Rheumatic Fever in Emergency Medicine Follow-up

Updated: Jan 04, 2017
  • Author: Steven J Parrillo, DO, FACOEP, FACEP; Chief Editor: Robert E O'Connor, MD, MPH  more...
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Follow-up

Further Outpatient Care

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  • 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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Further Inpatient Care

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  • 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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Transfer

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

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  • 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. [29]
  • Lennon et al believe that ARF cases would decrease by 60% using a school or community clinic to treat streptococcal pharyngitis in New Zealand. [34]
  • 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

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