Rheumatic Fever and Long-term Sequelae in Children

Rheumatic fever and rheumatic heart disease continue unabated, affecting young individuals in most of the developing nations. Focal outbreaks of smaller magnitude have also been reported since the mid-1980s from industrialized western nations, where this disease had almost disappeared. The introduction of penicillin in the mid-1940s has markedly changed the natural history of rheumatic fever, although the incidence of rheumatic fever declined in developed nations even before that, mainly due to better living conditions. Treatment of rheumatic fever chiefly involves the use of antibiotics (penicillin) and anti-inflammatory drugs, like salicylates or corticosteroids, to eradicate Streptococci. Patients with severe carditis, congestive heart failure, or pericarditis are best treated with corticosteroids because these are more potent anti-inflammatory agents than salicylates. Salicylates may be sufficient for cases with mild or no carditis. The treatment must be continued for 12 weeks. Several studies have shown that valvular regurgitation, and not myocarditis, is the cause of congestive heart failure in active rheumatic carditis. Therefore, surgery with mitral valve replacement or repair is indicated in cases with intractable hemodynamics due to mitral regurgitation. The development of chronic valvular lesion after an episode of rheumatic fever is dependent upon the presence or absence of carditis in the previous attack and compliance with secondary prophylaxis. Recurrences due to inadequate penicillin prophylaxis are responsible for hemodynamically significant chronic valvular lesions requiring surgery. Primary prevention of rheumatic fever is fraught with difficulties and may not be feasible in most of the countries where the disease is rampant. Secondary prevention, ie, preventing recurrence of rheumatic fever, is the appropriate strategy with proven efficacy. A repository form of penicillin, benzathine penicillin G, given as an intramuscular injection at 3 weekly intervals in the dose of 1,200,000 U, remains the treatment of choice for secondary prevention of rheumatic fever. Alternative antibiotics may be used in those allergic to penicillin. An effective and safe vaccine against rheumatic fever is not yet available.