eMedicine Specialties > Infectious Diseases > Cardiovascular and Intravascular Infections

Rheumatic Fever: Follow-up

Author: Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Coauthor(s): Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus; Jayashree Ravishankar, MD, Fellow, Department of Medicine, Division of Infectious Diseases, State University of New York Health Science Center at Brooklyn
Contributor Information and Disclosures

Updated: Apr 13, 2009

Follow-up

Further Inpatient Care

  • Most patients with acute rheumatic fever (ARF) can be treated at home.
  • Inpatient care may be appropriate when the patient has severe constitutional symptoms, chorea, carditis with CHF, or major toxicity with the anti-inflammatory drugs.

Further Outpatient Care

Patients should be closely observed until all acute symptoms have resolved and they have returned to their normal state of health. Secondary prophylaxis requires years of follow-up and is the critical step in maintaining the health of the recovered patient (see Medication).

Inpatient & Outpatient Medications

  • Patients with ARF need prolonged antibiotic prophylaxis to prevent recurrent attacks (see Medication).
  • The anti-inflammatory drugs are not usually required for more than 4-8 weeks.

Deterrence/Prevention

Primary prophylaxis (treatment of streptococcal pharyngitis) dramatically reduces the risk of ARF and should be provided whenever possible. Secondary prophylaxis is essential in all patients with rheumatic fever (see Medication).

Ultimately, a vaccine will be the prevention of choice for ARF. Research on such a product is ongoing.26

Complications

  • Immediate complications
    • Pancarditis that causes CHF, heart blocks, or pericardial effusion requires emergent inpatient care and cardiology evaluation.
    • Chorea can present months after the inciting infection and can be quite debilitating.14
  • Long-term sequelae
    • The only long-term sequela is rheumatic heart disease, which can present years later as valvular stenosis, most commonly involving the mitral valve. These patients are prone to infective endocarditis and stroke.
    • Valvular stenosis can lead to heart failure and may require surgery.

Prognosis

  • The prognosis of ARF has been improved greatly by preventing recurrent attacks with secondary antimicrobial prophylaxis. The ultimate prognosis of an individual attack is related directly to the severity of cardiac involvement during the acute phase.
  • About 60% of patients with carditis improve over a decade; in some, murmurs disappear. However, the overall prognosis is worse in those with severe carditis at first presentation,6 and most develop significant rheumatic heart disease.
  • Only 6% of patients without carditis (or questionable carditis) during their attack of ARF have an audible heart murmur in 10 years.

Patient Education

  • Patients, especially children, should receive medical attention when they develop a sore throat. Compliance with oral primary prophylaxis ("strep throat" treatment) and secondary prophylaxis regimens is essential to prevent ARF and its sequelae.

Miscellaneous

Medicolegal Pitfalls

  • Diagnostic pitfalls
    • Because the diagnostic scheme for acute rheumatic fever (ARF) is based on a combination of signs and symptoms that may be caused by many other processes, be cautious when diagnosing a patient with ARF. This is particularly true in adults and in areas of low incidence.
    • Be aware that flares of ARF with myocarditis may occur years after the initial episode and can be confused with complications of rheumatic valvulopathy.
  • Therapeutic pitfalls
    • Because of the potential for long-term valvular problems, even if the diagnosis of ARF is in doubt, consider beginning rheumatic fever prophylaxis as outlined above.
    • Although once-monthly intramuscular benzathine penicillin has been used for many years, breakthroughs during the final week have been reported, and a regimen of every 3 weeks may be preferable in those with severe rheumatic heart disease or breakthrough episodes (see Medication).
    • Determine the duration of prophylaxis into adulthood based on the patient's potential exposure to carriers of streptococcal infection (children). For example, an elementary school teacher would need longer prophylaxis than a lighthouse keeper.
 


More on Rheumatic Fever

Overview: Rheumatic Fever
Differential Diagnoses & Workup: Rheumatic Fever
Treatment & Medication: Rheumatic Fever
Follow-up: Rheumatic Fever
References
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References

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  3. Bisno AL, Pearce IA, Stollerman GH. Streptococcal infections that fail to cause recurrences of rheumatic fever. J Infect Dis. Aug 1977;136(2):278-85. [Medline].

  4. Shulman ST. Rheumatic heart disease in developing countries. N Engl J Med. Nov 15 2007;357(20):2089; author reply 2089. [Medline].

  5. McDonald M, Currie BJ, Carapetis JR. Acute rheumatic fever: a chink in the chain that links the heart to the throat?. Lancet Infect Dis. Apr 2004;4(4):240-5. [Medline].

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  7. Erdem G, Mizumoto C, Esaki D, Reddy V, Kurahara D, Yamaga K, et al. Group A streptococcal isolates temporally associated with acute rheumatic fever in Hawaii: differences from the continental United States. Clin Infect Dis. Aug 1 2007;45(3):e20-4. [Medline].

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  10. Wallace MR, Garst PD, Papadimos TJ, Oldfield EC 3rd. The return of acute rheumatic fever in young adults. JAMA. Nov 10 1989;262(18):2557-61. [Medline].

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  14. Weiner SG, Normandin PA. Sydenham chorea: a case report and review of the literature. Pediatr Emerg Care. Jan 2007;23(1):20-4. [Medline].

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  20. Lopez-Benitez JM, Miller LC, Schaller JG, Moreno LM, de Canata ME. Erroneous diagnoses in children referred with acute rheumatic fever. Pediatr Infect Dis J. Feb 2008;27(2):181-2. [Medline].

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  23. Pereira BA, da Silva NA, Andrade LE, Lima FS, Gurian FC, de Almeida Netto JC. Jones criteria and underdiagnosis of rheumatic fever. Indian J Pediatr. Feb 2007;74(2):117-21. [Medline].

  24. Voss LM, Wilson NJ, Neutze JM, Whitlock RM, Ameratunga RV, Cairns LM. Intravenous immunoglobulin in acute rheumatic fever: a randomized controlled trial. Circulation. Jan 23 2001;103(3):401-6. [Medline].

  25. Bilavsky E, Eliahou R, Keller N, Yarden-Bilavsky H, Harel L, Amir J. Effect of benzathine penicillin treatment on antibiotic susceptibility of viridans streptococci in oral flora of patients receiving secondary prophylaxis after rheumatic fever. J Infect. Apr 2008;56(4):244-8. [Medline].

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Further Reading

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Keywords

rheumatic fever, acute rheumatic fever, ARF, rheumatic heart disease, RHD, group A streptococcal pharyngitis, streptococcal pharyngitis, group A streptococci, group A Streptococcus, group A beta-hemolytic Streptococcus, group A beta-hemolytic streptococci, Duckett Jones criteria, Duckett-Jones criteria

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Contributor Information and Disclosures

Author

Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Mark Raymond Wallace, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Jayashree Ravishankar, MD, Fellow, Department of Medicine, Division of Infectious Diseases, State University of New York Health Science Center at Brooklyn
Jayashree Ravishankar, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Thomas J Marrie, MD, Chair, Professor, Department of Medicine, Division of Infectious Diseases, University of Alberta College of Medicine
Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Canadian Infectious Disease Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine
Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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