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, 29]} It may at least serve to reduce the spread of cauasative strain.

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.and maybe preferred in children.^[38] Steroids are also effective but should probably be reserved for patients in whom salicylates fail, since there is a risk of rebound when they are withdrawn.^[29]None of these anti-inflammatory agents has been shown to reduce the risk of subsequent rheumatic heart disease.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.^{[1, 6]}

Intravenous immunoglobulin has not been shown to reduce the risk of rheumatic heart disease or to substantially improve the clinical course.^[39]

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, 25, 29]}

Some promising work suggests a possible role for hydroxychloroquine in the treatment of ARF, although no clinical data are yet available to recommend its use.^[40]

Cardiac management

Bedrest 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 and vasodilators are the mainstays of therapy.^[29]Monitor for development of arrhythmias in patients with active myocarditis. Atrial fibrillation requires aggressive management to reduce the risk of stroke.^[20]

Prophylaxis

For details about penicillin prophylaxis, see Medication.

Surgical Care

Surgical care is not typically indicated in ARF. Surgical intervention is often required to treat long-term valvular cardiac sequelae of ARF including aortic and mitral regurgitation as well as mitral stenosis.^[20]

Consultations

Consultation with a cardiologist may be required to manage heart block,arrhythmias 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.

Diet

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

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]}

Prevention

Group A streptococcal vaccines hold out the promise of preventing rheumatic fever, and some are in development. Such vaccines will need to take into account the increase in rheumatogenic strains^[9] and the possibilty that groups C and G streptococci may be involved in the causation of rheumatic fever.^[7]

Medication

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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.