INTRODUCTION: During the past 2 decades the presentation of rheumatic fever (RF) has changed markedly from that of an acute florid illness to a more subtle subacute form that is frequently missed.
OBJECTIVE: With this work we attempted to describe the changing face of RF with its different patterns and time of presentation, particularly subclinical carditis.
METHODS: This work included 1732 patients with RF followed up in the pediatric department and pediatric cardiology clinic at Pediatric Hospital, Ain Shams University. Every patient was subjected to a thorough clinical examination, measurement of erythrocyte sedimentation rate and antistreptolysin O titer and C-reactive protein levels, a chest radiograph, electrocardiography, and echocardiography Doppler. Echocardiography was performed at the time of admission and repeated after 2, 4, and 6 weeks and 1 year after the attack. Diagnosis of RF was based on the revised Jones criteria.
RESULTS: Age at the first attack was <5 years for 10% of the patients, 5 to 10 years for 51%, 11 to 15 for 36%, and >15 for 3%; the male/female ratio was 1:1.34. Major clinical RF manifestations were carditis (60%), polyarthritis (56%), chorea (15%), erythema marginatum (0.12%), and subcutaneous nodules (0.12%). Seventy-two percent had carditis, after we combined clinical and echocardiographic criteria of cardiac affection 6 weeks after the attack. Pure arthritis was present in 41% of the patients, arthritis and carditis in 29%, and arthritis and subclinical carditis in 30%. One year after the initial attack the number of patients with echocardiographic features of valve affection remained the same. Pure chorea was present in 55% of the patients, chorea and carditis in 30%, and chorea and subclinical carditis in 25%. One year after the initial attack, 70% of the patients with chorea had echocardiographic features of valve affection. Chronicity of chorea is common with multiple relapses.
CONCLUSIONS: RF is not uncommon in children <5 years of age. Subclinical carditis should be anticipated and looked for at the right time in susceptible patients, particularly those with rheumatic arthritis and chorea. Multicenter studies should be carried out for the addition of the echocardiographic features of carditis to Jones' minor criteria for the diagnosis of RF. Diagnosis of carditis requires a high index of suspicion in at least 1 of 3 cases.
Submitted by Alyaa Kotby
- Copyright © 2008 by the American Academy of Pediatrics