Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Rheumatic Fever Treatment & Management

  • Author: Mark R Wallace, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 08, 2015
 

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.[1, 6] 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.[31]

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, 18]

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.

Prophylaxis

For details about penicillin prophylaxis, see Medication.

Next

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.

Previous
Next

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.

Previous
Next

Diet

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

Previous
Next

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.[1, 6]

Previous
 
 
Contributor Information and Disclosures
Author

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Jayashree Ravishankar, MD, MRCP Medical Director, STAR Health Center, State University of New York Downstate Medical Center

Jayashree Ravishankar, MD, MRCP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Thomas J Marrie, MD Dean of Faculty of Medicine, Dalhousie University Faculty of Medicine, Canada

Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References
  1. Cilliers AM. Rheumatic fever and its management. BMJ. 2006 Dec 2. 333(7579):1153-6. [Medline].

  2. Stollerman GH. Rheumatic fever. Lancet. 1997 Mar 29. 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. 1977 Aug. 136(2):278-85. [Medline].

  4. Shulman ST. Rheumatic heart disease in developing countries. N Engl J Med. 2007 Nov 15. 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. 2004 Apr. 4(4):240-5. [Medline].

  6. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005. 366:155-68. [Medline].

  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. 2007 Aug 1. 45(3):e20-4. [Medline].

  8. Guilherme L, Kalil J, Cunningham M. Molecular mimicry in the autoimmune pathogenesis of rheumatic heart disease. Autoimmunity. 2006 Feb. 39(1):31-9. [Medline].

  9. Guilherme L, Kalil J. Rheumatic Heart Disease: Molecules Involved in Valve Tissue Inflammation Leading to the Autoimmune Process and Anti-S. pyogenes Vaccine. Front Immunol. 2013. 4:352. [Medline].

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

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

  12. 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. 2007 Dec. 26(12):1158-9. [Medline].

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

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

  15. Joseph N, Madi D, Kumar GS, Nelliyanil M, Saralaya V, Rai S. Clinical spectrum of rheumatic Fever and rheumatic heart disease: a 10 year experience in an urban area of South India. N Am J Med Sci. 2013 Nov. 5(11):647-52. [Medline].

  16. Casey JD, Solomon DH, Gaziano TA, Miller AL, Loscalzo J. Clinical problem-solving. A patient with migrating polyarthralgias. N Engl J Med. 2013 Jul 4. 369(1):75-80. [Medline].

  17. Atatoa-Carr P, Lennon D, Wilson N,. Rheumatic fever diagnosis, management, and secondary prevention: a New Zealand guideline. N Z Med J. 2008 Apr 4. 121(1271):59-69. [Medline].

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

  19. 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. 2007 Aug 2. 357(5):470-6. [Medline].

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

  21. 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. 2008 Oct 10. 1-7. [Medline].

  22. Sahin M, Yildirim I, Ozkutlu S, Alehan D, Ozer S, Karagöz T. Clinical features and mid- and long-term outcomes of pediatric patients with subclinical carditis. Turk J Pediatr. 2012 Sep-Oct. 54(5):486-92. [Medline].

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

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

  25. 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. 2008 Feb. 27(2):181-2. [Medline].

  26. 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. 1970 Jul. 49(7):1405-14. [Medline].

  27. 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. 2003 Sep. 10(5):886-90. [Medline].

  28. Wilson NJ, Voss L, Morreau J, Stewart J, Lennon D. New Zealand guidelines for the diagnosis of acute rheumatic fever: small increase in the incidence of definite cases compared to the American Heart Association Jones criteria. N Z Med J. 2013 Aug 2. 126(1379):50-9. [Medline].

  29. Shivaram P, Ahmed MI, Kariyanna PT, Sabbineni H, Avula UM. Doppler echocardiography imaging in detecting multi-valvular lesions: a clinical evaluation in children with acute rheumatic fever. PLoS One. 2013. 8(9):e74114. [Medline].

  30. 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. 2007 Feb. 74(2):117-21. [Medline].

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

  32. 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. 2008 Apr. 56(4):244-8. [Medline].

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

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

  35. Ragupathi L, Herman J, Mather P. Late Recurrence of Rheumatic Fever. Am J Med Sci. 2015 Oct. 350 (4):342-3. [Medline].

 
Previous
Next
 
Clinical manifestations and time course.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.