Management of acute rheumatic fever a re-appraisal

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1 Management of acute rheumatic fever a re-appraisal Trinath Kumar Mishra, MD DM FACC FCSI* Biswajit Das, MD DM FICC** Satyanarayan Routray, MD DM FICC* Hrudananda Mishra, MD DM FACC FICC ABSTRACT Rheumatic fever (RF) has fallen off the radar of many physicians, yet remains a daily challenge to many working in less developed areas of India. Rheumatic fever and rheumatic heart disease (RHD) are diseases of poverty. Overcrowding, low socio-economic status, and illiteracy contribute to the high prevalence. Treatment of the disease is mostly supportive as there is no disease-modifying therapy. Nonsteroidal anti-inflammatory drugs should be withheld until the diagnosis is confirmed, and corticosteroids are an option in severe and acute carditis. Most cases of chorea do not require medication, but use of carbamazepine or sodium valproate is recommended in severe cases. New approaches to primary prevention are needed given the limitations of primary prophylaxis as a populationbased strategy. The most effective approach for control of RF is secondary prophylaxis, which is best delivered as part of a coordinated control program. Group A streptococcal vaccines are still years away from being available. Keywords Anti-inflammatory therapy, group A streptococcal vaccine, rheumatic fever, rheumatic fever prophylaxis INTRODUCTION Rheumatic fever (RF) results from an autoimmune response to infection with group A streptococcus. Although the acute illness causes considerable morbidity and some mortality, the major clinical and public health effects derive from long-term damage to the cardiac valves, i.e., rheumatic heart disease (RHD). Over the past century, the incidence of the disease has declined considerably in Western countries as the socio-economic status of people has improved leading to better hygiene, and less overcrowding. However, in developing countries, the disease *Associate Professor, **Assistant Professor, Professor and Head, President, Indian College of Cardiology, Department of Cardiology, SCB Medical College and Hospital, Cuttack, Odisha Correspondence: Trinath Kumar Mishra, Associate Professor, Department of Cardiology, SCB Medical College, Cuttack, Odisha drtkmishra@yahoo.com continues to ravage millions of people where poverty is rampant, thus setting the milieu for widespread occurrence of the disease. Though the disease is known to be prevalent since medieval days, its etiopathogenesis continues to remain enigmatic. As one flounders for the etiology of the disease, the treatment also remains mainly empirical. Following discussion revolves around treatment and prophylaxis of the RF knowing fully well the limitation of any intervention. All the treatments for RF have not been tested in randomized clinical trials. Some are based on anecdotal evidence, common sense and proven safety. 1 For example, penicillin is considered mandatory for the eradication of possibly persistent group A streptococcus infection of the upper respiratory tract, though this treatment has not been shown to alter the cardiac outcome after 1 year in controlled studies. 2 In the present description, we shall discuss about general measures, antimicrobial therapy, anti-inflammatory drugs, treatment of heart failure, chorea and role of primary and secondary prevention of the RF. GENERAL MEASURES Hospitalization is needed for moderate to severe carditis, severe arthritis, or chorea. The duration of rest should be individualized depending upon severity of symptoms, and resolution of acute phase reactants. The patient can be ambulated when fever subsides and erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) levels return to normal. Caution should be observed for patients with carditis, for whom a rest period of 4 weeks is generally recommended. Patients with chorea need a protective environment so that they do not injure themselves. For arthritis, rest for 2 weeks is adequate. Appropriate diet is a must for growing children with cardiac involvement. Patient and family education must be done at every opportunity so as to address their concern and ensure complete co-operation in patient management. Management of Streptococcal Pharyngitis The antibiotic regimen for eradicating streptococcal pharyngitis does not have any impact on the subsequent course of RF either in term of severity of illness or occurrence of carditis. 3 Injection benzathine penicillin G is given intramuscularly at a dose of 1.2 million units (>27 Kg) or 0.6 million unit (<27 Kg) after sensitivity test. Those allergic to penicillin are given azithromycin (12.5 mg/kg/day once daily). 4 Management of Inflammatory Process There is no specific disease-modifying therapy for RF. 5 The anti-inflammatory therapy is targeted at reducing the constitutional symptoms, controlling toxic manifestations, and improving cardiac function. 5 The arthritis of RF is exquisitely responsive to treatment with nonsteroidal anti-inflammatory drugs (NSAIDS). Indeed, this can be a useful diagnostic feature, as arthritis continuing unabated >3 days after starting NSAID therapy is unlikely to be JICC Vol 2 Issue ICC

2 Mishra, et al Table 1 Drugs for control of inflammation in acute rheumatic fever. Inflammation Arthritis ± mild carditis aspirin* Naproxen* (if aspirin intolerance detected) No response to aspirin in 4 days Moderate to severe carditis Steroids* Nonresponders Methyl prednisolone (intravenous [i.v.]) Doses Regime I Starting doses: Children 100 mg/kg/day for 2 3 weeks Adult 6 8 g/day divide in 4 5 doses Tapering doses: once symptoms resolved, taper to mg/kg/day. For older children 50 mg/kg/day (Level of evidence: class I) Regime II mg/kg/day for total 12 weeks (Level of evidence: class Ib) mg/kg/day Switch over to steroid. Rule out other conditions like chronic inflammatory/myeloproliferative disorders before switching over to steroids Regime I Prednisolone: 2 mg/kg/day, maximum 80 mg/day till erythrocyte sedimentation rate (ESR) normalizes usually 2 weeks. Taper over 2 4 weeks, reduce dose by mg every 3rd day Start aspirin mg/kg/day simultaneously, to complete total 12 weeks (Level of evidence: class I) Regime II Prednisolone same doses X 3 4 weeks. Taper slowly to cover total period of weeks. (Level of evidence: class IIb) If no response to oral steroid therapy then start i.v. methyl prednisolone 30 mg/kg/day for 3 days *Consider antacids. Avoid gastric irritants. Allow frequent feeding. Medicines must not be taken on empty stomach. due to RF. 6 Equally, withholding NSAIDs in patients with mono-arthralgia or mono-arthritis to observe the development of polyarthritis can help confirm the diagnosis of RF. Therefore, salicylates, or NSAIDs should be withheld until the diagnosis confirmed. In the meantime, paracetamol can be used to treat joint pain. 6 Acetyl salicylic acid (aspirin) has been the most widely used and validated anti-inflammatory agent for use in RF (Table 1). Aspirin, 100 mg/kg/day divided in 4 5 doses, is usually adequate. In children, the dose may be increased to 125 mg/kg/day, and in adults, up to 6 8 g/day can be given. If symptoms like anorexia, nausea, vomiting and tinnitus appear, they usually subside after a few days despite continuation of the medication. 5 Serum salicylate levels of around 20 mg/dl are required for optimal anti-inflammatory effects. Hence, salicylate blood should be monitored if facilities are available. 7 Aspirin leads to rapid resolution of fever, arthritis, and arthralgia. However, the available evidence suggests that salicylates should not be used for the treatment of carditis, and results of comparison of salicylates with no treatment or bed rest alone suggest that they do not decrease the incidence of residual RHD. 1 Hence, salicylates should be used only for the symptomatic treatment of fever, arthritis, and arthralgia. In patients allergic to penicillin, naproxen has been used (10 20 mg/kg/day) successfully. 8 Corticosteroids are potent anti-inflammatory agents used in patients with RF. Prednisolone in a dose of 1 2 mg/kg/day in single or divided doses up to a maximum of 80 mg/day is the drug of choice. In life-threatening situations, i.v. methyl prednisolone is often used to initiate therapy. Steroids greatly reduce the inflammatory response to RF, especially fever and raised concentrations of acute phase reactants. Many physicians believe they lead to more rapid resolution of cardiac compromise than other drugs and can be life saving in severe cases of acute carditis, though there is little objective evidence. 9 Results of randomized trials done before echocardiography became widely available and those of subsequent meta-analyses have not shown benefit of steroids over placebo or salicylates in the prevalence of residual RHD in the 10 years after RF. 9 However, all of the studies included in meta-analysis were done >40 years ago and most did not test the steroids that are in common use today. Hence, large, probably multicenter, randomized controlled trials are needed to assess the potential benefits of steroids and other newer anti-inflammatory agents on acute rheumatic carditis and long-term cardiac outcome. However, most interventions to alter the outcome of RF will be hampered by the inherent delays in making the diagnosis associated with 1 5 week interval between infection with group A streptococcus and the onset of symptoms, and delays between onset of symptoms JICC Vol 2 Issue ICC

3 Management of acute rheumatic fever a re-appraisal and seeking medical attention and between seeing a physician and confirmation of the diagnosis. 1 Further complicating the assessment of new treatments is the natural improvement of rheumatic carditis that occurs in the absence of recurrences. At present, in spite of the controversies, steroids are recommended in patients with significant cardiac involvement (with pericarditis and heart failure). The use of steroids results in faster resolution of inflammation, toxic state and pericardial effusion as compared to aspirin in these conditions. 5 The duration of therapy is arbitrarily based on the severity of illness and response to therapy and should be individualized. Mild attacks of RF with no or little cardiac involvement can be treated with aspirin only for about 4 weeks or until there is sufficient evidence of anti-inflammatory inactivity. 5 If serum levels can be monitored, it is suggested that after maintaining therapeutic levels for 2 3 weeks, the dose of aspirin can be reduced to mg/kg daily and treatment continued for further 3 6 weeks. 7 In more severe cases of RF (moderate to severe carditis) when prednisolone is chosen as the inflammatory agent, the therapeutic dose should be continued for 8 12 weeks, followed by gradual taper (20 25%) every week. Overlap with aspirin (75 mg/kg/day) is recommended during the tapering phase to reduce the chance of rebound (Table 1). 4 Approximately 5% of patients continue to demonstrate rheumatic activity in spite of prolonged therapy. 5 Management of Heart Failure Salt restriction and fluid restriction are usual measures. Diuretics may be added. Bed rest and steroids are supposed to help in resolution of heart failure symptoms. However, gradual mobilization is advised, once the initial symptoms begin to resolve which usually takes about 4 weeks in patients with carditis. Patients with severe symptoms will need digitalis and angiotensin converting enzyme (ACE) inhibitors, though data supporting the use of these agents in RF is lacking. Table 2 enlists the drugs and their dosages to control HF. 4 Management of Chorea Mild chorea is usually treated with quiet environment, and sedatives like oral phenobarbitone or diazepam. 4 If there is no response, other drugs that can be used are haloperidol ( mg/kg/day), sodium valproate (15 mg/kg/day), or carbamazepine (7 20 mg/kg/day). Treatment should be continued for 2 4 weeks after clinical improvement. Steroids have no role in chorea associated with RF. One small study has suggested use of i.v. immunoglobulin might hasten recovery from Sydenham s chorea. 10 PROPHYLAXIS OF RHEUMATIC FEVER The overall lack of effective treatment for RF means that any reduction of burden of RF and RHD will most likely come for new initiatives in prevention. 1 The prophylaxis of RF can be either primary or secondary. Table 2 Drugs and dosages for heart failure. Drug Digoxin Diuretics Angiotensin converting enzyme inhibitors Sodium nitroprusside Inotropes Surgery Dose 30 μg/kg total digitalization dose, 7.5 μg/kg/day maintenance dose Frusemide mg/kg/day Metolazone mg/kg/day Adults mg/day Captopril 0.25 mg/kg test dose, build up doses from mg/kg/day in three divided doses (Uncontrolled congestive heart failure [CHF]) μg/kg/min infusion, monitor cyanide level Dobutamine 2 20 μg/kg/min infusion Dopamine 2 20 μg/kg/min infusion Milrinone μg/kg/min infusion Severe mitral regurgitation due to chordal rupture leading to refractory CHF Primary Prophylaxis Ideally, primary prevention entails elimination of major risk factors for streptococcal infection, particularly poverty, overcrowding and inadequate hygiene infrastructure. This is difficult to achieve in a poor, overpopulated country like India. Therefore, the mainstay of primary prophylaxis is timely and complete treatment of group A streptococcal (GAS) sore throat with antibiotics (Table 3). 4 To arrive at a diagnosis, one should take into account factors such as age <15 years, history of fever, tonsillar swelling or exudates, tender anterior cervical lymphadenopathy and absence of cough. 11 If 4 or 5 of factors are present, the likelihood ratio (LR) for GAS infection is 4.9 (approximately 50% of cases); if 3 factors are present the ratio decrease to 2.5 (approximately 25% of cases); and if only 2 factors are present the ratio becomes 0.9 (approximately 10% of cases). Throat swab culture and anti-streptolysin O titers (ASO) aid in diagnosis. Effective antibiotic therapy eradicates GAS from the upper respiratory tract and can prevent RF, if therapy is started within 9 days after onset of symptoms. A single intramuscular (i.m.) injection of 1.2 million units of benzathine penicillin is often enough. Oral penicillin V (500 mg twice daily) has to be given for full 10 days (Table 3). 4 First generation cephalosporins are also useful. Macrolide antibiotics (erythromycin, azithromycin) can be tried in patients with penicillin allergy. But the prevalence of macrolide resistant strains are high and may pose problems. 12 Antibiotics should not be prescribed to GAS carriers, as they are unlikely to spread to contacts and are at lowrisk of developing RF. JICC Vol 2 Issue ICC

4 Mishra, et al Table 3 Drugs for the treatment of streptococcal pharyngitis and secondary prophylaxis. Drugs Dose Sore throat treatment Secondary prophylaxis (duration) (interval) Benzathine penicillin G 1.2 million unit (>27 Kg) (after sensitivity test [AST]) Single dose 21 d (deep i.m. inj) 0.6 million unit (<27 Kg) (after sensitivity test) Single dose 15 d contraindication penicillin allergy Penicillin-V (oral) Children: 250 mg qid 10 d Twice a day Adult: 500 mg bid contraindication penicillin allergy 10 d Twice a day Azithromycin (oral) 12.5 mg/kg/day once daily 5 Not recommended Cephalexin (oral) mg/kg/dose bid 10 d Not recommended Erythromycin (oral) 20 mg/kg/dose max 500 mg contraindication liver Not recommended Twice a day disorder i.m.: intramuscular. However, whether or not primary prophylaxis is effective on a wide scale in populations at high-risk for RF is difficult to prove unless accompanied by a comprehensive healthcare program and general improvement in health services delivery. 1 Highly sensitive and specific clinical diagnostic algorithms for group A streptococcus pharyngitis are not available, microbiological diagnosis is expansive and not feasible in primary care settings in most developing countries, and little is known about health-seeking behavior for sore throat in these population. 13 Even in optimum circumstances, the effectiveness of primary prophylaxis is limited by the fact that up to two-third of patients with RF do not get a sore throat and do not therefore seek medical alteration. 14 The best available data for the effectiveness of intensive school-based sore throat diagnosis and treatment came from a study done in high RF incidence region of Auckland, New Zealand, in which schools were randomized to intervention or no intervention. 15 Results of initial analysis indicate no reduction of RF incidence (odds ratio 0.76, 95% confidence interval ). Hence, even the most intensive program of sore throat diagnosis and treatment might not lead to substantial reduction in RF incidence. 1 Although primary prophylaxis should be promoted to health staff and the patients with sore throats, coordinated programs are unlikely to be practical, affordable, or cost-effective in a poor country like ours. At present, no practical and affordable strategy exists for primary prophylaxis of RF in developing countries. Secondary Prophylaxis The only proven cost-effective intervention is secondary prophylaxis: the long-term administration of antibiotics to people with a history of RF or RHD to prevent recurrences and the development or deterioration of RHD. The best drug for this purpose is i.m. injection of benzathine penicillin-g administered once every 3 weeks (Table 3). Benzathine penicillin is a repository form of penicillin-g designed to provide a sustained bactericidal serum concentration. Serum levels of penicillin remain above the minimum inhibitory concentration for group-a streptococci for 3 4 weeks. The reconstituted or lyophilized penicillin should be stored at temperatures not exceeding 30 C and be protected from moisture. Sensitivity testing should be done prior to the injection every time. Hypersensitivity to penicillin is reported to occur in 2 5% of patients while anaphylactic reactions occur in about 0 2% of patients. 16 The most common allergic manifestations is skin rash. Allergic reactions are less common in children <12 years of age and duration of prophylaxis does not increase the risk of allergic reactions. Skin testing with intradermal penicillin is appropriate method for identifying patients at high-risk of allergic reactions as chances of serious reactions are extremely low in patients with a negative skin test. 5 Detailed history of allergy to beta lactams (including all types of penicillin and cephalosporin) should however be obtained from all patients prior to skin testing on each visit. Persons performing skin testing should be trained in the technique and in managing anaphylaxis, which may occur rarely ( ) with skin testing itself. 17 Techniques used to reduce the pain of benzathine penicillin injections includes use of small gauze needles, increased injection volumes, and addition of 1% lignocaine or procaine penicillin. Simple measures of applying direct pressure to the injection site, warming the medication to room temperature, ensuring that skin swabbed with alcohol is dry before injecting, distracting the patient with conversation, and delivering the injection slowly (preferably over 3 minutes) ensure that the injection is well-tolerated. 1 Duration of Secondary Prophylaxis The duration of secondary prophylaxis is determined by many factors, in particular the duration since the last episode of RF (recurrence becomes less likely with increasing time), age (recurrences are less likely with increasing age, and the severity of RHD (if severe, it is prudent to avoid even a small risk of recurrence because of the potentially serious consequences). 1 The Table 4 lists the category of patient and duration of prophylaxis. 18 Secondary prophylaxis is best delivered in the context of a formal, register-based RF and RHD control program. The Indian JICC Vol 2 Issue ICC

5 Management of acute rheumatic fever a re-appraisal Table 4 Suggested duration of secondary prophylaxis. Category of patient Duration of prophylaxis Patient without proven For 5 years after the last attack, carditis or until 18 years of age (whichever is longer) Patient with carditis (mild For 10 years after the last mitral regurgitation or healed attack, or at least until 25 years carditis) of age (whichever is longer) More severe valvular disease Lifelong After valve surgery Lifelong NH 2 LT-B polyvalent vaccine made from locally prevalent strains ineffective, paucity of clinical trials, and likely exorbitant cost of the vaccine. 20 L M5 15 aa COOH Figure 1 Recombinant molecule in which haptenic M5 peptide is linked to the B subunit of Escherichia coli labile toxin (LT-B). CONTROL PROGRAMS FOR RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE Council of Medical Research (ICMR) has started RF registry for secondary prophylaxis. 19 Control programs have added benefits beyond improving adherence to secondary prophylaxis, such as ensuring good clinical follow-up of patients with RF and RHD, providing a means to undertake educational and health problems activities, and providing accurate epidemiological data for monitoring and research purposes. PROSPECTS OF VACCINE AGAINST RHEUMATIC FEVER In view of lack of any clear and viable strategy for primary prophylaxis of group-a streptococcus (GAS) infections, there is definitely a place for safe, efficacious, and affordable GAS vaccine. 20 An effective vaccine against GAS infections would serve not just in preventing RF and RHD, but also poststreptococcal glomerulonephritis, sore throat, impetigo, and invasive forms of streptococcal infections. 21 Several GAS protein components and the streptococcal polysaccharide have been considered for utilization in developing a vaccine. 20 Most work has been done with the M-protein, considered to be the virulent factor for the GAS. Gentle acid extraction from the surface of GAS by dilute pepsin has yielded the peptide, Pep-M, which is the terminal of a very long molecule and is a feature of rheumatogenic, but no other strains of group-a streptococci. 22 The Pep-M, a coiled-coil polypeptide, frequently undergoes genetic recombination leading to loss in opsonizing ability of type-specific antibodies. Vaccines directed at the Pep-M are therefore strain-specific. Since more than 100 different strains have been identified, it is essential that the vaccines must be polyvalent, that is, it should incorporate all strains prevalent in the community. The Pep-M protein is separated from the more proximal, toxic part of the M-molecules. The recombinant hybrid protein is then linked to the B subunit of Escherichia coli labile toxin (LTB), which serves as a mucosal stimulant for the production of protective IgA type-specific antibodies 22 (Figure 1). Several practical issues have so far impeded development of a viable GAS vaccine. These include orphan status of the vaccine (vaccine has not been wholeheartedly accepted by the industry), potential of GAS to mutate rapidly thus making a Desirable elements of RF and RHD control program include a central register of patients, a dedicated coordinator, an advisory committee, guaranteed funding, guaranteed supply of benzathine penicillin-g, and mechanisms for finding new patients, facilitating communication between health procedures in hospital and communities and providing education for health staff and the wider community. 1 Though India relies on secondary prevention in a organized way, a study conducted at Puducheri, on the free economics of RF, concludes that primary prophylaxis is the most viable economic option in the long run. 23 A coordinated control program is the most effective approach for improving adherence to penicillin prophylaxis and clinical follow-up of people with RHD. 18 Maintaining register of people with RHD or a history of RF is a key element of RF/RHD control at individual, community, and national level. Registerbased programs improve case detection, increase adherence to secondary prophylaxis, reduce recurrences of RF, and reduce hospitalizations for RF and RHD. 6 Registers also provide data for monitoring the success of program and changes in disease epidemiology. Active screening and legislated notification of RF and RHD should also be actively considered. The pattern of an ideal coordinated control program is enlisted in Table 5. 6 CONCLUSION Rheumatic fever and RHD continue to be major public health problem in India. Considerable number of children and adolescents still suffer from RF and its long-term sequel such as RHD, causing enormous morbidity and mortality. Reports of declining incidence of RF/RHD in parts of India having experienced human development should not distract our attention from the alarming frequency or the disease in less developed areas. Actually, there is paucity of epidemiological data from poorly served rural population, urban slums, and tribal pockets where the disease prevalence is expected to be high. Till date, there is no evidence that anti-inflammatory therapy during RF alters the course of carditis or incidence of subsequent heart disease. Efficacy of primary prophylaxis on wide scale in population is difficult to prove unless accompanied by a comprehensive healthcare program and general improvement in health services JICC Vol 2 Issue ICC

6 Mishra, et al Table 5 Recommended routine review and management plan for acute rheumatic fever and rheumatic heart disease. Classification Criteria* Review and Management Plan Frequency Low-risk ARF with no evidence of RHD Secondary prophylaxis (BPG) 4-weekly OR Doctor review Yearly Trivial to mild valvular disease Echocardiography Children 2-yearly Medium-risk Any moderate valve lesion in the Secondary prophylaxis (BPG) 4-weekly Adults 2 3 yearly absence of symptoms and with Doctor review 6-monthly normal left ventricular function Influenza vaccination Yearly OR ECG (optional) Yearly Mechanical prosthetic valves Cardiologist/physician/pediatrician review Yearly Echocardiography Yearly Dental review Yearly Polysaccharide pneumococcal vaccination 5-yearly (max 3 doses) (Pneumovax 23 [Merck Sharp & Dohmel]) As required Endocarditis prophylaxis High-risk Severe valvular disease Secondary prophylaxis (BPG) 3 4 weekly OR Doctor review 3 6 monthly Moderate/severe valvular lesion Cardiologist/physician/pediatrician review 3 6 monthly with symptoms Influenza vaccination Yearly OR Echocardiography 3 6 monthly Tissue prosthetic valves and valve Dental review Within 3 months and yearly repairs Polysaccharide pneumococcal vaccination thereafter Endocarditis prophylaxis 5-yearly (max 3 doses) Warfarin + aspirin As required As prescribed Additional Following valve surgery Medical assessment considerations ECG Chest radiograph Echocardiography Full blood count Urea, creatinine, electrolytes International normalized ratio if indicated 3 4 weeks after discharge Missed doses of BPG Patient should be contacted if they have not presented within 3 days of due injection Patient traveling to another Consideration should be given to bringing community when injection is due forward the date of injection to 2 3 weeks, or arrangements made with other service providers in advance ARF: acute rheumatic fever; BPG: benzathine penicillin G; ECG: electrocardiogram; INR: international normalized ratio; RHD: rheumatic heart disease. *Serial echocardiographic assessments are required for long-term management of RHD. If cultural differences or difficulties with communication hinder standard clinical measures of heart failure (e.g., New York Heart Association criteria), serial echocardiography becomes an essential tool for determining the progress of cardiac damage and optimal timing of surgery. Thus, risk stratification should be based on clinical and echocardiographic findings. Frequency of review should be determined according to individual needs and local capacity. Most critically, review should become more frequent in the event of symptom onset, symptomatic deterioration, or a change in clinical findings. In patients with no evidence of valvular disease on echocardiography, no documented acute renal failure recurrences, good adherence to secondary prophylaxis, and no cardiac murmurs on examination at follow-up appointments, echocardiography may be needed less frequently. Any patient with severe valvular disease or moderate to severe valvular disease with symptoms should be referred for cardiological and surgical assessment as soon as possible. delivery. Even in optimum circumstances, the effectiveness of primary prophylaxis is limited by the fact that up to two-thirds of patients with RF do not get a sore throat and therefore do not seek medical attention. The only proven cost-effective intervention at present is secondary prophylaxis: the long-term administration of antibiotics to people with a history of RF or RHD, to prevent RF recurrences and the development or deterioration of RHD. Secondary prophylaxis is best delivered in the context of a formal, register-based RF and RHD control program. JICC Vol 2 Issue ICC

7 Management of acute rheumatic fever a re-appraisal REFERENCES 1. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet 2005;366: Carter MF, Bywaters EGL, Thomas GTG. Rheumatic fever treated with penicillin in bactericidal dosage for six weeks: report of a small controlled trial. BMJ 1962;1: Tompkins DG, Boxerbaum B, Liebman J. Long-term prognosis of rheumatic fever patients receiving regular intramuscular benzathine penicillin. Circulation 1972;45: Saxena A, Kumar RK, Gera RP, Radhakrishnan S, Mishra S, Ahmed Z. Working group on pediatric acute rheumatic fever and cardiology chapter of Indian Academy of Pediatrics. Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease. Indian Paediatr 2008;45: Kasliwal RR, Mehrotra R. Rheumatic fever: diagnosis and management. In: ECAB Clinical Update: Cardiology Rheumatic Heart Disease Kumar RR, ed. Elsevier: India 2008: Carapetis JR, Brown A, Wilson NJ, Edwards KN. An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline. Med J Aust 2007;186: Thatai D, Turi ZG. Current guidelines for the treatment of patients with rheumatic fever. Drugs 1999;57: Uziel Y, Hashkes PJ, Kassen E, et al. The use of naproxen in the treatment of children with rheumatic fever. J Pediatr 2000;137: Cilliers AM, Manyemba J, Saloojee H. Anti-inflammatory treatment for carditis in acute rheumatic fever. Chocrane Database Syst Rev 2003;2:CD Swedo SE. Sydenham s chorea: a model for childhood autoimmune neuropsychiatric disorders. JAMA 1994;272: Ebell MH. The rational clinical examination. Does this patient have strep throat? JAMA 2000;284: Sathyamurthy I, Jayanthi K. Prevention of rheumatic fever recurrences. In: ECAB Clinical Update: Cardiology Kumar RK, ed. Elsevier: India 2008: Anon. Strategy for controlling rheumatic fever/rheumatic heart disease, with emphasis on primary prevention: memorandum from a joint WHO/ISFC meeting. Bull World Health Orgon 1995;73: Veasy LG, Tani LY, Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States. J Pediatr 1994;124: Lennon DR. The decline of acute rheumatic fever (ARF): unrelated to sore throat management? 42nd Inter-science Conference on Antimicrobial Agents and Chemotherapy San Diego 2002:C Markowitz M, Lue HC. Allergic reactions in rheumatic fever patients on long-term benzathine penicillin-g: the role of skin testing for penicillin allergy. Paediatrics 1996;97: Warrington RJ, Lee KR, McPhillips S. The value of skin testing for penicillin allergy in an inpatient population: analysis of the subsequent patient management. Allergy Asthma Pro 2000;21: WHO. Rheumatic fever and rheumatic heart disease: Report of a WHO expert consultation, Geneva, 29 October 1 November Geneva: World Health Organsiaiton Padmavati S. Rheumatic fever and rheumatic heart disease in India at the turn of the century. Indian Heart J 2001;53: Group-A streptococcal vaccine development: current status and issues of relevance to less developed countries, group-a streptococcal disease. Discussion papers on child health: WHO Geneva Kumar RK. Epidemiology of rheumatic fever and rheumatic heart disease in India. In: ECAB Clinical Up-date: Cardiology Rheumatic Heart Disease Kumar RK, ed. Elsevier: India 2008: Dale JB, Chiang EC. Intranasal immunization with recombinant group a streptococcal M protein fragment fused to the B subunit of Escherichia coli labile toxin protects mice against systemic challenge infections. J Infect Dis 1995;171: Soudarssaname MB, Karthigeyan M, Balachander J. Rheumatic fever and rheumatic heart disease. Primary prevention is the cost effective option. Indian J Pediatr 2007;74: JICC Vol 2 Issue ICC