Rheumatic fever medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]

Overview

The management of acute rheumatic fever is geared toward the reduction of inflammation with anti-inflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for strep throat should also be treated with antibiotics. Another important cornerstone in treating rheumatic fever includes the continuous use of low dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence.

Treatment

Antibiotic treatment in patients with rheumatic fever is aimed at eradication of group A streptococcus from the body. Patients with positive cultures for streptococcus pyogenes and even those suspected to have strep infection should be treated with penicillin as long as allergy is not present. This treatment will not alter the course of the acute disease. Oral penicillin V is the drug of choice, but ampicillin and amoxicillin are equally effective. Intramuscular benzathine penicillin is an alternative when oral penicillin is not feasible. Patients allergic to penicillin should be treated with cephalosporin or erythromycin.

Infection control among patients with streptococcus pharyngitis should be managed as follows:

• Hospitalized patients should be placed on droplet precautions and other standard precautions until 24hours after initiation of antibiotics.
• People in contact with patients with streptococcus pharyngitis should undergo evaluation for infection and treatment if infected.
• Infected children should not attend school or childcare until 24hours after initiation of antibiotics.

Arthritis/Arthralgia

Pain and inflammation in joints can be controlled with paracetamol or salicylates. Mild arthalgia and fever may respond to paracetamol alone. If arthalgia is severe, high dose of aspirin can be used. But patient should be monitored for symptoms of salicylate toxicity such as tinnitus, headache, or hyperpnea. 20-30mg/100dL are desired serum levels and should be maintained until the signs and symptoms of acute rheumatic fever are resolved or residing.

Duration of treatment is usually 1-2weeks and may be extended if the symptoms persists. When discontinuing therapy, aspirin should be discontinued gradually over weeks to avoid rebound reaction.

Sydenham's chorea

Sydenham's chorea is usually self limiting, resolving within few weeks. Long term antibiotic prophylaxis is indicated in patients with Sydenham's chorea even in the absence of other manifestations of rheumatic fever. Chorea aggravates with emotional stress and attenuates with sleep. Therefore it can be controlled by sedating the patient with diazepam or phenobarbital. In severe cases, patient should be placed at high risk of injury and treated with carbamazepine or valproic acid. Anti-inflammatories such as glucocorticoids and aspirin have no effect on Sydenham's chorea.

Heart failure

Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure which includes diuretics, ACE inhibitors and digoxin. Unlike normal heart failure, rheumatic heart failure responds well to corticosteroids. Prednisone or prednisolone (1-2mg/kg/day) are the corticosteroids of choice with maximum dose being 80mg/day. The treatment with corticosteroids is usually for a period of 2-4 weeks after which the dose is tapered by 25% each week while maintaining high levels of salicylates to minimize adverse effects.

Valve defects

Mitral regurgitation or stenosis may develop in patients with rheumatic fever. Patients with mild MR may remain asymptomatic, but should be followed regularly yearly. Patients with moderate MR should be assessed with echocardiogram yearly or when symptoms develop. Patients with severe MR should undergo serial echocardiographic studies every 6 to 12 months to assess left ventricular size and ejection fraction which is important for timing of surgery.

National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand Treatment Guidelines

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All cases Single dose intramuscular benzathine penicillin G (preferable) or oral penicillin V for 10 days (intravenous penicillin not needed; oral erythromycin may be used if patient allergic to penicillin) Arthritis and fever Paracetamol (first-line) or codeine until diagnosis confirmed Aspirin (first-line) or naproxen once diagnosis confirmed, if arthritis or severe arthralgia present Mild arthralgia and fever may respond to paracetamol alone Influenza vaccine for children receiving aspirin during the influenza season (autumn/winter) Chorea No treatment for most cases Carbamazepine or valproic acid if treatment is necessary Carditis/heart failure Bed-rest Urgent echocardiogram Anti-heart failure medication Diuretics/fluid restriction for mild to moderate heart failure ACE inhibitors for more severe heart failure, particularly if aortic regurgitation present Glucocorticoids optional for severe carditis (consider treating for possible opportunistic infections) Digoxin if atrial fibrillation present Valve surgery for life-threatening acute carditis (rare) Long-term preventive measures Give first dose of secondary prophylaxis Notify case for recording in ARF/RHD register, if available Contact local health staff to ensure follow-up Provide culturally appropriate education to patient and family Arrange dental review and ongoing dental care to reduce risk of endocarditis

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