-risk groups. The presence of a single episode of a fever of at least 38°C and a slight elevation of the erythrocyte sedimentation rate to at least 30 mm/hour are classified as minor criteria in moderate- and high-risk populations. A monoarthritis or polyarthralgia are included as major criteria in the same risk group.

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QT dispersion in acute rheumatic fever

Cardiology in the Young ◽

10.1017/s1047951106000060 ◽

2006 ◽

Vol 16 (2) ◽

pp. 141-146 ◽

Cited By ~ 7

Author(s):

Tugcin Bora Polat ◽

Yalim Yalcin ◽

Celal Akdeniz ◽

Cenap Zeybek ◽

Abdullah Erdem ◽

...

Keyword(s):

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Qt Dispersion ◽

Control Group ◽

Healthy Children ◽

Rheumatic Carditis ◽

Normal Children ◽

A Value ◽

The Mean

Background:Disturbances of conduction are well known in the setting of acute rheumatic fever. The aim of this study is to investigate the QT dispersion as seen in the surface electrocardiogram of children with acute rheumatic fever.Methods:QT dispersion was quantitatively evaluated in 88 children with acute rheumatic fever. Patients were divided into two groups based on the absence or presence of carditis. As a control group, we studied 36 healthy children free of any disease, and matched for age with both groups. Repeat echocardiographic examinations were routinely scheduled in all patients at 3 months after the initial attack to study the evolution of valvar lesions.Results:The mean QT dispersion was significantly higher in children with rheumatic carditis. But there was no statistical difference between children without carditis and normal children. Among the children with carditis, the mean dispersion was higher in those with significant valvar regurgitation. Dispersion of greater than 55 milliseconds had a sensitivity of 85%, and specificity of 70%, in predicting rheumatic carditis, while a value of 65 milliseconds or greater had sensitivity of 81% specificity of 85% in predicting severe valvar lesions in acute rheumatic carditis. At follow-up examination, a clear reduction on the QT dispersion was the main finding, reflecting an electrophysiological improvement.Conclusions:These observations suggest that QT dispersion is increased in association with cardiac involvement in children with acute rheumatic fever.

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Acute rheumatic fever in south-east of Turkey: clinical features and epidemiological evaluation of the patients over the last 25 years

Cardiology in the Young ◽

10.1017/s1047951120001596 ◽

2020 ◽

Vol 30 (8) ◽

pp. 1086-1094

Author(s):

Sevcan Erdem ◽

Fadli Demir ◽

Mustafa Ayana ◽

Oguz Canan ◽

Yankı Kaan Okuducu ◽

...

Keyword(s):

Rheumatic Fever ◽

Medical Records ◽

Acute Rheumatic Fever ◽

Aortic Valves ◽

Cardiology Department ◽

Epidemiological Evaluation ◽

Valve Lesions ◽

Common Manifestation ◽

Important Disease

AbstractThis study evaluates clinical and epidemiological features of acute rheumatic fever using the data of last 25 years in our hospital in south-east of Turkey. The medical records of 377 patients with acute rheumatic fever admitted to Pediatric Cardiology Department of Çukurova University during 1993–2017 were retrospectively analysed. Two hundred and six patients were admitted between 1993 and 2000, 91 between 2001 and 2008, and 80 between 2009 and 2017. The largest age group (52%) were between 9 to 12 years of age and approximately two-thirds of the patients presented in the spring and winter seasons (62.8%). Among the major findings, the most common included carditis 83.6% (n = 315), arthritis at 74% (n = 279), Sydenham’s chorea at 13.5% (n = 51), and only two patients (0.5%) had erythema marginatum and two patients (0.5%) had subcutaneous nodule. Carditis was the most common manifestation observed in 315 patients (83.6%). The most commonly affected valve was the mitral valve alone (54.9%), followed by a combined mitral and aortic valves (34%) and aortic valve alone (5.7%). Of the patients with carditis, 48.6% (n = 153) had mild carditis, of which 45 had a subclinical. Sixty-two patients (19.7%) had moderate and 100 patients (31.7%) had severe carditis. At the follow-up, 2 patients died and 16 patients underwent valve surgery. Twenty-eight (7.4%) patients’ valve lesions were completely resolved. Conclusion: Although the incidence of acute rheumatic fever decreased, it still is an important disease that can cause serious increases in morbidity and mortality rates in our country.

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