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 lasts for years and is the critical step in maintaining the health of the recovered patient.

Compliance with long-term secondary antibiotic prophylaxis is often poor, so close follow-up is mandatory.

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.

Inpatient & Outpatient Medications

Patients with ARF need prolonged antibiotic prophylaxis to prevent recurrent attacks.

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.

Ultimately, a vaccine will be the prevention of choice for ARF. Research on such a product is ongoing.^{[42, 43]}

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.^[25]

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 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.

Questions

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Media Gallery

Clinical manifestations and time course.

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Author

Mark R Wallace, MD, FACP, FIDSA Infectious Disease Physician, Skagit Valley Hospital, Skagit Regional Health

Disclosure: Nothing to disclose.

Coauthor(s)

Larry I Lutwick, MD, FACP Editor-in-Chief, ID Cases; Moderator, Program for Monitoring Emerging Diseases; Adjunct Professor of Medicine, State University of New York Downstate College of Medicine

Larry I Lutwick, MD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American Association for the Study of Liver Diseases, American College of Physicians, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, Infectious Diseases Society of New York, International Society for Infectious Diseases, New York Academy of Sciences, Veterans Affairs Society of Practitioners in Infectious Diseases

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; Fellow of the Royal College of Physicians, London

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

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.