Pediatric Rheumatic Fever Follow-up
- Author: Thomas K Chin, MD; Chief Editor: Lawrence K Jung, MD more...
Further Outpatient Care
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- Patients with rheumatic fever (RF) usually demonstrate significant improvement after initiation of anti-inflammatory therapy; however, do not allow patients to resume full activities until all clinical symptoms and laboratory values have returned to normal.
- Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever. Each recurrent episode of rheumatic carditis produces further valve damage and the likelihood of valve replacement. Patients should remain on antibiotic prophylaxis at least until the early third decade of life. Many physicians believe lifelong prophylaxis is appropriate.
- Monitor patients routinely for the signs and symptoms of mitral stenosis, pulmonary hypertension, arrhythmia, and congestive heart failure (CHF).
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- Potential complications include CHF from valve insufficiency (acute rheumatic fever) or stenosis (chronic rheumatic fever).
- Associated cardiac complications include atrial arrhythmias, pulmonary edema, recurrent pulmonary emboli, infective endocarditis, thrombus formation, and systemic emboli.
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- The manifestations of acute rheumatic fever resolve during a period of 12 weeks in 80% of patients and may extend as long as 15 weeks in the remaining 20% of patients.
- Rheumatic fever was the leading cause of death in patients aged 5-20 years in the United States 100 years ago. At that time, the mortality rate was 8-30% from carditis and valvulitis but decreased to a 1-year mortality rate of 4% by the 1930s. Following the development of antibiotics, the mortality rate decreased to nearly 0% by the 1960s in the United States. However, the mortality rate has remained 1-10% in developing countries.
- The development of penicillin also has affected the likelihood of developing chronic valvular disease after an episode of acute rheumatic fever. Prior to penicillin, 60-70% of patients developed valve disease; since the introduction of penicillin, 9-39% of patients develop valve disease.
- In patients who developed murmurs from valve insufficiency from acute rheumatic fever, numerous factors (eg, severity of initial carditis, presence or absence of recurrences, amount of time since episode of rheumatic fever) affected the likelihood that valve abnormalities and the murmur would disappear. The type of treatment and the promptness of its initiation did not affect the likelihood that the murmur would disappear. In general, incidence of residual rheumatic heart disease (RHD) at 10 years was 34% in patients without recurrences but was 60% in patients with recurrent rheumatic fever. In patients in whom the murmur disappeared, it did so within 5 years in 50%. Thus, a significant number of patients experience resolution of valve abnormalities even 5-10 years after their episode of rheumatic fever.
- The importance of preventing recurrences of rheumatic fever is evident.
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- Emphasize measures that minimize further damage to the valves of the heart.
- Timely evaluation and treatment of pharyngitis in children help prevent rheumatic fever.
- Secondary prophylaxis of patients with previous rheumatic fever and valve involvement with penicillin injections every 3-4 weeks decrease the recurrence of RHD.
- Additional prophylactic antibiotics prior to dental and surgical procedures decrease the likelihood of bacterial endocarditis.
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