Rheumatic Fever in Children Under 5 Years Old
Berna Canter, MDRana Olguntürk, MD
F. Sedef Tunaoglu, MD
Department of Pediatric Cardiology
Gazi University School of Medicine
06520, Ankara, Turkey
To the Editor. —
This letter is in response to the article "Rheumatic Fever in Children Younger Than 5 Years: Is the Presentation Different?" published in Pediatrics by Tani et al.1 The article alerts pediatricians to rheumatic fever (RF) in children <5 years old in the differential diagnosis, although the disease is uncommon in this age group.
Based on this study, we also reviewed our experience with the RF cases in the last 20 years. Data on 609 RF attacks seen in 564 patients seen from January 1982 through December 2001 were collected from the medical records. The diagnoses were based on revised Jones criteria before 1992 and on updated Jones criteria afterward. Age at presentation, gender, major Jones criteria fulfilled, and the severity of carditis (if present) were noted. The criteria used by Tani et al were applied to evaluate the severity of carditis. Isolated arthritis (arthritis without any other major finding of RF) and isolated carditis (carditis without any other major finding of RF) cases were determined. Regarding these features, the clinical presentation of the attacks that occurred in the first 5 years of life were compared with that of attacks that occurred after 5 years of age using 
2 or Fisher’s exact test. P < .05 was considered statistically significant.
Of 609 RF attacks, 16 (2.6%) had occurred in the first 5 years of life, with a mean age of 4.69 ± 0.48 (range: 43–59 months). The male/female ratio (1.0 [8 girls, 8 boys]), carditis and arthritis rates (50.1% and 62.5%), and isolated carditis and isolated arthritis rates (37.5% and 50%) did not differ from those of 593 attacks that occurred after 5 years of age (male/female: 1.0; carditis and arthritis rates: 46.2% and 61.4%; isolated carditis and isolated arthritis rates: 32.5% and 48.1%). The severity of carditis was also similar among cases with carditis in both groups (moderate to severe carditis: 28.6% of the 16 attacks occurring at a younger age vs 36.8% of the attacks occurring after the age of 5 years). Therefore, unlike the study by Tani et al, we cannot conclude that arthritis tends to be isolated, nor can we say that carditis tends to be moderate to severe in RF cases occurring at <5 years of age. In our study, the only difference between the 2 groups was regarding chorea, which was not seen in any of the 16 attacks, whereas 7.1% of the rest of the attacks involved chorea. In the mentioned study, 11% of the children <5 years of age had chorea, which was significantly lower than the chorea rate of older patients.
As Tani et al stated in their report, the occurrence rate of RF under the age of 5 years differs from 1 study to another.2–4 Although our sample size was as large as that of the Tani et al study, the rate we found is almost half the rate that they reported (2.6% vs 5%). Therefore, the inconsistent results in the literature do not seem to be resolved by making studies involving large series; rather, the awareness of pediatricians of RF in patients <5 years old determines these reported rates. No matter what the incidence is, studies such as ours show that RF occurs in these young children, and if it goes unnoticed, sequelae from reactivations caused by the lack of prophylaxis seem inevitable for these patients.
REFERENCES
- Tani LY, Veasy LG, Minich LL, Shaddy RE. Rheumatic fever in children younger than 5 years: is the presentation different?
Pediatrics. 2003;112
:1065
–1068
[Abstract/Free Full Text] - Zaman MM, Rouf MA, Haque S, et al. Does rheumatic fever occur usually between the ages of 5 and 15 years? Int J Cardiol. 1998;66 :17 –21[CrossRef][Web of Science][Medline]
- Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic fever in an endemic region: a guide to the susceptibility of the population? Epidemiol Infect. 2000;124 :239 –244[CrossRef][Medline]
- Arora R, Subramanyam G, Khalilullah M, Gupta MP. Clinical profile of rheumatic fever and rheumatic heart disease: a study of 2,500 cases. Indian Heart J. 1981;33 :264 –269[Medline]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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  L. Y. Tani, L. G. Veasy, L. L. Minich, and R. E. Shaddy Rheumatic Fever in Children Under 5 Years Pediatrics, September 1, 2004; 114(3): 906 - 906. [Full Text] [PDF]
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