Neftaly: Management of Rheumatic Fever
Overview
Rheumatic fever (RF) is an inflammatory disease that occurs as a complication of untreated or inadequately treated group A streptococcal (GAS) pharyngitis. It primarily affects children aged 5–15 years and can lead to chronic rheumatic heart disease (RHD), which remains a major cause of cardiovascular morbidity in low- and middle-income countries.
Key Features
- Major manifestations (Jones Criteria):
- Carditis
- Polyarthritis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
- Minor manifestations:
- Fever
- Arthralgia
- Elevated inflammatory markers (ESR, CRP)
- Prolonged PR interval on ECG
- Preceding infection: Evidence of recent GAS infection (positive throat culture, rapid antigen test, or elevated anti-streptolysin O titre).
Management Principles
1. Eradication of Streptococcal Infection
- First-line antibiotics:
- Benzathine penicillin G intramuscularly (IM) single dose
- Oral phenoxymethylpenicillin (10 days)
- Penicillin-allergic patients:
- Erythromycin or azithromycin
2. Anti-inflammatory Therapy
- For arthritis or carditis:
- Aspirin: high dose (60–100 mg/kg/day divided every 6 hours) until symptoms resolve
- Corticosteroids: for severe carditis or heart failure (prednisone or equivalent)
3. Management of Heart Failure (if carditis present)
- Supportive care:
- Bed rest during acute phase
- Diuretics for fluid overload
- ACE inhibitors for ventricular dysfunction
- Monitor for progression to valvular disease
4. Symptomatic Management of Chorea
- Usually self-limiting
- Mild cases: reassurance and supportive care
- Severe cases: may require anticonvulsants (e.g., sodium valproate) or haloperidol
5. Secondary Prophylaxis (Prevention of Recurrence)
- Long-term penicillin prophylaxis:
- Benzathine penicillin G IM every 3–4 weeks
- Duration depends on severity:
- Without carditis: 5 years or until age 21
- With carditis but no residual heart disease: 10 years or until age 21
- With carditis and residual heart disease: 10 years or until age 40, sometimes lifelong
- Patient and caregiver education is critical for adherence.
6. Lifestyle and Supportive Care
- Encourage rest during acute phase
- Nutritional support and monitoring growth in children
- Regular follow-up with echocardiography if carditis present
Key Takeaways
- Early recognition and treatment of streptococcal pharyngitis prevents RF.
- Management requires a combination of antibiotics, anti-inflammatory therapy, and supportive care.
- Lifelong secondary prophylaxis may be needed for patients with rheumatic heart disease.
- Multidisciplinary approach improves long-term outcomes.