Rheumatic Fever in Emergency Medicine Treatment & Management

Updated: Jul 19, 2021
  • Author: Steven J Parrillo, DO, FACOEP, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Treatment

Prehospital Care

Although no specific prehospital interventions exist for those with acute rheumatic fever, the patient's presentation may warrant establishment of intravenous access and placement of a cardiac monitor.

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Emergency Department 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. Transfer to an appropriate pediatric facility is essential.  The emergency medicine physician's primary responsibilities are to suspect the diagnosis and to treat complications. Consider early administration of antibiotics.

Anti-inflammatory agents are used to control the arthritis, fever, and other acute symptoms. ARF arthritis is very responsive to non-steroidal anti-inflammatory drug (NSAID) treatment. [31]

Acute rheumatic fever (ARF) is usually preventable if antibiotics are initiated within 9 days of the onset of streptococcal infection. Remember, however, that most patients are not susceptible to developing ARF, even when infected with group A beta-hemolytic streptococci (GABHS).

The best approach to treating the patient with pharyngitis is beyond the scope of this discussion (see Pharyngitis).  However, the number needed to treat to prevent one case of ARF is estimated to be 100.

The controversy regarding the need to treat all cases of streptococcal pharyngitis is acknowledged. However, it remains true that appropriate treatment of such infection can and does prevent ARF. [32, 33]

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Consultations

Consider consulting a cardiologist, a rheumatologist, and a neurologist, for the following reasons:

  • Carditis is not only a major clinical finding, but is also the cause of much of the disability.
  • Arthritis is one of the major manifestations.
  • Movement disorders associated with acute rheumatic fever may be difficult to differentiate from those of other clinical problems.
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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 treatment of 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. [30]

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

The Centers for Disease Control and Prevention (CDC) recommends using either a rapid antigen detection test (RADT) or throat culture to confirm group A strep pharyngitis in children older than 3 years. If the RADT is negative in a child with symptoms of pharyngitis, however, the CDC recommends following up with a throat culture, which remains the gold standard diagnostic test. [1]

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 RADT or with formal culture) and advise antibiotic therapy when streptococci are 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.

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 and after 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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