Rheumatic Fever in Emergency Medicine Follow-up

  • Author: Steven J Parrillo, DO, FACOEP, FACEP; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Mar 22, 2012
 

Further Inpatient Care

  • Most patients with acute rheumatic fever (ARF) will be managed as inpatients by a multidisciplinary team of pediatrics, internal medicine, cardiology, infectious disease, and rheumatology specialists.
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Further Outpatient Care

  • Several regimens exist to prevent recurrences—"secondary prevention."
    • Duration of prophylaxis is determined by the number of previous attacks, time since last attack, the risk of exposure to streptococcal infections, patient age, and—very importantly—presence or absence of cardiac involvement. Although the emergency medicine physician is not likely to be the prescriber of such a regimen, it is worth knowing what our colleagues may prescribe.
    • Penicillin is still the drug of choice and may be given daily by mouth or monthly by intramuscular injection. Macrolides are acceptable in penicillin-allergic patients.
    • Those who have had carditis should be treated well into adulthood and may require lifelong prophylaxis.
    • Those without carditis may be treated until they reach their 20s andafter at least 5 years have elapsed since the past episode. Duration may increase if patients in this group are at risk for exposure to streptococcal infection.
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Transfer

  • Transfer to an appropriate pediatric facility is essential.
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Deterrence/Prevention

  • The literature reports that acute rheumatic fever (ARF) can effectively be prevented if appropriate antibiotics are given within 9 days of symptom onset. Though somewhat controversial, most authorities believe this to be a valid conclusion. Others believe that GABHS infection in most cases is not needed because most people are not genetically susceptible.
  • At least one third of acute rheumatic fever episodes occur after inapparent streptococcal infections making prevention in that group impossible.[21]
  • Lennon et al believe that ARF cases would decrease by 60% using a school or community clinic to treat streptococcal pharyngitis in New Zealand.[30]
  • The CDC believes that, in most cases, the Centor criteria are adequate to rule in or rule out streptococcal pharyngitis. Culture is not needed. Infectious disease specialists argue that culture is still the standard. Use of the Centor criteria is more practical in the ED.
  • Differences exist among nations in terms of diagnosing and treating GABHS pharyngitis. Most North American, French, and Finnish guidelines consider diagnosis of streptococcal infection essential (with either rapid antigen detection or with formal culture) and advise antibiotic therapy when streptococci is detected. Several European guidelines consider streptococcal infection a self-limited disease and do not recommend antibiotics. The North American guidelines refer primarily to North American studies. European guidelines did not reference North American studies as frequently.
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Complications

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Prognosis

  • Sequelae are limited to the heart and are dependent upon the severity of the carditis during the acute attack.
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Contributor Information and Disclosures
Author

Steven J Parrillo, DO, FACOEP, FACEP  Associate Professor, Emergency Medicine, Jefferson Medical College and Philadelphia College of Osteopathic Medicine; Medical Director, Department of Emergency Medicine, Einstein Elkins Park Hospital and Roxborough Memorial Hospital; Chair, Emergency Management Committee, Albert Einstein Healthcare Network; Adjunct Professor, School of Health and Science, Philadelphia University; Medical Director and Faculty, Disaster Medicine and Management Masters Program, Philadelphia University

Steven J Parrillo, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Association, Society for Academic Emergency Medicine, and World Association for Disaster and Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Catherine V Parrillo, DO, FACOP, FAAP  Retired Clinical Assistant Professor, Department of Pediatrics, Philadelphia College of Osteopathic Medicine

Catherine V Parrillo, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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