Rheumatic Fever Treatment & Management

  • Author: Mark Raymond Wallace, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Apr 13, 2009
 

Medical Care

Management and prevention of acute rheumatic fever (ARF) can be divided into the following 4 approaches:

  • Treatment of the group A streptococcal infection that led to the disease: Although never proven to improve the one-year outcome, this is a standard practice.[6, 1] It may at least serve to reduce the spread of rheumatogenic strains.
  • General treatment of the acute episode
    • Anti-inflammatory agents are used to control the arthritis, fever, and other acute symptoms. Salicylates are the preferred agents, although other nonsteroidal agents are probably equally efficacious. Steroids are also effective but should probably be reserved for patients in whom salicylates fail. None of these anti-inflammatory agents has been shown to reduce the risk of subsequent rheumatic heart disease.
    • Bed rest is a traditional part of ARF therapy and is especially important in those with carditis. Patients are typically advised to rest through the acute illness and to then gradually increase activity; some clinicians monitor the patient’s ESR and restart activity only as it normalizes.[6, 1]
    • Intravenous immunoglobulin has not been shown to reduce the risk of rheumatic heart disease or to substantially improve the clinical course.[24]
    • Chorea is usually managed conservatively in a quiet nonstimulatory environment; valproic acid is the preferred agent if sedation is needed. Intravenous immunoglobulin, steroids, and plasmapheresis have all been used successfully in refractory chorea, although conclusive evidence of their efficacy is limited.[6, 14]
  • Cardiac management: Bed rest is essential in patients with cardiac involvement. Carditis resulting in heart failure is treated with conventional measures; some use corticosteroids for severe carditis, although data to support this are scant.[6] Diuretics are the mainstay of therapy. Monitor for development of arrhythmias in patients with active myocarditis.
  • Penicillin prophylaxis (see Medication)
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Surgical Care

Surgical care is not typically indicated in ARF. Surgical intervention is required only to treat long-term valvular cardiac sequelae of ARF that cause stenosis.

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Consultations

  • Consultation with a cardiologist may be required to manage heart blocks and CHF.
  • Consultation with a neurologist or psychiatrist may be required to confirm the diagnosis of chorea and to assist in its management.
  • Consultations with an infectious disease specialist and rheumatologist may be helpful in diagnosis.
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Diet

No specific dietary recommendation exists. CHF may require salt restriction.

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Activity

Bed rest is a time-honored part of ARF therapy and is especially important in those with carditis. Patients are typically advised to rest through the acute illness and to then gradually increase activity; some clinicians monitor the ESR and restart activity only as it normalizes.[6, 1]

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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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

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.

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.

References

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  2. Stollerman GH. Rheumatic fever. Lancet. Mar 29 1997;349(9056):935-42. [Medline].

  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].

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  9. Veasy LG, Wiedmeier SE, Orsmond GS. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med. Feb 19 1987;316(8):421-7. [Medline].

  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].

  11. Erdem G, Dodd A, Tuua A, Sinclair S, I'atala TF, Marrone JR, et al. Acute rheumatic fever in American Samoa. Pediatr Infect Dis J. Dec 2007;26(12):1158-9. [Medline].

  12. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. Nov 2005;5(11):685-94. [Medline].

  13. Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med. Aug 2 2007;357(5):439-41. [Medline].

  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].

  15. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. Aug 2 2007;357(5):470-6. [Medline].

  16. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Sidi D, et al. Echocardiographic screening for rheumatic heart disease. Bull World Health Organ. Feb 2008;86(2):84. [Medline].

  17. Vijayalakshmi IB, Vishnuprabhu RO, Chitra N, Rajasri R, Anuradha TV. The efficacy of echocardiographic criterions for the diagnosis of carditis in acute rheumatic fever. Cardiol Young. Oct 10 2008;1-7. [Medline].

  18. Narula J, Kaplan EL. Echocardiographic diagnosis of rheumatic fever. Lancet. Dec 8 2001;358(9297):2000. [Medline].

  19. Tubridy-Clark M, Carapetis JR. Subclinical carditis in rheumatic fever: a systematic review. Int J Cardiol. Jun 25 2007;119(1):54-8. [Medline].

  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].

  21. Kaplan EL, Anthony BF, Chapman SS, Ayoub EM, Wannamaker LW. The influence of the site of infection on the immune response to group A streptococci. J Clin Invest. Jul 1970;49(7):1405-14. [Medline].

  22. Ayoub EM, Nelson B, Shulman ST, Barrett DJ, Campbell JD, Armstrong G. Group A streptococcal antibodies in subjects with or without rheumatic fever in areas with high or low incidences of rheumatic fever. Clin Diagn Lab Immunol. Sep 2003;10(5):886-90. [Medline].

  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].

  26. Dale JB. Current status of group A streptococcal vaccine development. Adv Exp Med Biol. 2008;609:53-63. [Medline].

  27. Veasy LG. Time to take soundings in acute rheumatic fever. Lancet. Jun 23 2001;357(9273):1994-5. [Medline].

 
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