eMedicine Specialties > Rheumatology > Miscellaneous Inflammatory Arthritis

Acute Rheumatic Fever: Follow-up

Author: Robert J Meador, MD, Rheumatology Fellow, Department of Rheumatology, Baylor Garland Family Practice Clinic
Coauthor(s): I Jon Russell, MD, PhD, MS, FACR, Director, University Clinical Research Center, Associate Professor, Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University of Texas Health Science Center at San Antonio
Contributor Information and Disclosures

Updated: Jul 31, 2009

Follow-up

Further Inpatient Care

  • Although inpatient care is believed to be initially mandatory in individuals with active carditis, prolonged hospitalization is usually not necessary.

Further Outpatient Care

  • Periodic monitoring at 3- to 4-month intervals is critical to evaluate for progress with the resumption of physical activity, resolution of the constitutional symptoms, and freedom from adverse effects from medications.
  • Less frequent visits, perhaps once a year, are appropriate while following a prophylaxis regimen.

Transfer

  • Transfer to a short-term–care facility should be arranged when patients have active life-threatening sequelae, notably carditis.

Deterrence/Prevention

  • Patients should be educated to seek medical attention upon the first signs of pharyngitis.
  • Once the disease is established, patients should be educated regarding benefits and risks of compliance with their medical regimen, which may be protracted.

Complications

  • Acute episodes are self-limited, with an average duration of 3 months for untreated attacks. Recurrence tends to occur within the first few years of the attack.
  • The outcome of carditis is likely to be more severe if patients have pre-existing heart disease. Carditis resolves without sequelae in 65-75% of patients.
  • Severe cardiac failure, total disability, and death may occur years after the acute attack.
  • The risk of developing a new episode is highest during the 5 years following an acute attack. This justifies prophylaxis for all patients for at least 5 years or until the patient reaches age 18 years.

Prognosis

  • The course followed by a patient after a first attack is highly variable and unpredictable. Approximately 90% of episodes last less than 3 months. Only a minority persist longer, in the form of unremitting rheumatic carditis or prolonged chorea.

Miscellaneous

Medicolegal Pitfalls

  • Pitfalls arise when misdiagnosis occurs. Many physicians who are unfamiliar with acute rheumatic fever (ARF) may not have a high enough index of suspicion for this disease. Inadequate treatment of streptococcal pharyngitis also may contribute to a legal quagmire.
  • Inappropriate or inadequate referral also may invite litigation. Patients who are critically ill with cardiomyopathy must be efficiently transferred an intensive-care setting. In addition, patients must be educated about their disease and the chronicity of it.
 


More on Acute Rheumatic Fever

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

  1. Yoshinoya S, Pope RM. Detection of immune complexes in acute rheumatic fever and their relationship to HLA-B5. J Clin Invest. Jan 1980;65(1):136-45. [Medline].

  2. Chun LT, Reddy DV, Yamamoto LG. Rheumatic fever in children and adolescents in Hawaii. Pediatrics. Apr 1987;79(4):549-52. [Medline].

  3. Jones TD. Diagnosis of rheumatic fever. JAMA. 1944;126:481-85.

  4. Digenea AS, Ayoub EM. Guidelines for the diagnosis of rheumatic fever: Jones criteria updates 1992. Circulation 87. Circulation. 1993;87:302.

  5. Barash J, Mashiach E, Navon-Elkan P, Berkun Y, Harel L, Tauber T, et al. Differentiation of post-streptococcal reactive arthritis from acute rheumatic fever. J Pediatr. Nov 2008;153(5):696-9. [Medline].

  6. Bryant PA, Robins-Browne R, Carapetis JR, Curtis N. Some of the people, some of the time: susceptibility to acute rheumatic fever. Circulation. Feb 10 2009;119(5):742-53. [Medline].

  7. Carapetis JR, Brown A, Wilson NJ, Edwards KN, Rheumatic Fever Guidelines Writing Group. An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline. Med J Aust. Jun 4 2007;186(11):581-6. [Medline].

  8. Erdem G, Mizumoto C, Esaki D, Reddy V, Kurahara D, Yamaga K. 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].

  9. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51. [Medline].

  10. Gibofsky A, Kerwar S, Zabriskie JB. Rheumatic fever. The relationships between host, microbe, and genetics. Rheum Dis Clin North Am. May 1998;24(2):237-59. [Medline].

  11. Guzman, L. Rheumatic Fever. In: Klippel J, ed. Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation; 1997:168-71.

  12. Gündogdu F, Islamoglu Y, Pirim I, Gurlertop Y, Dogan H, Arslan S. Human leukocyte antigen (HLA) class I and II alleles in Turkish patients with rheumatic heart disease. J Heart Valve Dis. May 2007;16(3):293-9. [Medline].

  13. Kaplan EL. Pathogenesis of acute rheumatic fever and rheumatic heart disease: evasive after half a century of clinical, epidemiological, and laboratory investigation. Heart. Jan 2005;91(1):3-4. [Medline].

  14. McLean A, Waters M, Spencer E, Hadfield C. Experience with cardiac valve operations in Cape York Peninsula and the Torres Strait Islands, Australia. Med J Aust. Jun 4 2007;186(11):560-3. [Medline].

  15. Minola E, Arosio M, Rizzo G, et al. Clinical and laboratory features of acute rheumatic fever: a 18-year experience. Infez Med. 2005;13(1):28-32. [Medline].

  16. Parrillo S, Parrillo CV. Rheumatic Fever. eMedicine Journal [serial online]. 2001;Available at: http://www.emedicine.com/emerg/topic509.htm. [Full Text].

  17. Rubio C. Acute Rheumatic Fever. In: West SR, ed. Rheumatology Secrets. Vol 1. Philadelphia, Pa: Hanley & Belfus; 1997:260-4.

  18. Soudarssanane MB, Karthigeyan M, Mahalakshmy T, Sahai A, Srinivasan S, Subba Rao KS. Rheumatic fever and rheumatic heart disease: primary prevention is the cost effective option. Indian J Pediatr. Jun 2007;74(6):567-70. [Medline].

  19. Stanevicha V, Eglite J, Zavadska D, Sochnevs A, Shantere R, Gardovska D. HLA Class II DR and DQ genotypes and haplotypes associated with rheumatic fever among clinically homogenous patients in children in Latvia. Arthritis Res Ther. Jun 10 2007;9(3):R58. [Medline].

  20. Steinhoff MC, Abd el Khalek MK, Khallaf N, et al. Effectiveness of clinical guidelines for the presumptive treatment of streptococcal pharyngitis in Egyptian children. Lancet. Sep 27 1997;350(9082):918-21. [Medline].

  21. Stollerman GH. The nature of rheumatogenic streptococci. Mt Sinai J Med. May-Sep 1996;63(3-4):144-58. [Medline].

  22. [Guideline] Thatai D, Turi ZG. Current guidelines for the treatment of patients with rheumatic fever. Drugs. Apr 1999;57(4):545-55. [Medline].

  23. Tibazarwa KB, Volmink JA, Mayosi BM. Incidence of acute rheumatic fever in the world: a systematic review of population-based studies. Heart. Dec 2008;94(12):1534-40. [Medline].

  24. Weidebach W, Goldberg AC, Chiarella JM, et al. HLA class II antigens in rheumatic fever. Analysis of the DR locus by restriction fragment-length polymorphism and oligotyping. Hum Immunol. Aug 1994;40(4):253-8. [Medline].

  25. Zakkar M, Amirak E, Chan KM, Punjabi PP. Rheumatic mitral valve disease: current surgical status. Prog Cardiovasc Dis. May-Jun 2009;51(6):478-81. [Medline].

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Further Reading

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Keywords

acute rheumatic fever, ARF, group A streptococcal pharyngitis, streptococcal pharyngitis, Sydenham chorea, painful migratory arthritis, rheumatic heart disease, chorea, erythema marginatum, subcutaneous nodules, antistreptococcal antibodies, antistreptolysin O, ASO, Aschoff nodules, carditis, Jones criteria, valvular murmurs, streptococcal infection, migratory polyarthritis

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Contributor Information and Disclosures

Author

Robert J Meador, MD, Rheumatology Fellow, Department of Rheumatology, Baylor Garland Family Practice Clinic
Robert J Meador, MD is a member of the following medical societies: Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

I Jon Russell, MD, PhD, MS, FACR, Director, University Clinical Research Center, Associate Professor, Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University of Texas Health Science Center at San Antonio
I Jon Russell, MD, PhD, MS, FACR is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, International Association for the Study of Pain, and International MYOPAIN Society (IMS)
Disclosure: Jazz Pharma Consulting fee Consulting; Jazz Pharma Grant/research funds Independent contractor; Jazz Pharma Consulting fee Board membership; Pfizer Pharma Grant/research funds Independent contractor; Pfizer Pharma Consulting fee Consulting; Pfizer Pharma Consulting fee Board membership; Lily Pharma  Independent contractor; Lily Pharma Consulting fee Speaking and teaching; Pfizer Pharma Consulting fee Speaking and teaching; Forest Laboratories Pharma Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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