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Acute Rheumatic Fever

Last Updated: August 10, 2001

  AUTHOR INFORMATION Section 1 of 11   

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Author: Robert J Meador, MD, Rheumatology Fellow, Department of Rheumatology, University of Pennsylvania

Coauthor(s): I Jon Russell, MD, PhD, Director, University Clinical Research Center, Associate Professor, Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University of Texas Health Science Center at San Antonio Robert J Meador, MD, is a member of the following medical societies: Texas Medical Association Editor(s): Anne Davidson, MD, Program Director, Associate Professor, Department of Internal Medicine, Division of Rheumatology, Albert Einstein College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Lawrence H Brent, MD, Chair, Program Director, Associate Professor, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center, Thomas Jefferson University; Alex J Mechaber, MD, FACP, Director of Clinical Skills Program, Assistant Professor, Department of Internal Medicine, Division of General Internal Medicine, University of Miami School of Medicine; and Arthur Weinstein, MD, Professor, Department of Medicine, Georgetown University Medical Center; Director, Division of Rheumatology, Department of Medicine, Washington Hospital Center

  INTRODUCTION Section 2 of 11   

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Background: The incidence of acute rheumatic fever (ARF) has declined in most developed countries, and many physicians have little or no practical experience with the diagnosis and management of this condition. Occasional outbreaks in the United States make complacency a threat to public health.

Diagnosis rests on a combination of clinical manifestations that can develop in relation to group A streptococcal pharyngitis. These include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis. Because the inciting infection is completely treatable, attention has been refocused on prevention.

Pathophysiology: While the inciting bacterial agent is well known, susceptibility factors remain unclear. The location of the streptococcal infection seems to play an important role. The clinical syndrome typically follows a streptococcal pharyngitis, but streptococcal cellulitis has never been implicated.

The earliest and most common feature is a painful migratory arthritis, which is present in approximately 80% of patients. Large joints such as knees, ankles, elbows, or shoulders typically are affected. Sydenham chorea was a common late-onset clinical manifestation in the past but rarely is observed now. Carditis (with progressive congestive heart failure, a new murmur, or pericarditis) may be the presenting sign of unrecognized past episodes and is the most lethal manifestation.

Genetics may contribute, as evidenced by an increase in family incidence. No significant association with class-I human leukocyte antigens (HLAs) has been found, but an increase in class-II HLA antigens DR2 and DR4 has been found in black and white patients, respectively. Evidence has been found that suggests that elevated immune-complex levels in blood samples from patients with ARF are associated with HLA-B5.

Frequency:

In the US: The incidence of an acute rheumatic episode following streptococcal pharyngitis is 0.5-3%. The peak age is 6-20 years. While the incidence has declined steadily, mortality has declined even more steeply. Credit can be attributed to improved sanitation and antibiotic therapy. Several sporadic outbreaks in the United States could not be blamed directly on poor living conditions. New virulent strains are the best explanation.

Internationally: Most major outbreaks occur under conditions of impoverished overcrowding where access to antibiotics is limited. Rheumatic heart disease accounts for 25-50% of all cardiac admissions internationally. Regions of major public health concern include the Middle East, the Indian subcontinent, and some areas of Africa and South America. As many as 20 million new cases occur each year. The introduction of antibiotics has been associated with a rapid worldwide decline in the incidence of ARF. Now the incidence is 0.23-1.88 patients per 100,000 population. From 1862-1962, the incidence declined from 250 patients to 100 patients per 100,000 population, primarily in teenagers. Notably, natives of Polynesian ancestry in Hawaiian and Maori populations are an exception. The incidence continues to be 13.4 patients per 100,000 hospitalized children per year.

Mortality/Morbidity:

Mortality is steadily improving as a result of better sanitation and health care.

The current pattern of morbidity is difficult to measure because the first attack of rheumatic fever follows an unpredictable course. As many as 90% of episodes are clinically contained within 3 months.

Carditis causes the most severe clinical manifestation because heart valves can be permanently damaged. The disorder also can involve the pericardium, myocardium, and the free borders of valve cusps. Death and/or total disability may occur years after the initial presentation of carditis.

Race:

An association has been reported between certain class-II HLA antigens (DR2 in blacks and DR4 in whites).

Sex:

No clear-cut sex predilection exists for the syndrome in general, but its manifestations seem to be sex-variable. For example, a predominance for certain clinical manifestations (ie, chorea and tight mitral stenosis) occurs in women, while men are more likely to develop aortic stenosis.

Age:

The initial attack of ARF occurs most frequently in persons aged 6-20 years and rarely occurs in persons older than 30 years.

The disease may cluster in families.

In some countries, a shift into older groups may be a trend.

  CLINICAL Section 3 of 11   

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History:

The diagnosis is challenging to make for several reasons as follows:

o Older children and young adults recollect pharyngitis approximately 70% of the time. However, young children only recollect pharyngitis approximately 20% of the time. Therefore, one must maintain a higher index of suspicion with younger children who manifest signs

or symptoms consistent with ARF.

o The rate of isolation of group A streptococci from the oropharynx is extremely low in all populations.

Usually a latent period of approximately 18 days occurs between the onset of streptococcal pharyngitis and ARF. Rarely is this latent period shorter than 1 week or longer than 5 weeks.

o Typically, the first manifestation is a very painful migratory polyarthritis. Often, associated fever and constitutional toxicity develop.

o Acute attacks usually resolve within 12 weeks.

Guidelines for diagnosis published more than 50 years ago by T. Duckett Jones have been slightly revised by the American Heart Association (AHA). Prior history of a preceding group A streptococcal infection is helpful but not required. In addition, 2 major manifestations or 1 major and 2 minor manifestations must be present.

o Major manifestations include carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.

o Minor manifestations include arthralgias and fever. Laboratory findings include elevated acute phase reactants (erythrocyte sedimentation rate [ESR] and C-reactive protein) and prolonged PR interval. A prolonged PR interval is not specific and has not been associated with later cardiac sequelae. The utility of echocardiography also is controversial.

The Jones criteria should be viewed as a guide to determine who is at high risk but cannot be used to define diagnosis with absolute certainty.

o An exception includes chorea, which can present as the sole manifestation of ARF, in spite of negative laboratory data.

o Another possible exception is indolent carditis.

A throat culture with positive results for Streptococcus is found in approximately 25% of patients at the time of presentation.

Physical:

Physical findings can be nonspecific and misleading; therefore, a high

index of suspicion is required to make the diagnosis.

Suspicious signs for carditis include new or changing valvular murmurs, cardiomegaly, congestive heart failure, and/or pericarditis.

Isolated mitral valve involvement occurs in nearly 60% of patients with carditis, followed in prevalence by combined mitral and aortic valve involvement.

When present, Sydenham chorea is seldom evident at the time of initial presentation.

Erythema marginatum and subcutaneous nodules are rare (<10% of patients).

Arthritis, which occurs in 80% of patients, usually involves multiple large joints, particularly the knees, ankles, elbows, and wrists.

o Hips and smaller joints of hands and feet are involved less commonly.

o Migratory polyarthritis usually is associated with a febrile illness. It involves a series of painful joints, followed by another series of painful joints.

o This form of arthritis rarely causes permanent joint deformity.

Unusual presentations, such as indolent carditis and isolated chorea, also may occur. Even rarer manifestations include epistaxis and abdominal pain due to serositis.

Causes:

Although the mechanism by which streptococcal organisms cause disease is not entirely clear, overwhelming epidemiologic evidence suggests that ARF is caused by streptococcal infection, and recurrences can be prevented by prophylaxis.

Strains of group A streptococci that are heavily encapsulated and rich in M protein (signifying virulence in streptococcal strains) seem to be most likely to result in infection.

Group A Streptococcus is thought to cause the myriad of clinical diseases where the host's immunologic response to bacterial antigens cross-react with various target organs in the body, resulting in molecular mimicry. In fact, autoantibodies reactive against the heart have been found in patients

with rheumatic carditis. The antibody can cross-react with brain and cardiac antigens, and immune complexes are present in the serum. The problem has been uncertainty whether these antibodies are the cause or result of myocardial tissue injury.

  DIFFERENTIALS Section 4 of 11   

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Kawasaki Disease Sepsis, Bacterial Septic Arthritis Systemic Lupus Erythematosus

Other Problems to be Considered:

Bacterial endocarditisStill disease - Systemic-onset juvenile rheumatoid arthritis or adult Still diseaseVasculitis

  WORKUP Section 5 of 11   

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Lab Studies:

Acute rheumatic fever is diagnosed based on clinical manifestations supported by laboratory tests.

Group A streptococcal antigen detection tests are specific but not very sensitive.

In contrast, antistreptococcal antibodies usually reach a peak titer (in Todd units) at the time of onset of rheumatic fever and are more useful.

o Specific antibodies to streptococcal antigens also indicate true infection rather than mere carriage of the organism. However, note that an isolated positive antistreptolysin O (ASO) titer can be found in children without ARF. It also can be found in certain related diseases such as rheumatoid arthritis and Takayasu arteritis. Therefore, rising ASO titers should be combined with a careful clinical evaluation and finding other antistreptococcal antibodies in order to support the diagnosis of ARF.

o Antistreptococcal antibodies include ASO, antideoxyribonuclease B (anti-DNAse B), antistreptokinase, antihyaluronidase, and anti-DNAase (anti-DNPase).

o These antibodies target extracellular products produced by streptococci.

o Although age, geographic location, and season affect the titers, an elevated titer of at least one of these antibodies indicates streptococcal infection in 95% of patients.

o ASO is positive in 80-85% of patients with ARF.

The sensitivity of throat culture as evidence of recent streptococcal infection is 25-40%.

o For comparison, the sensitivity of ASO titer (adults with >240 Todd U and children with >320 Todd U) is 80%.

o The sensitivity of an elevated ASO titer in addition to anti-DNAse B or antihyaluronidase is 90%.

Acute phase reactants such as C-reactive protein and ESR usually are elevated and helpful to monitor disease activity.

Other lab tests may be helpful, but not for definitive diagnosis. If obtained, synovial fluid analysis reveals a sterile inflammatory reaction, usually with less than 20,000 cells/mm3 (mainly polymorphonuclear) without crystals.

Imaging Studies:

Echocardiography is more sensitive than standard auscultation for helping detect regurgitant lesions, but the prognostic significance of these subauscultory findings is unclear.

Standard auscultation is favored for detecting carditis and can disclose mitral regurgitation in as many as 80% of patients.

Chest x-ray may reveal cardiomegaly.

Other Tests:

ECG is helpful for diagnosing carditis and may reveal a prolonged PR interval, but this finding is not necessarily associated with later cardiac sequelae.

Conventional throat swab cultures have the potential to demonstrate streptococcal organisms.

Procedures:

Synovial tissue biopsy rarely is performed.

Endomyocardial biopsies have not contributed significantly to diagnosis thus far.

Histologic Findings: Synovial biopsy reveals mild inflammatory changes. The synovial membrane may be thickened, erythematous, and covered by a fibrinous exudate. Focal fibrinoid lesions in the heart and histiocytic granulomas called Aschoff nodules may be late findings. Pancarditis develops with involvement of all layers of the heart. Subcutaneous nodule histopathology discloses edema, fibrinoid necrosis, and mononuclear cell infiltrate.

  TREATMENT Section 6 of 11   

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Medical Care: Treatment strategies can be divided into management of an ARF attack, management of the current infection, and prevention of further infection and attacks.

The primary goal of treating the ARF attack is to eradicate streptococcal organisms and bacterial antigens from the pharyngeal region.

o Penicillin is the drug of choice in persons who are not at risk of allergic reaction.

o A single parenteral injection of benzathine benzylpenicillin can ensure compliance.

o Oral cephalosporins, rather than erythromycin, are recommended as an alternative in patients who are allergic to penicillin. However, be cautious of the 20% cross-reactivity of the cephalosporins with penicillin.

By promptly treating streptococcal pharyngitis in susceptible hosts, repetitive exposure to pathologically reactive antigens can be avoided. However, management of the current infection probably will not affect the course of the current attack.

Antimicrobial therapy does not alter the course, frequency, or severity of cardiac involvement.

Analgesia is optimally achieved with high doses of salicylates, often inducing dramatic clinical improvement.

o A lower dose may be required to avert symptoms of nausea and

vomiting. o When salicylates are used as therapy, the dosage should be

increased until the drug produces either a clinical effect or systemic toxicity characterized by tinnitus, headache, or hyperpnea.

Corticosteroids should be reserved for the treatment of severe carditis. o After 2-3 weeks, the dosage may be tapered, reduced by 25% each

week. o Overlap with high-dose salicylate therapy is recommended as the

dosage of the prednisone is tapered over a 2-week period to avoid poststeroid rebound. In extreme cases, intravenous methylprednisolone may be used.

Mild heart failure usually responds to rest and corticosteroid therapy. Digoxin can be useful in patients with severe carditis, but its use should be

monitored closely because of the possibility of heart block. Nocturnal tachycardia may be a sign of cardiac involvement that may be

responsive to digoxin. Vasodilators and diuretics also may be used.

Protracted Sydenham chorea has responded to haloperidol. o Chorea requires long-term antimicrobial prophylaxis, even if no other

manifestations of rheumatic fever evolve. o The signs and symptoms of chorea usually do not respond well to

treatment with antirheumatic agents. o Complete physical and mental rest is essential because the

manifestations of chorea may be exaggerated by emotional trauma. o Glucocorticoids or salicylates have little or no effect on chorea. o Because chorea disappears with sleep, adequate sedation should be

provided.

Prevention has been successful in developed societies. The recommended approach can be divided into primary and secondary prevention.

o Primary prevention: Eradicate Streptococcus from the pharynx, which generally entails administering a single intramuscular injection of benzathine benzylpenicillin.

o Secondary prevention: The AHA Committee on Acute Rheumatic Fever recommends a regimen consisting of benzathine benzylpenicillin at 1.2 million units intramuscularly every 4 weeks. However, in high-risk situations, administration every 3 weeks is justified and advised. High-risk situations include patients with heart disease who are at risk of repetitive exposure.

o Oral prophylaxis, which is less reliable, consists of phenoxymethylpenicillin (penicillin V) or sulfadiazine. These can be used in compliant patients.

o If penicillin allergy is suspected, oral cephalosporins should be used. o Although no consensus on the required duration of antibacterial

prophylaxis has been reached, the AHA recommends prophylaxis be continued for at least 10 years after the last episode of rheumatic

fever or until patients are well into adulthood. For those with heart disease who are at risk of repetitive exposures, prophylaxis should be continued for a longer duration, probably indefinitely. However, for those who have reached their early 20s, in whom more than 5 years have passed since their last attack, and who are free from rheumatic heart disease, discontinuing prophylaxis may be reasonable. The principles of treatment include the following:

The risk of rheumatic fever recurrence is greatest during the first 3-5 years.

Prophylaxis must continue indefinitely for those with established heart disease or for those frequently exposed to streptococci.

Treatment for an indefinite period is required for those with frequent exposure to streptococci or those who are difficult to monitor.

In underdeveloped countries, prophylaxis should be continued as follows: o Continue for 5 years after the first attack. o Continue indefinitely for patients with established heart disease. o Continue indefinitely for those who are frequently exposed to

streptococci, are less than optimal, and difficult to monitor.

The decision to withdraw the antibacterial drugs should be individualized after carefully assessing the risk of repetitive exposures.

Surgical Care:

Valve replacement should be considered in patients with active carditis, especially if patients are refractory to medical care or require high doses of vasodilators and diuretics.

Regurgitant lesions respond to valve replacement, while pure stenotic lesions may benefit from more conservative balloon mitral commissurotomy.

Consultations:

Primary care physicians should be considered the patient's advocate and guide to medical resources.

Rheumatologists usually assist in making the diagnosis in the face of a substantial differential. Then, they can advise on the therapy plan.

A cardiologist should be consulted when cardiac involvement is present.

A neurologist may offer interventions to help manage chorea.

Diet:

No dietary factors are known.

Activity:

All patients should be restricted to bed rest and monitored closely for carditis.

Aggressive use of acutely inflamed joints or other exercise has the potential to cause permanent joint injury to acutely inflamed joints.

When carditis has been documented, a 4-week period of bed rest is recommended. As soon as the signs of acute inflammation subside, patients should resume active ambulation as tolerated.

Most patients can be treated safely in an outpatient setting.

  MEDICATION Section 7 of 11   

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Treatment and prevention may involve multiple fields of discipline, including infectious diseases, cardiology, and neurology. For this reason, several different classes of medications are used. These include antibiotic, neuroleptic, and cardiac medications.

Drug Category: Antibiotics -- Initial pharmacotherapy for prevention and treatment of rheumatic fever.

Drug Name

Penicillin G procaine (Crysticillin) -- Long-acting parenteral penicillin indicated in the treatment of moderately severe infections caused by microorganisms sensitive to penicillin G. IM administration only.Adults: Deep IM injection into the upper outer quadrant of the buttock only.Infants and small children: IM injection into midlateral aspect of the thigh is suggested.Some authors prefer 10 d of therapy.

Adult Dose 2.4 million U IM once

Pediatric Dose<30 lb: 600,000 U IM once30-60 lb: 900,000-1,200,000 U IM once

Contraindications Documented hypersensitivity

Interactions

Increases risk of bleeding when administered concurrently with warfarin; ethacrynic acid, aspirin, indomethacin, and furosemide may compete with penicillin G for renal tubular secretion, thereby increasing penicillin serum concentrations

PregnancyB - Usually safe but benefits must outweigh the risks.

Precautions

Never use IV route to administer penicillin G procaine; administer for more than 10 d to eliminate the organism and prevent complications such as endocarditis and rheumatic fever; perform cultures after treatment to confirm streptococci eradication

Drug Name

Penicillin G benzathine (Bicillin L-A) -- Interferes with synthesis of cell wall mucopeptides during active multiplication, which results in bactericidal activity. Long-acting depot form of penicillin G. Due to its prolonged blood level, several authors believe this to be the DOC. Others prefer daily injections with short-acting penicillin.

Adult Dose 2.4 million U IM once

Pediatric Dose<30 lb: 600,000 U IM once30-60 lb: 900,000-1,200,000 U IM once

Contraindications Documented hypersensitivity

Interactions

Probenecid can increase penicillin effectiveness by decreasing clearance; tetracyclines are bacteriostatic, possibly decreasing penicillin effect

PregnancyB - Usually safe but benefits must outweigh the risks.

PrecautionsCaution in renal dysfunction, adjust dose accordingly

Drug Name

Penicillin VK (Beepen-VK, Betapen-VK, Robicillin VK, Veetids) -- Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. PO alternative.

Adult Dose 500 mg PO q6h for 10 d

Pediatric Dose<12 years: 25-50 mg/kg/d PO divided tid/qid, not to exceed to 3 g/d>12 years: Administer as in adults

Contraindications Documented hypersensitivity

Interactions

Probenecid can increase effects of penicillin by decreasing clearance; coadministration of tetracyclines can decrease effects of penicillin

PregnancyB - Usually safe but benefits must outweigh the risks.

PrecautionsCaution in impaired renal function, adjust dose accordingly

Drug Name

Erythromycin (EES, E-Mycin, Ery-Tab, Erythrocin) -- Alternative for patients allergic to penicillin (although not the DOC).Drug may inhibit RNA-dependent protein synthesis by stimulating the dissociation of peptidyl t-RNA from ribosomes. Inhibits bacterial growth.In children, age, weight, and the severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken every 12 h. For more severe infections, dose may be doubled.

Adult Dose

250 mg erythromycin stearate, base, or estolate salts (or 400 mg ethylsuccinate) q6h PO or 500 mg PO q12h for 10 d; not to exceed 1 g/d; alternatively, 333 mg (as the base) q8h

Pediatric Dose30-50 mg/kg/d (base or ethylsuccinate) PO divided q6-8h; not to exceed 1 g/d

ContraindicationsDocumented hypersensitivity, severe hepatic impairment

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; inhibits CYP1A2 CYP3A4 isoenzymes

PregnancyB - Usually safe but benefits must outweigh the risks.

Precautions

Caution in liver disease, estolate formulation may cause cholestatic jaundice; adverse GI effects are common; discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Drug Category: Anti-inflammatory agents -- Inhibit inflammation to prevent destruction in the joints and heart.

Drug Name

Aspirin (Ascriptin, Bayer Buffered Aspirin, Ecotrin) -- For treatment of mild to moderate pain and headache. Considered the first DOC for the treatment of ARF arthritis.

Adult Dose6-8 g/d PO for 2 mo or until ESR has returned to normal, adjust dose according to serum levels

Pediatric Dose80-100 mg/kg/d PO for 2 mo or until ESR has returned to normal, adjust dose according to serum levels

Contraindications

Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, aspirin-sensitive asthma; due to association with Reye syndrome, do not use in children <16 y who have influenza or varicella infections

Interactions Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may

antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs; serum levels of 20-30 mg/100 dL required to control inflammatory response; high doses may cause gastric irritation or salicylate toxicity (ie, serum levels >20 mg/100 dL) and require dose reduction or alternative treatment with corticosteroids

Pregnancy D - Unsafe in pregnancy

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid with severe anemia or blood coagulation defects

Drug Category: Glucocorticosteroids -- Demonstrate anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids produce profound and varied metabolic effects. These agents also modify the body's immune response to diverse stimuli.

Drug Name

Prednisone (Deltasone, Liquid-Pred, Meticorten, Orasone, Sterapred) -- Patients with carditis require prednisone. The goal is to decrease myocardial inflammation. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. After 2-3 wk, dosage may be tapered, reduced 25% each week.

Adult Dose1-2 mg/kg/d PO for 2-3 wk initially; then discontinue by gradual taper over 3 wk; not to exceed 80 mg/d

Pediatric Dose0.05-2 mg/kg/d PO for 2-3 wk initially; then discontinue by gradual taper over 3 wk

Contraindications

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Interactions May cause water and salt retention,

thereby exacerbating hypertension and increasing requirement for antihypertensive drugs in hypertensive patients; may aggravate hyperglycemia, thereby increasing requirement for hypoglycemic agents in patients with diabetes; coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (adjust dose); hypokalemia may occur with coadministration of diuretics

PregnancyB - Usually safe but benefits must outweigh the risks.

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; may cause hyperglycemia, edema, weight gain, osteonecrosis, myopathy, dyspepsia, peptic ulcer, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, cataracts, glaucoma, and infections

Drug Category: Neuroleptic agents -- Used for chorea associated with ARF.

Drug Name

Haloperidol (Haldol) -- Dopamine receptor blocker used for irregular spasmodic movements of the limbs or facial muscles.

Adult Dose 0.5-2 mg PO bid/tid

Pediatric Dose

<3 years: Not established3-12 yearsInitial: 0.05 mg/kg/d or 0.25-0.5 mg/d PO divided bid/tid, may increase by 0.25-0.5 mg/d PO q5-7dMaintenance: 0.05-0.15 mg/kg/d PO in 2-3 divided doses; not to exceed 0.15 mg/kg/d>12 years: Administer as in adults

Contraindications Documented hypersensitivity; narrow-angle glaucoma, bone marrow

suppression, severe cardiac or liver disease, severe hypotension, or subcortical brain damage

Interactions

May increase tricyclic antidepressant serum concentrations; may increase hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent administration of lithium

PregnancyC - Safety for use during pregnancy has not been established.

Precautions

Severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; monitor for hypotension with parenteral administration; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if it occurs)

Drug Category: Positive inotropic agents -- Digoxin may be indicated for patients with congestive heart failure.

Drug Name

Digoxin (Lanoxin) -- Acts directly on cardiac muscle, increasing myocardial systolic contractions. Its indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.

Adult Dose 0.125-0.375 mg PO qd

Pediatric Dose Digitalizing dose (administer in divided doses over 24 h)2-5 years: 30-40 mcg/kg PO5-10 years: 20-35 mcg/kg PO>10 years: 10-15 mcg/kg POMaintenance dose<10 years: 25-35% of PO loading doses

divided bid>10 years: 25-35% of PO loading dose qd

Contraindications

Documented hypersensitivity; beriberi heart disease, idiopathic hypertrophic subaortic stenosis, constrictive pericarditis, and carotid sinus syndrome

Interactions

Medications that may increase levels include alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, oral amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil; drugs that may decrease serum levels include aminoglutethimide, antihistamines, cholestyramine, neomycin, d-penicillamine, aminoglycosides, oral colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, and procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid

PregnancyC - Safety for use during pregnancy has not been established.

Precautions Hypokalemia may reduce positive inotropic effect of digitalis; IV calcium may produce arrhythmias in digitalized patients; hypercalcemia predisposes patient to digitalis toxicity, and hypocalcemia can make digoxin ineffective until serum calcium levels are normal; magnesium replacement therapy must be instituted in patients with hypomagnesemia to prevent digitalis toxicity; patients diagnosed with

incomplete AV block may progress to complete block when treated with digoxin; exercise caution in hypothyroidism, hypoxia, and acute myocarditis

  FOLLOW-UP Section 8 of 11   

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Further Inpatient Care:

Although the perception exists that inpatient care is mandatory initially for individuals with active carditis, prolonged hospitalization usually is not necessary.

Further Outpatient Care:

Periodic monitoring at 3- to 4-month intervals is critical to evaluate for progress with the resumption of physical activity, resolution of the constitutional symptoms, and freedom from adverse effects from medications.

Less frequent visits, perhaps once a year, are appropriate while following a prophylaxis regimen.

Transfer:

Transfer to an acute facility should be arranged when patients have active life-threatening sequelae, notably carditis.

Deterrence/Prevention:

Patients should be educated to seek medical attention at the first signs of pharyngitis.

Once the disease is established, patients should be educated regarding benefits and risks of compliance with their medical regimen, which may be protracted.

Complications:

Acute episodes are self-limited, with an average duration of 3 months for untreated attacks. Recurrence tends to occur within the first few years of the attack.

The outcome of carditis is likely to be more severe if patients have

preexisting heart disease. Carditis resolves without sequelae in 65-75% of patients.

Severe cardiac failure, total disability, and death may occur years after the acute attack.

The risk of developing a new episode is highest during the 5 years following an acute attack. This justifies prophylaxis for all patients for at least 5 years or until the patient reaches age 18 years.

Prognosis:

The course followed by a patient after a first attack is highly variable and unpredictable. Approximately 90% of episodes last less than 3 months. Only a minority persists longer, in the form of unremitting rheumatic carditis or prolonged chorea.

  MISCELLANEOUS Section 9 of 11   

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Medical/Legal Pitfalls:

Pitfalls arise when misdiagnosis occurs. Many physicians who are unfamiliar with ARF may not have a high enough index of suspicion for this disease. Inadequate treatment of streptococcal pharyngitis also may contribute to a legal quagmire.

Inappropriate or inadequate referral also may invite litigation. For those who are critically ill with cardiomyopathy, efficient transfer must be made to an intensive setting. In addition, patients must be educated about their disease and the chronicity of it.

  BIBLIOGRAPHY Section 11 of 11   

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Guzman, Leonardo: Rheumatic Fever. In: Klippel J, ed. Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation; 1997: 168-71.

Jones TD: Diagnosis of rheumatic fever. JAMA 1944; 126: 481-85.

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