Adherence to penicillin treatment is essential for effective secondary prevention of rheumatic heart disease: a systematic review and meta-analysis

Background

Penicillin is essential for secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). However, the incidences of ARF recurrence and RHD progression remain high, particularly in endemic countries. This meta-analysis evaluated the effectiveness of penicillin adherence in secondary prevention of ARF recurrence and RHD progression.

Methods

The authors included original articles employing an observational study design in which the study population included patients with ARF or RHD and documented adherence to secondary prophylaxis with penicillin for secondary prevention. Systematic searches of the PubMed, Scopus, and Cochrane databases were performed. Moreover, the authors also conducted a snowballing literature search from Europe PMC to expand the included studies. The quality of each study was assessed using the National Institute of Health Quality Assessment Tool. The statistical analyses were conducted using Review Manager 5.4.1 software developed by Cochrane. In addition, the authors utilized pooled odds ratios (ORs) to compare the adherence techniques.

Results

A total of 310 studies were identified, of which 57 full-text articles were assessed for eligibility. The authors included six studies with 1364 patients for the qualitative synthesis and meta-analysis. Good adherence to penicillin for the secondary prophylaxis of ARF and RHD, significantly reduced the odds of ARF recurrence or RHD progression by up to 71% compared to that associated with poor adherence [pooled OR 0.29 (0.21-0.40); I²=0% (p=0.56); Z=7.64 (p <0.00001)].

Conclusion

Good adherence to penicillin for secondary prophylaxis in patients with ARF or RHD is essential for reducing the risk of ARF recurrence or RHD progression.

Preventive Interventions to Reduce the Burden of Rheumatic Heart Disease in Populations at Risk: A Systematic Review

BACKGROUND

Rheumatic heart disease (RHD) is a devastating yet preventable condition that disproportionately affects low-middle-income countries and indigenous populations in some high-income countries. Various preventive interventions have been implemented across the globe, but evidence for the effectiveness of these measures in reducing the incidence or prevalence of acute rheumatic fever and RHD is scattered. This systematic review aims to assess the effectiveness of preventive interventions and identify the strategies used to reduce the burden of RHD.

METHODS AND RESULTS

A comprehensive search was conducted to identify relevant studies on RHD prevention interventions including interventions for primordial, primary, and secondary prevention. Effectiveness measures for the interventions were gathered when available. The findings indicate that school-based primary prevention services targeting the early detection and treatment of Group A Streptococcus pharyngitis infection with penicillin have the potential to reduce the incidence of Group A Streptococcus pharyngitis and acute rheumatic fever. Community-based programs using various prevention strategies also reduced the burden of RHD. However, there is limited evidence from low-middle-income countries and a lack of rigorous evaluations reporting the true impact of the interventions. Narrative synthesis was performed, and the methodological quality appraisal was done using the Joanna Briggs Institute critical appraisal tools.

CONCLUSIONS

This systematic review underscores the importance of various preventive interventions in reducing the incidence and burden of Group A Streptococcus pharyngitis, acute rheumatic fever, and RHD. Rigorous evaluations and comprehensive analyses of interventions are necessary for guiding effective strategies and informing public health policies to prevent and reduce the burden of these diseases in diverse populations.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020170503.

Distinguishing Acute Rheumatic Fever From Post-streptococcal Reactive Arthritis

We report an initial episode of post-streptococcal reactive arthritis (PRSA) in a 61-year-old male with group A streptococcal (GAS) bacteremia. The disease is commonly reported in young children and young adults. Additionally, this patient exemplifies the nonlinear boundaries of acute rheumatic fever (ARF) and PRSA, bringing into question whether they are truly distinct disease entities. These two conditions oftentimes present in similar fashions, making it difficult for clinicians to determine a specific diagnosis. We highlight the importance of recognizing ARF versus PRSA as an incorrect diagnosis can lead to the development of harmful complications including rheumatic heart disease (RHD).

Acute Rheumatic Fever in Children: The Known and the Unknown Among Saudi Mothers in the Jazan Region

Background Acute rheumatic fever (ARF) is a significant public health problem that causes morbidity and mortality in low and middle-income countries. Therefore, this study aims to assess mothers' knowledge of acute rheumatic fever and their attitudes in the Jazan region. Methods A cross-sectional study was conducted between the mothers using an online survey. The knowledge level was ranked as poor, fair, and good. In contrast, the attitudes were ranked as positive or negative. Association with sociodemographic variables was assessed, and statistical significance was set at p < 0.05. Results Four hundred thirty-six (436) mothers were included; 39.9% of them were aged 21-30 years, 68.8% were married, 57.3% were non-workers, and 72.2% were university-educated. Most of the mothers had a poor level of knowledge (53%); however, positive attitudes toward the disease were reported in 79.1% of mothers. The poor knowledge levels were related to age, marital status, occupation, and monthly income. Conclusion Despite having positive attitudes toward diagnosing and managing ARF, most of the mothers showed poor knowledge of acute rheumatic fever. This study highlights the situation in the Jazan region, which could be an essential basis for constructing an educational program to raise awareness and knowledge of acute rheumatic fever in the community.

Silent Acute Rheumatic Fever Unmasked by Using Handheld Echocardiography for Febrile Children Presenting in a Rheumatic Heart Disease-Endemic Area

OBJECTIVE

To understand the burden of acute rheumatic fever (ARF) among children living in low-income countries who present to the hospital with febrile illness and to determine the role of handheld echocardiography (HHE) in uncovering subclinical carditis as a major manifestation of ARF.

STUDY DESIGN

This was a cross-sectional study carried at the Pediatric Hospital in Al Obeid, North Kordofan, Sudan, from September 2022 to January 2023 and including febrile children 3 through 18 years of age with or without clinical features of ARF and without another cause for their fever (not excluding malaria). History, examination, blood investigations, and HHE were done. ARF was diagnosed according to the Jones criteria. Clinical ARF was diagnosed if there was a major clinical Jones criterion and silent ARF if the only major Jones criteria was subclinical carditis.

RESULTS

The study cohort included 400 children with a mean age of 9 years. Clinical ARF was diagnosed in 95 patients (95/400, 24%), most of whom presented with a joint major manifestation (88/95, 93%). Among the 281 children who did not present with a clinical manifestation of ARF, HHE revealed rheumatic heart disease (RHD) in 44 patients (44/281, 16%); 31 of them fulfilled criteria for silent ARF (31/281, 11%). HHE increased the detection of ARF by 24%. HHE revealed mild RHD in 41 of 66 (62%) and moderate or severe RHD in 25 of 66 (38%) patients. Both sensitivity and specificity of HHE compared with standard echocardiography were 88%.

CONCLUSIONS

There is a significant burden of ARF among febrile children in Sudan. HHE increased the sensitivity of diagnosis, with 11% of children having subclinical carditis as their only major manifestation (ie, silent ARF). RHD-prevention policies need to prioritize decentralization of echocardiography to improve ARF detection.

[Rheumatic cardiopathies and its risk factors: about 50 cases]

INTRODUCTION

Acute rheumatic fever (ARF) is a multi-systemic disease, in which cardiac involvement is the most serious major manifestation of disease. The aim of this study was to analyse cardiac involvement in children with ARF and his risk factors.

MATERIALS AND METHODS

It were a retrospective study including all children under the age of 14 years who were hospitalized for ARF in the pediatric department of the CHU Hédi Chaker of Sfax, during a period of twelve years (2010-2022).

RESULTS

We collected 50 cases (31 boys and 19 girls). Twenty-two patients (44%) developed cardiac lesions. The mean age at diagnosis was 9.6 years [5-14 years]. A pathological heart murmur was detected in 14 cases (n = 14/22) was classified as mild carditis in 15 cases, moderate carditis in 5 cases and severe in 2 cases. The median follow-up time was 3,3 years. Nineteen patients developed valvular sequelae Risk factors of cardiac lesions was: age more than 8 years, heart murmur, allonged PR, CRP > 100 mg/l and VS > 100 mm.

CONCLUSION

CR is still a public health problem in Tunisia. It is a serious pathology that can cause serious increases in morbidity rates. Thus, we must strengthen preventive strategies.

Echocardiographic Screening of Rheumatic Heart Disease: Current Concepts and Challenges

The incidence of acute rheumatic fever (ARF), which most commonly affects children aged 5-15 years after group A Streptococcus (GAS) infection, ranges from 8 to 51 per 100 000 people worldwide. Rheumatic heart disease (RHD), which occurs when patients with ARF are inappropriately treated or not given regular prophylaxis, is the most common cause of non-congenital heart disease in children and young adults in low-income countries. Timely treatment of GAS infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is a key aspect of RHD control. The most important factor determining the prognosis of RHD is the severity of cardiac involvement. Although approximately 70% of patients with carditis in the acute phase of the disease recover without sequelae, carditis is important because it is the only complication of ARF that causes sequelae. One-third of patients with ARF are asymptomatic. Patients with mild symptoms of recurrent ARF and silent RHD will develop severe morbidities within 5-10 years if they do not receive secondary preventive treatments. A new screening program should be established to prevent cardiac morbidities of ARF in moderate- and highrisk populations. In the present study, we examined the applicability of echocardiographic screening programs for RHD. Cite this article as: Topçu S, Uçar T. Echocardiographic screening of rheumatic heart disease: Current concepts and challenges. Turk Arch Pediatr. 2024;59(1):3-12.

Temporal Relationship of Acute Rheumatic Fever Following COVID-19 Infection: A Pediatric Case Report

Coronavirus disease 2019 (COVID-19) has the potential to trigger the onset of autoimmune disorders, one of which is acute rheumatic fever (ARF). ARF is an immune system response that can manifest after an individual has been infected with Streptococcus pyogenes. In this study, we document a unique case involving a previously healthy child who exhibited symptoms of fever, polyarthritis, and ankle swelling after history of COVID-19 infection one month ago. This rare pediatric case report discussed the occurrence of ARF after a one-month period of COVID-19 infection, and we observed significant improvement in our patient after a three-month treatment regimen.

Acquired brown syndrome in a child with acute rheumatic fever

PURPOSE

To describe a rare case of acquired Brown syndrome (ABS) associated with acute rheumatic fever (ARF).

CASE REPORT

a healthy 9-year-old girl developed polyarthritis, carditis, and elevated inflammatory markers 10 days after suffering from a sore throat. She was diagnosed with ARF and was treated with systemic antibiotics and high-dose non-steroidal anti-inflammatory drug (NSAID). After 2 weeks, despite improvement of ARF symptoms, the patient presented with binocular vertical diplopia, periorbital pain, and limited elevation in adduction of the left eye. Imaging revealed a thickened trochlea-superior oblique tendon complex, and ABS due to trochleitis was diagnosed. The patient underwent a successful regional corticosteroid injection as a second-line treatment, and within a month, all signs and symptoms of ABS resolved.

CONCLUSIONS

ABS is an infrequent yet possible manifestation of ARF.

Secondary Prophylaxis Among First Nations People With Acute Rheumatic Fever in Australia: An Integrative Review

INTRODUCTION

The prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Australia's First Nations populations are some of the highest in the world, accounting for 95% of the 2,244 ARF notifications between 2015 and 2019 in Australia. A key issue in treating ARF is long-term secondary prophylaxis, yet only one in five patients received treatment in 2019. This review identifies barriers to secondary prophylaxis of ARF in Australia's First Nations people.

METHODS

An integrative review was undertaken utilizing PubMed, CINAHL, ProQuest, and Wiley Online. Joanna Briggs Institute critical appraisal tools were used, followed by thematic analysis.

RESULTS

The key themes uncovered included: issues with database and recall systems, patient/family characteristics, service delivery location and site, pain of injection, education (including language barriers), and patient-clinician relationship.

CONCLUSIONS

A national RHD register, change in operation model, improved pain management, improved education, and need for consistent personnel is suggested.

Pediatric Rheumatic Fever With Acute Fulminant Carditis: A Case Report

Acute rheumatic fever (ARF) is a multi-system inflammatory autoimmune disease. It is a significant cause of heart disease and early death worldwide, especially in children in developing countries. We present a case of acute fulminant rheumatic carditis in a child with no obvious predisposing factors, who resided in a developed country where this disease is not endemic. After pathological examination, a diagnosis of ARF with pancarditis was confirmed. This disease was not suspected before the pathological examination because of its low prevalence in Belgium.

Safety of Streptococcus pyogenes Vaccines: Anticipating and Overcoming Challenges for Clinical Trials and Post-Marketing Monitoring

Streptococcus pyogenes (Strep A) infections result in a vastly underestimated burden of acute and chronic disease globally. The Strep A Vaccine Global Consortium's (SAVAC's) mission is to accelerate the development of safe, effective, and affordable S. pyogenes vaccines. The safety of vaccine recipients is of paramount importance. A single S. pyogenes vaccine clinical trial conducted in the 1960s raised important safety concerns. A SAVAC Safety Working Group was established to review the safety assessment methodology and results of more recent early-phase clinical trials and to consider future challenges for vaccine safety assessments across all phases of vaccine development. No clinical or biological safety signals were detected in any of these early-phase trials in the modern era. Improvements in vaccine safety assessments need further consideration, particularly for pediatric clinical trials, large-scale efficacy trials, and preparation for post-marketing pharmacovigilance.

Corrigendum: IgG2 rules: N-acetyl-β-D-glucosamine-specific IgG2 and Th17/Th1 cooperation may promote the pathogenesis of acute rheumatic heart disease and be a biomarker of the autoimmune sequelae of Streptococcus pyogenes

[This corrects the article DOI: 10.3389/fcvm.2022.919700.].

Effectiveness of Valproic Acid in the Treatment of Sydenham's Chorea and a Literature Review

There is still no evidence-based guideline and consensus on the treatment Sydenham's Chorea (SC). The first-line medication preference of specialists depends on personal experience and is variable. In this study, we evaluate the treatment results of pediatric patients who were treated with valproic acid (VPA). The medical records of 17 patients diagnosed with SC were reviewed retrospectively. The mean time to clinical improvement was found as approximately 5 days, the mean duration of remission as 13.60 ± 3.94 weeks and the mean duration of medication use was found as 17.96 ± 3.81 weeks. No side effects were observed in any of the patients and relapse occurred in 2 patients. A positive correlation was found between the initial C-reactive protein (CRP) level and the duration of medication use. Until evidence-based guidelines are established, VPA can be used as an effective, safe, and inexpensive first-line treatment option, especially in pediatric patients.

The evidence that rheumatic heart disease control programs in Australia are making an impact

OBJECTIVE

Rheumatic heart disease (RHD) comprises heart-valve damage caused by acute rheumatic fever (ARF). The Australian Government Rheumatic Fever Strategy funds RHD Control Programs to support detection and management of ARF and RHD. We assessed epidemiological changes during the years of RHD Control Program operation.

METHODS

Linked RHD register, hospital and death data from four Australian jurisdictions were used to measure ARF/RHD outcomes between 2010 and 2017, including: 2-year progression to severe RHD/death; ARF recurrence; secondary prophylaxis delivery and earlier disease detection.

RESULTS

Delivery of secondary prophylaxis improved from 53% median proportion of days covered (95%CI: 46-61%, 2010) to 70% (95%CI: 71-68%, 2017). Secondary prophylaxis adherence protected against progression to severe RHD/death (hazard ratio 0.2, 95% CI 0.1-0.8). Other measures of program effectiveness (ARF recurrences, progression to severe RHD/death) remained stable. ARF case numbers and concurrent ARF/RHD diagnoses increased.

CONCLUSIONS

RHD Control Programs have contributed to major success in the management of ARF/RHD through increased delivery of secondary prevention yet ARF case numbers, not impacted by secondary prophylaxis and sensitive to increased awareness/surveillance, increased.

IMPLICATIONS FOR PUBLIC HEALTH

RHD Control Programs have a major role in delivering cost-effective RHD prevention. Sustained investment is needed but with greatly strengthened primordial and primary prevention.

Frequency of Familial Mediterranean Fever Gene Mutation in Patients Presenting With Joint Pain and Diagnosed With Acute Rheumatic Fever

Introduction Acute rheumatic fever (ARF) is a non-suppurative systemic inflammatory disease that manifests 1-5 weeks following a Group A beta-hemolytic streptococcal infection. On the other hand, familial Mediterranean fever (FMF) is a hereditary autoinflammatory disease characterized as an autosomal recessive disease, with affected individuals having pathogenic mutations in the Mediterranean fever gene (MEFV) gene located on the short arm of chromosome 16. FMF and ARF have overlapping symptoms and signs, and both disorders are common in Turkey. In ARF, the target organ is the heart, while in FMF, the target organ is the kidney; both organs can benefit from prophylactic measures. Our study aims to determine the frequency of the FMF gene mutation in patients with ARF in Turkey and detect any overlapping conditions. Method Patients who were diagnosed with a first-attack ARF between May 2015 and May 2018 were retrospectively screened. Patients who underwent MEFV gene analysis considering FMF in the differential diagnosis were included in the study. Results In this study, no statistical difference was found between the presence of MEFV gene mutations, carditis, high anti-streptolysin-O antibody (ASO) levels, and the groups with monoarthritis, polyarthritis, and polyarthralgia (p >0.05). Conclusions In conclusion, patients with ARF should be evaluated for FMF to avoid irreversible complications.

Sydenham Chorea in Sudan; Presentation Panorama

Introduction

Sydenham's chorea (SC) is the most common form of acquired chorea in childhood, it is considered a neurological complication of streptococcal pharyngitis. In this study, we aimed to determine the clinical pattern, association of Sydenham's chorea with other manifestations of acute rheumatic fever, and the laboratory findings of Sydenham's chorea among Sudanese patients.

Methods

A prospective cross-sectional study involving fifty patients of various ages diagnosed with Sydenham's chorea and followed up at The National Center for Neurological Sciences from January 2017 to November 2019. Data were obtained after patients' consent through personal interviews or personal review of patients' records via a structured questionnaire composed of demographic data, symptoms, co-morbid illness, risk factors, physical examination, and related investigations.

Results

About 50 patient was enrolled in this study with a median age of 13.7 years. Females were (n=35) (70%) and (30%) (n=15) s were males. Generalized chorea was seen in 33 (66%) and hemichorea in 17 (34%) patients. Weakness (38%) and hypotonia (46%) were common, such as behavior change (44%), dysarthria (70%), gait change (18%), and deterioration of handwriting (12%). Arthritis occurred in (36%), carditis in 30 (60%), both arthritis and carditis in 18 (36%), and pure chorea in 14 (28%). Erythema marginatum and subcutaneous nodules were not observed in our patients. Only 13 patients (26%) gave a history of pharyngitis.

Conclusion

Sydenham chorea is more common in young female Sudanese, with a familial predominance and a tendency towards mitral valve disease. All pediatric Patients with chorea should be screened for Sydenham's chorea.

Managing and treating Sydenham chorea: A systematic review

INTRODUCTION

Sydenham's chorea (SC), prevalent in developing countries and occasionally affecting developed ones, poses a clinical challenge due to the lack of systematic guidelines for diagnosis and treatment. Resulting from Group A Beta-Hemolytic Streptococcus infection, SC presents various symptoms. This review aims to collect and evaluate available data on SC management to propose a cohesive treatment plan.

METHODS

We searched PubMed, the Cochrane Library, Google Scholar, and ClinicalTrials.gov for literature on SC management from inception until 24th July 2022. Studies were screened by titles and abstracts. Cochrane Collaboration's Risk of Bias tool (RoB-1) assessed Randomized Controlled Trials, while the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool evaluated nonrandomized studies.

RESULTS

The review includes 11 articles assessing 579 patients. Excluding one study with 229 patients, of the remaining 550 patients, 338 (61.5%) were females. Treatments used were dopamine antagonists in 118 patients, antiepileptics in 198, corticosteroids in 134, IVIG in 7, and PE in 8 patients. Dopamine antagonists, particularly haloperidol, were the primary treatment choice, while valproic acid (VPA) was favored among antiepileptics. Prednisolone, a corticosteroid, showed promising results with weight gain as the only side-effect. Our review emphasizes the importance of immunomodulators in SC, contrasting previous literature.

CONCLUSION

Despite limitations, dopamine antagonists can serve as first-line agents in SC management, followed by antiepileptics. The role of immunomodulators warrants further investigation for conclusive recommendations.

Coexistence of Graves' disease with acute rheumatic fever treated as thyroid storm in young Thai patient

OBJECTIVES

This report presents a case of acute onset of chorea, concurrent Graves' disease, and acute rheumatic fever in an 8-year-old female patient.

CASE PRESENTATION

The child had intermittent involuntary movement of all extremities and both eyes for 4 days, with a previous history of increased appetite, weight lost, and heat intolerance over a period of two months. Physical examination revealed fever, tachycardia, exophthalmos, eyelid retraction, as well as diffused thyroid enlargement. Initial clinical features and thyroid function testing suggested a thyroid storm due to Graves' disease. Methimazole, propranolol, potassium iodide (SSKI), and dexamethasone were prescribed. Congestive heart failure developed after propranolol and cardiovascular re-evaluation and Revised Jones criteria suggested acute rheumatic fever. Chorea was successfully treated with pulse methylprednisolone.

CONCLUSIONS

We reported Graves' disease patients with acute rheumatic fever simulating a thyroid storm. The underlying cardiac disease must be considered, especially where chorea and congestive heart failure are present.

IgG2 rules: N-acetyl-β-D-glucosamine-specific IgG2 and Th17/Th1 cooperation may promote the pathogenesis of acute rheumatic heart disease and be a biomarker of the autoimmune sequelae of Streptococcus pyogenes

Antecedent group A streptococcal pharyngitis is a well-established cause of acute rheumatic fever (ARF) where rheumatic valvular heart disease (RHD) and Sydenham chorea (SC) are major manifestations. In ARF, crossreactive antibodies and T cells respond to streptococcal antigens, group A carbohydrate, N-acetyl-β-D-glucosamine (GlcNAc), and M protein, respectively, and through molecular mimicry target heart and brain tissues. In this translational human study, we further address our hypothesis regarding specific pathogenic humoral and cellular immune mechanisms leading to streptococcal sequelae in a small pilot study. The aims of the study were to (1) better understand specific mechanisms of pathogenesis in ARF, (2) identify a potential early biomarker of ARF, (3) determine immunoglobulin G (IgG) subclasses directed against GlcNAc, the immunodominant epitope of the group A carbohydrate, by reaction of ARF serum IgG with GlcNAc, M protein, and human neuronal cells (SK-N-SH), and (4) determine IgG subclasses deposited on heart tissues from RHD. In 10 pediatric patients with RHD and 6 pediatric patients with SC, the serum IgG2 subclass reacted significantly with GlcNAc, and distinguished ARF from 7 pediatric patients with uncomplicated pharyngitis. Three pediatric patients who demonstrated only polymigrating arthritis, a major manifestation of ARF and part of the Jones criteria for diagnosis, lacked the elevated IgG2 subclass GlcNAc-specific reactivity. In SC, the GlcNAc-specific IgG2 subclass in cerebrospinal fluid (CSF) selectively targeted human neuronal cells as well as GlcNAc in the ELISA. In rheumatic carditis, the IgG2 subclass preferentially and strongly deposited in valve tissues (n = 4) despite elevated concentrations of IgG1 and IgG3 in RHD sera as detected by ELISA to group A streptococcal M protein. Although our human study of ARF includes a very small limited sample set, our novel research findings suggest a strong IgG2 autoantibody response against GlcNAc in RHD and SC, which targeted heart valves and neuronal cells. Cardiac IgG2 deposition was identified with an associated IL-17A/IFN-γ cooperative signature in RHD tissue which displayed both IgG2 deposition and cellular infiltrates demonstrating these cytokines simultaneously. GlcNAc-specific IgG2 may be an important autoantibody in initial stages of the pathogenesis of group A streptococcal sequelae, and future studies will determine if it can serve as a biomarker for risk of RHD and SC or early diagnosis of ARF.

Acute rheumatic fever and rheumatic heart disease in children and adolescents in Victoria, Australia

AIM

To describe the epidemiology and clinical profile of children and adolescents with acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Victoria, Australia.

METHODS

A retrospective audit was undertaken of children and adolescents with ARF and RHD attending the Royal Children's and Monash Children's Hospitals in Victoria, Australia between 2010 and 2019. Potential cases were identified by searching multiple sources for relevant ICD-10-AM codes and keywords, then reviewed manually. For confirmed cases, we collected data on patient demographics, clinical features, comorbidities and management.

RESULTS

Of 179 participants included, there were 108 Victorian residents and 71 non-Victorian residents. 126 had at least one episode of ARF during the study period and 128 were diagnosed with RHD. In the Victorian resident group, the overall incidence of ARF was 0.8 per 100 000 5-14 year olds. This incidence was higher in Victorian Aboriginal and/or Torres Strait Islander (3.8 per 100 000) and Pacific Islander (32.1 per 100 000) sub-populations. Of 83 Victorian residents who had an ARF episode, 11 (13%) had a recurrence. Most Victorian residents with RHD had mixed aortic and mitral valve pathology (69.4%) and moderate to severe disease (61.9%). Most non-Victorian residents were Aboriginal and/or Torres Strait Islander people (80.3%) and were commonly transferred for tertiary or surgical management of RHD (83.1%).

CONCLUSIONS

ARF and RHD continue to affect the health of significant numbers of children and adolescents living in Victoria, including severe and recurrent disease. Specialised services and a register-based control program may help to prevent complications and premature death.

Rheumatic Heart Disease: JACC Focus Seminar 2/4

It is a sad reality that although eminently preventable, and despite possessing such knowledge for >70 years, rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and early mortality in young people worldwide. A disease of the poor, RHD is one of the most neglected diseases. Several challenges are unique to the acute rheumatic fever/RHD continuum and contribute to its persistence, including its sequestration among the poorest, its protracted natural history, the erratic availability of penicillin, and the lack of a concerted effort in endemic regions. However, there is cause for optimism following a resurgence in scientific interest over the last 15 years. This review presents the latest advancements in epidemiology, diagnosis, and management. It also discusses pressing research questions on disease pathophysiology, the barriers to implementation of effective management strategies, and pragmatic policy solutions required for translation of current knowledge into meaningful action.

Changes in the frequency and clinical features of acute rheumatic fever in the COVID-19 era: a retrospective analysis from a single center

OBJECTIVE:

Coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes in the frequency of many diseases. In this study, we aimed to investigate the changes in the frequency and clinical features of acute rheumatic fever (ARF) in this period and determine the effect of health measures taken against COVID-19 on this change.

METHODS:

The cases with initial attack of ARF between January 2016 and March 2022 in Ataturk University, Division of Pediatric Cardiology, were determined from the clinic’s database, and case per month ratios were calculated for each period, retrospectively. Also the frequency of the clinical manifestations was compared among patients before and during the outbreak.

RESULTS:

Frequency of the major clinical manifestations among patients before and during the outbreak was similar. On average, the number of cases reported per month in the years 2016, 2017, 2018, and 2019 are, respectively, 1.75, 2, 2.25, and 2.58. In the first 3 months of 2020, the average number of cases reported per month was 3.67. After the advent of the pandemic, in the period from April to December 2020 and from January to September 2021, an average of 0.56 and 0.22 cases were reported per month, respectively. The frequency of clinical features between patients diagnosed before and during the outbreak was similar.

CONCLUSIONS:

Our results indicated an important decrease in frequency of ARF, but no change in the clinical features of the disease during the COVID-19 pandemic. It is thought that this is the result of health measures taken for COVID-19. Children with an increased risk of acute rheumatic fever should be encouraged in terms of wearing mask, social distance, and cleaning, especially during the seasons when upper respiratory tract infections are common. Thus, a permanent decrease in the incidence of ARF and its recurrences may be achieved.

Psychopathological Impact in Patients with History of Rheumatic Fever with or without Sydenham's Chorea: A Multicenter Prospective Study

Sydenham's chorea (SC) is a post-streptococcal autoimmune disorder of the central nervous system, and it is a major criterium for the diagnosis of acute rheumatic fever (ARF). SC typically improves in 12-15 weeks, but patients can be affected for years by persistence and recurrencies of both neurological and neuropsychiatric symptoms. We enrolled 48 patients with a previous diagnosis of ARF, with or without SC, in a national multicenter prospective study, to evaluate the presence of neuropsychiatric symptoms several years after SC's onset. Our population was divided in a SC group (n = 21), consisting of patients who had SC, and a nSC group (n = 27), consisting of patients who had ARF without SC. Both groups were evaluated by the administration of 8 different neuropsychiatric tests. The Work and Social Adjustment Scale (WSAS) showed significantly (p = 0.021) higher alterations in the SC group than in the nSC group. Furthermore, 60.4% (n = 29) of the overall population experienced neuropsychiatric symptoms other than choreic movements at diagnosis and this finding was significantly more common (p = 0.00) in SC patients (95.2%) than in nSC patients (33.3%). The other neuropsychiatric tests also produced significant results, indicating that SC can exert a strong psychopathological impact on patients even years after its onset.

Acute rheumatic fever in adult patients

Acute rheumatic fever (ARF) is considered as a disorder of children, and attacks in adults are usually a recurrence of disease acquired in the child's life. Although the incidence of ARF in children has a decreasing trend in developed countries, resurgent and sporadic epidemics still occur in adults. The first attacks of ARF in adult patients without a childhood history can lead to a diagnostic dilemma. A medical record review in adults at least 18 years of age with an arthralgia complaint fulfilling 2015 revised Jones criteria was performed from January 1, 2000 to December 31, 2019. Eleven ARF patients were identified, including 8 with initial attacks (6 females aged 26-42 years, 33.9 ± 5.3) and 3 pre-existing valvular heart disease with recurrent attacks (2 females aged 38-52 years, 45.0 ± 7.0). In addition to febrile pharyngitis and migratory polyarthritis in initial attacks, pericarditis was encountered in 1, valvulitis in 2, prolong PR interval in 3 and skin involvement in 2 patients with erythema marginatum and IgA vasculitis. All responded to antibiotics and nonsteroidal anti-inflammatory drugs therapy with normalized clinical and laboratory abnormalities, no new-onset carditis, and no recurrent disease during a long-term follow-up (3.8-19.8 years, 12.7 ± 5.4). A sporadic occurrence of adult ARF is observed in southern Taiwan. This disease should be considered by physicians for the differential diagnosis of febrile pharyngitis with arthritis and/or carditis in adults, even in areas with a low incidence of ARF.

Concomitant rapidly progressive glomerulonephritis and acute rheumatic fever after streptococcus infection: a case report

Acute post-streptococcal glomerulonephritis (APSGN) and acute rheumatic fever (ARF) are common immune-mediated complications after group A streptococcus (GAS) infection. The causative antigenic epitopes on GAS are different for APSGN and ARF, and their simultaneous occurrence is uncommon. A 12-year-old boy presented with fever and gross haematuria. He had subcutaneous nodules on the dorsum of both feet along with a new holosystolic murmur at the apex, and he developed hypertension and generalised oedema after admission. Investigation confirmed the diagnosis of ARF with APSGN. He received a corticosteroid to control inflammation of both the conditions. His clinical signs gradually improved but he still had rheumatic heart disease. As both diseases can occur in the same patient, treatment should be provided for both conditions.Abbreviations: APSGN: acute post-streptococcal glomerulonephritis; ARF: acute rheumatic fever; ASO: antistreptolysin O; Cr: serum creatinine; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GAS: group A streptococcus; RBC: red blood cells; RPGN: rapidly progressive glomerulonephritis; S1: first heart sound; S2: second heart sound; TTE: transthoracic echocardiogram.

Comment: Sedation as part of secondary prophylaxis to prevent recurrent rheumatic fever in Aboriginal and Torres Strait Islander peoples: time for a reset?

Australia's national clinical practice guidelines recommend intramuscular (IM) penicillin every 28 days for persons diagnosed with an initial episode of acute rheumatic fever (ARF). This antibiotic coverage is initiated to reduce recurrent ARF episodes by preventing repeat infections with the causative bacterium, group A Streptococcus. Because disease has already occurred, this regimen is known as secondary prophylaxis (SP), done in order to prevent more episodes of ARF (known as recurrences). In 2020, eight authors shared with readers of Rural and Remote Health their experience of introducing off-label an oral, centrally acting, alpha agonist sedative to the prescribed SP regimen of IM penicillin for each of three Aboriginal children previously diagnosed with ARF. The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. We find the clinical case report perpetuates a troubling academic tone about this singular priority for SP. Injecting a child with IM penicillin appears to supersede all other objectives. Off-label sedation in remote settings is legitimised in order to succeed in this imperative. Those articles that peer-reviewed medical journals choose to publish privilege directions for priorities, policy and practice. In this commentary, we present alternative perspectives and initiatives for consideration.

Assessment of serum galectin-3 levels in acute rheumatic fever

BACKGROUND

Galectin-3 is a biomarker which takes a role in both acute and chronic inflammation as well as fibrosis and oxidative stress. Increased levels of it are associated with cardiovascular diseases. This study was performed to investigate the levels of galectin-3 in acute rheumatic fever (ARF).

METHODS

30 patients with ARF and 26 healthy children were included. Galectin-3 levels of the patients were compared with the controls, as well as within the patients before and after the treatment.

RESULTS

The patients had significantly lower galectin-3 levels on admission than the control (p=0.02), but its levels were not significantly different between these groups at the end of treatment (p=0.714). The mean galectin-3 levels of the patients were increased after the treatment (p < 0.001). Severity of carditis and galectin-3 levels were negatively correlated (r=-539, p=0.02).

CONCLUSIONS

Children with ARF have significantly reduced levels of galectin-3 and there is a negative correlation between the severity of the carditis and galectin-3 levels. Studies with larger sample sizes may give more accurate data about the role of galectin-3 in ARF.

Evaluation of executive functions in children with rheumatic heart diseases

BACKGROUND

Acute rheumatic fever (ARF) is a multisystemic inflammatory disease in children and young adults. The most notable complications of ARF are rheumatic heart disease (RHD) and Sydenham's chorea (SC). There have been many reports about executive dysfunctions with children who have SC. "Executive function" is an umbrella term that is used to describe higher level cognitive functions. The aim of this study is to determine the executive functions of children with RHD. We evaluated executive functions in healthy children with the same sociodemographic characteristics as children with RHD.

METHODS

Our study was designed as a cross-sectional randomized study, including children with RHD aged between 12 and 18, and healthy controls. The difference between the patient and control group participants in terms of age, gender, education level, education level of the parents, family income level, and executive functions were investigated. Executive functions composed of Digit Sequence Test, Verbal Fluency Test, Trail-Making Test, Stroop Test, Wisconsin Card Sorting Test.

RESULTS

In our study, a total of 30 children with RHD were followed up at the pediatric cardiology outpatient clinic of Bezmialem Vakif University Hospital composed the patient group. The control group was made up of 30 healthy children of the same sex and age group as the patient group. The mean age of the case group was 14.73 ± 1.84 years. The Digit Span Test, Verbal Fluency Test, Trail-Making Test, Wisconsin Card Sorting Test, and Stroop Test produced no statistically significant differences between the RHD patients and the controls.

CONCLUSIONS

No statistically significant difference was found between the RHD patients and control patients in any executive function test. It was suggested that executive dysfunction might not develop in RHD patients before developing SC.

The effectiveness and safety of ibuprofen and acetylsalicylic acid in acute rheumatic fever

BACKGROUND

Acetylsalicylic acid (ASA) is a non-steroidal anti-inflammatory drug used in the treatment of acute rheumatic fever (ARF) and it can cause serious adverse effects. This study aimed to evaluate the clinical efficacy and side effects of ibuprofen in the treatment of ARF compared to the classic treatment, ASA.

METHODS

Children who were hospitalized for the treatment of ARF with isolated arthritis and mild carditis between October 2015 and October 2018 and who received non-steroidal anti-inflammatory therapy were evaluated in the study. We compared the demographic data, clinical findings, efficacy, and side effects of the treatments of the children, who were divided into ASA and ibuprofen groups.

RESULTS

Of the 38 patients included in the study, 21 were treated with ASA (ASA group), and 17 were given ibuprofen (IBU group). There was no difference between the groups regarding the length of hospital stay, total treatment time, time to resolution of clinical symptoms, and normalization of acute-phase reactants. Liver enzymes increased during treatment in 13 patients (62%) in the ASA group and three patients (18%) in the IBU group (P = 0.009). In the ASA group, 69% of patients with increased liver enzymes were under 11 years of age during treatment. Clinical side effects were observed in three patients in the ASA group while none were observed in the IBU group.

CONCLUSION

The results of this study suggest that ibuprofen can be a safe alternative in the treatment of ARF, especially in young children. Although ibuprofen can be a safe and effective alternative to ASA, studies including larger series are needed on this subject.

Incidence and clinical characteristics of acute rheumatic fever in Turkey: Results of a nationwide multicentre study

AIM

To evaluate the incidence and clinical features of acute rheumatic fever (ARF) in Turkey, following the revised Jones criteria in 2015.

METHODS

This multicentre study was designed by the Acquired Heart Diseases Working Group of the Turkish Pediatric Cardiology and Pediatric Cardiac Surgery Association in 2016. The data during the first attack of 1103 ARF patients were collected from the paediatric cardiologists between 1 January 2016 and 31 December 2016.

RESULTS

Turkey National Institute of Statistics records of 2016 were used for the determination of ARF incidence with regard to various cities and regions separately. The estimated incidence rate of ARF was 8.84/100 000 in Turkey. The ARF incidence varied considerably among different regions. The highest incidence was found in the Eastern Anatolia Region as 14.4/100 000, and the lowest incidence was found in the Black Sea Region as 3.3/100 000 (P < 0.05). Clinical carditis was the most common finding. The incidence of clinical carditis, subclinical carditis, polyarthritis, aseptic monoarthritis, polyarthralgia and Sydenham's Chorea was 53.5%, 29.1%, 52.8%, 10.3%, 18.6% and 7.9%, respectively. The incidences of clinical carditis, subclinical carditis, polyarthritis and polyarthralgia were found to be significantly different among different regions (P < 0.05).

CONCLUSION

The findings of this nationwide screening of ARF suggest that Turkey should be included in the moderate-risk group.

Morbidity and mortality of rheumatic heart disease and acute rheumatic fever in the inpatient setting in Timor-Leste

AIM

To describe the clinical features, treatment and outcomes of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in children admitted to the national referral hospital in Dili, Timor-Leste.

METHODS

This prospective study documented cases of ARF and RHD in children aged 14 years and under who were admitted between June 2017 and May 2019. ARF was diagnosed using an adapted version of the 2015 Jones criteria and presumed (rather than proven) exposure to group A Streptococcus. Clinical and echocardiographic findings, comorbidities and discharge outcomes are reported.

RESULTS

A total of 63 patients were admitted with ARF or RHD; 54 were diagnosed with RHD for the first time. Median age was 11 years (range 3-14); 48% were female. Of those with echocardiograms, 56/58 had RHD, 55/56 (98%) had mitral regurgitation (37/55 (67%) severe), 11/56 (20%) had mitral stenosis and 43/56 (77%) had aortic regurgitation. Left ventricular dysfunction (55%), pulmonary hypertension (64%) and cardiac failure (78%) were common. Four (6%) patients died in hospital, and 30/59 (51%) of surviving patients were lost to follow up.

CONCLUSIONS

Community echocardiography screening has reported a high prevalence of undetected mild to moderate cases of RHD in Timor-Leste, whereas this hospital study documents mostly severe disease among hospitalised patients with a high case fatality rate and loss to follow up. RHD is a significant health problem in Timor-Leste and improved recognition and diagnosis, as well as effective delivery of treatment and follow-up are imperative.

Concomitant Acute Rheumatic Fever and Acute Post Streptococcal Glomerulonephritis

Acute rheumatic fever (RF) and acute post Streptococcal glomerulonephritis (APSGN) are non-suppurative complications of a Group A Streptococcus (GAS) infection. The concomitant incidence of both complications in a patient is rare because nephritogenic and rheumatogenic strains belong to different serotypes of Group A beta-hemolytic Streptococcus (GABHS). We present a case of a 47-year-old female who had concomitant acute RF and APSGN from a Streptococcus pyogenes infection. It is important to have a high clinical suspicion for the sequela of GABHS infection in the setting of cardiac and renal disease following upper respiratory infection (URI) symptoms even in adults and in geographic locations with the nearly undetectable burden of acute RF because of the importance of secondary prophylaxis with an antibiotic.

Rheumatic Heart Disease in the United States: Forgotten But Not Gone: Results of a 10 Year Multicenter Review

Background

Recent evaluation of rheumatic heart disease (RHD) mortality demonstrates disproportionate disease burden within the United States. However, there are few contemporary data on US children living with acute rheumatic fever (ARF) and RHD.

Methods and Results

Twenty‐two US pediatric institutions participated in a 10‐year review (2008–2018) of electronic medical records and echocardiographic databases of children 4 to 17 years diagnosed with ARF/RHD to determine demographics, diagnosis, and management. Geocoding was used to determine a census tract‐based socioeconomic deprivation index. Descriptive statistics of patient characteristics and regression analysis of RHD classification, disease severity, and initial antibiotic prescription according to community deprivation were obtained. Data for 947 cases showed median age at diagnosis of 9 years; 51% and 56% identified as male and non‐White, respectively. Most (89%) had health insurance and were first diagnosed in the United States (82%). Only 13% reported travel to an endemic region before diagnosis. Although 96% of patients were prescribed secondary prophylaxis, only 58% were prescribed intramuscular benzathine penicillin G. Higher deprivation was associated with increasing disease severity (odds ratio, 1.25; 95% CI, 1.08–1.46).

Conclusions

The majority of recent US cases of ARF and RHD are endemic rather than the result of foreign exposure. Children who live in more deprived communities are at risk for more severe disease. This study demonstrates a need to improve guideline‐based treatment for ARF/RHD with respect to secondary prophylaxis and to increase research efforts to better understand ARF and RHD in the United States.

Ethnically Disparate Disease Progression and Outcomes among Acute Rheumatic Fever Patients in New Zealand, 1989-2015

We investigated outcomes for patients born after 1983 and hospitalized with initial acute rheumatic fever (ARF) in New Zealand during 1989-2012. We linked ARF progression outcome data (recurrent hospitalization for ARF, hospitalization for rheumatic heart disease [RHD], and death from circulatory causes) for 1989-2015. Retrospective analysis identified initial RHD patients <40 years of age who were hospitalized during 2010-2015 and previously hospitalized for ARF. Most (86.4%) of the 2,182 initial ARF patients did not experience disease progression by the end of 2015. Progression probability after 26.8 years of theoretical follow-up was 24.0%; probability of death, 1.0%. Progression was more rapid and ≈2 times more likely for indigenous Māori or Pacific Islander patients. Of 435 initial RHD patients, 82.2% had not been previously hospitalized for ARF. This young cohort demonstrated low mortality rates but considerable illness, especially among underserved populations. A national patient register could help monitor, prevent, and reduce ARF progression.

Distribution of Streptococcal Pharyngitis and Acute Rheumatic Fever, Auckland, New Zealand, 2010-2016

Group A Streptococcus (GAS) pharyngitis is a key initiator of acute rheumatic fever (ARF). In New Zealand, ARF cases occur more frequently among persons of certain ethnic and socioeconomic groups. We compared GAS pharyngitis estimates (1,257,058 throat swab samples) with ARF incidence (792 hospitalizations) in Auckland during 2010–2016. Among children 5–14 years of age in primary healthcare clinics, GAS pharyngitis was detected in similar proportions across ethnic groups (≈19%). Relative risk for GAS pharyngitis was moderately elevated among children of Pacific Islander and Māori ethnicities compared with those of European/other ethnicities, but risk for ARF was highly elevated for children of Pacific Islander and Māori ethnicity compared with those of European/other ethnicity. That ethnic disparities are much higher among children with ARF than among those with GAS pharyngitis implies that ARF is driven by factors other than rate of GAS pharyngitis alone.

Sydenham Chorea Managed With Immunoglobulin in Acute Rheumatic Fever

Sydenham chorea (SC) is common in childhood with extensive differential diagnoses, including inherited disease, autoimmunity, endocrine disorders, and infections. SC due to acute rheumatic fever (ARF) is rare. Herein, we present a case of SC in an eight-year-old child who presented with choreiform movements of her face and limbs, including facial grimacing, difficulty walking, and slurred speech. She also had a runny nose and odynophagia. She had two episodes of sore throat in the last two months, and her physical examination was unremarkable except for hypertrophic tonsils and generalized hypotonia. Throat and blood culture were negative for group A streptococcus. Antistreptolysin O titer was 1139 IU/mL, and anti-deoxyribonuclease B titer was 2100 IU/mL, suggesting a recent group A streptococcal infection. Magnetic resonance imaging (MRI) of the brain revealed hyperintense signals in the thalami and corpus striatum. Echocardiogram was normal with no evidence of carditis. She was diagnosed with ARF and was commenced on amoxicillin and valproic acid. Later on, she was started on IVIG due to the persistence of chorea. Her symptoms improved, and she was discharged a week later on oral haloperidol for the next ten days.

Requirements for a Robust Animal Model to Investigate the Disease Mechanism of Autoimmune Complications Associated With ARF/RHD

The pathogenesis of Acute Rheumatic Fever/Rheumatic Heart Disease (ARF/RHD) and associated neurobehavioral complications including Sydenham's chorea (SC) is complex. Disease complications triggered by Group A streptococcal (GAS) infection are confined to human and determining the early events leading to pathology requires a robust animal model that reflects the hallmark features of the disease. However, modeling these conditions in a laboratory animal, of a uniquely human disease is challenging. Animal models including cattle, sheep, pig, dog, cat, guinea pigs rats and mice have been used extensively to dissect molecular mechanisms of the autoimmune inflammatory responses in ARF/RHD. Despite the characteristic limitations of some animal models, several rodent models have significantly contributed to better understanding of the fundamental mechanisms underpinning features of ARF/RHD. In the Lewis rat autoimmune valvulitis model the development of myocarditis and valvulitis with the infiltration of mononuclear cells along with generation of antibodies that cross-react with cardiac tissue proteins following exposure to GAS antigens were found to be similar to ARF/RHD. We have recently shown that Lewis rats injected with recombinant GAS antigens simultaneously developed cardiac and neurobehavioral changes. Since ARF/RHD is multifactorial in origin, an animal model which exhibit the characteristics of several of the cardinal diagnostic criteria observed in ARF/RHD, would be advantageous to determine the early immune responses to facilitate biomarker discovery as well as provide a suitable model to evaluate treatment options, safety and efficacy of vaccine candidates. This review focuses on some of the common small animals and their advantages and limitations.

Aspirin-induced hepatotoxicity and anemia in children with acute rheumatic fever

BACKGROUND

The aim of this study was to investigate the frequency of anemia and hepatotoxicity associated with aspirin use in patients with acute rheumatic fever.

METHODS

Patients with acute rheumatic fever followed at Erciyes University, Faculty of Medicine, Department of Pediatric Cardiology between 2015-2018 were reviewed retrospectively.

RESULTS

A total of 286 patients with acute rheumatic fever were analysed. Aspirin treatment was started in 53 of the 286 patients (18.5%) due to arthritis. The mean age of the patients who used aspirin was 10.7 ± 2.5 years. Aspirin-induced hepatotoxicity developed in 9 (17%) of the 53 patients. Naproxen or ibuprofen was given to these patients as an alternative to aspirin. No side effects occurred in patients receiving naproxen or ibuprofen. In addition, 30% of 53 patients were initially anemic. The mean duration of aspirin use in the hepatotoxic patients who had anemia was longer than patients without anemia (p=0.02).

CONCLUSIONS

Patients with acute rheumatic fever should be closely monitored for aspirin hepatotoxicity. When aspirin hepatotoxicity develops, naproxen or ibuprofen treatment can be used safely.

Adherence rates and risk factors for suboptimal adherence to secondary prophylaxis for rheumatic fever

AIM

Secondary prophylaxis with 3-4 weekly benzathine penicillin G injections is necessary to prevent disease morbidity and cardiac mortality in patients with acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This study aimed to determine secondary prophylaxis adherence rates in the Far North Queensland paediatric population and to identify factors contributing to suboptimal adherence.

METHODS

A retrospective analysis of data recorded in the online RHD register for Queensland, Australia, was performed for a 10-year study period. The proportion of benzathine penicillin G injections delivered within intervals of ≤28 days and ≤35 days was measured. A multi-level mixed model logistic regression assessed the influence of age, gender, ethnicity, suburb, Accessibility and Remoteness Index of Australia class, number of people per dwelling, Index of Relative Socio-economic Advantage and Disadvantage, Index of Education and Occupation, year of inclusion on an ARF/RHD register and individual effect.

RESULTS

The study included 277 children and analysis of 7374 injections. No children received ≥80% of recommended injections within a 28-day interval. Four percent received ≥50% of injections within ≤28 days and 46% received ≥50% of injections at an extended interval of ≤35 days. Increasing age was associated with reduced delivery of injections within 35 days. Increasing year of inclusion was associated with improved delivery within 28 days. The random effect of individual patients was significantly associated with adherence.

CONCLUSIONS

Improved timely delivery of secondary prophylaxis for ARF and RHD is needed as current adherence is very low. Interventions should focus on factors specific to each individual child or family unit.

Acute Rheumatic Fever: Where Do We Stand? An Epidemiological Study in Northern Italy

Acute rheumatic fever (ARF) is a non-septic complication of group A β-hemolytic streptococcal (GAS) throat infection. Since 1944, ARF diagnosis relies on the Jones criteria, which were periodically revised. The 2015 revision of Jones criteria underlines the importance of knowing the epidemiological status of its own region with updated data. This study aims to describe ARF features in a retrospective cohort retrieved over a 10-year timespan (2009–2018) and to report the annual incidence of ARF among children in the Province of Monza-Brianza, Lombardy, Italy during the same period. This is a multicentric cross-sectional/retrospective study; 70 patients (39 boys) were diagnosed with ARF. The median age at diagnosis was 8.5 years (range, 4–14.2 years). Overall, carditis represented the most reported major Jones criteria followed by arthritis and chorea (40, 27, and 20 cases, respectively). In order to calculate the annual incidence of ARF, only children resident in the Province of Monza-Brianza were included in this part of the analysis. Therefore, 47 patients aged between 5 and 14 years were identified. The median incidence during the study time was 5.7/100,000 (range, 2.8–8.3/100,000). In the Province of Monza-Brianza, we found an incidence rate of ARF among children aged 5–14 years constantly above the threshold of low-risk area as defined in the 2015 revision of Jones criteria. Therefore, the diagnosis of ARF should be based on the moderate–high-risk set of Jones criteria. However, given the burden of secondary prophylaxis, expert opinion is advisable when the diagnosis of ARF is uncertain.

Acute Rheumatic Fever: A Review of Essential Cutaneous and Histological Findings

Acute rheumatic fever (ARF) is an autoimmune response that may occur after infection with group A Streptococcus. Clinical manifestations are protean, making the syndrome difficult to recognize in the 21st century. Secondary prophylaxis with benzathine penicillin is given for 10 years after an episode of ARF to prevent recurrence and reduce the risk of rheumatic heart disease. This case highlights the importance of providing a detailed clinical history to the dermatopathologist when considering ARF in the differential diagnosis.

Toward the Knowledge of the Epidemiological Impact of Acute Rheumatic Fever in Italy

Background: To estimate the incidence of Acute Rheumatic Fever (ARF) in Tuscany, a region of Central Italy, evaluating the epidemiological impact of the new diagnostic guidelines, and to analyse our outcomes in the context of the Italian overview. Methods: A multicenter and retrospective study was conducted involving children <18 years old living in Tuscany and diagnosed in the period between 2010 and 2019. Two groups were established based on the new diagnostic criteria: High-Risk (HR) group patients, n = 29 and Low-Risk group patients, n = 96. Results: ARF annual incidence ranged from 0.91 to 7.33 out of 100,000 children in the analyzed period, with peak of incidence registered in 2019. The application of HR criteria led to an increase of ARF diagnosis of 30%. Among the overall cohort joint involvement was the most represented criteria (68%), followed by carditis (58%). High prevalence of subclinical carditis was observed (59%). Conclusions: Tuscany should be considered an HR geographic area and HR criteria should be used for ARF diagnosis in this region.

Post-Streptococcal Reactive Arthritis

INTRODUCTION

Post-Streptococcal Reactive Arthritis (PSRA) is defined as inflammatory arthritis of ≥1 joint associated with a recent group A streptococcal infection in a patient who does not fulfill the Jones criteria for the diagnosis of Acute Rheumatic Fever (ARF).

METHODS

In this narrative review, we conducted a systematic search on MEDLINE, EMBASE, Cochrane Library and Google Scholar using the words poststreptococcal reactive arthritis. The search covered the time period between 1982 and 2016. The purpose of this review is to summarize the current state of knowledge of PSRA with respect to the definition, epidemiology, clinical presentation and treatment. We also summarize the key differences between PSRA, reactive arthritis (ReA) and ARF.

RESULTS

PSRA has a bimodal age distribution at ages 8-14 and 21-37 years with an almost equal male to female ratio. Clinically, it causes acute asymmetrical non-migratory polyarthritis, however, tenosynovitis and small joint arthritis may occur. This disease entity can be associated with extraarticular manifestations, including erythema nodosum, uveitis and glomerulonephritis. The frequency of HLA-B27 in PSRA does not differ from that of the normal population, which suggests that it is a separate entity from ReA. Involvement of the axial skeleton, including sacroiliitis, is uncommon in PSRA. PSRA tends to occur within 10 days of a group A streptococcal infection, as opposed to the 2 to 3 weeks delay for ARF. PSRA can be associated with prolonged or recurrent arthritis, in contrast to ARF, in which arthritis usually lasts a few days to 3 weeks. Treatment usually involves NSAIDs or corticosteroids.

CONCLUSION

We summarize clinical features that help differentiate PSRA from ARF and ReA. First-line treatment options include NSAIDs and corticosteroids. Most cases resolve spontaneously within a few weeks, but some cases are recurrent or prolonged. There are no published randomized controlled trials of PSRA.

Clonidine for pain-related distress in Aboriginal children on a penicillin regimen to prevent recurrence of rheumatic fever

CONTEXT

Indigenous children and adolescents in Australia and globally bear the burden of acute rheumatic fever (ARF). It has been virtually eliminated in well-resourced, developed settings. ARF is an autoimmune response to infection with group A Streptococcus. The mainstay of management is long-acting intramuscular penicillin injections to prevent recurrence of ARF and development of rheumatic heart disease (RHD), comprising valvular pathology and attendant complications. In Australia, penicillin injections are currently prescribed every 28 days for 5-10 years after diagnosis of ARF, depending on cardiac involvement. Adherence to this regimen reduces ARF recurrences and RHD progression. 'Days at risk' of ARF recurrence are calculated as the number of days after day 28 that an injection is not received. Adherence to the injection schedule has been reported as difficult in most global locations due to the painful nature of the injections, the long timeframes of the prescription, young age of patients, access problems and costs in some locations. The newly updated Australian guideline on the prevention, diagnosis and management of ARF and RHD has a chapter dedicated to secondary prophylaxis. This chapter takes into account cultural considerations and advises on ways to minimise pain and distress of injections in children such as pain gate strategies, distraction techniques and concurrent injection of local anaesthetic.

ISSUES

Some children continue to find the injection regimen traumatising despite strategies to reduce pain and fear. Clinicians providing the injections to children also find the injecting episodes distressing if pain is not effectively minimised. An Aboriginal Community Controlled Health Service in a remote setting in northern Australia addressed the issue of severe trauma of injection episodes experienced by an Aboriginal boy aged 7 years. Usual strategies were not effective, so advice was sought from an expert anaesthetist at a tertiary hospital. As a result, oral clonidine 3 &micro;g/kg was trialled 45 minutes prior to the penicillin injection. Procedural coaching and monitoring protocols specific to administration of clonidine in children under their care were created by the health service. The initial dose of clonidine was delivered with the child as an inpatient.

LESSONS LEARNED

Clonidine was successful in reducing pain related distress and facilitating adherence to the penicillin regimen. Subsequent doses were delivered and monitored in a remote setting by nurses. After 18 months, the boy no longer required clonidine due to his increased coping capacity. A second child was recognised with similar trauma and has been taking clonidine for pre-procedural sedation for 6 months with good effect and no adverse effects. An additional child was similarly prescribed clonidine without success. Failure in that instance was attributed to lack of procedural coaching and receiving the initial dose of clonidine in an emergency department in hurried circumstances. Individualised child-focused and culturally appropriate care in remote settings is feasible: in this instance team planning for use of clonidine and procedural coaching when other measures have failed. However, for children with RHD, or other comorbidities, advice from the child's treating cardiologist is required prior to prescribing clonidine due to possible adverse consequences. These include hypotension and atrioventricular block, which could lead to haemodynamic compromise in the setting of moderate to severe RHD.

School-based Streptococcal A Sore-throat Treatment Programs and Acute Rheumatic Fever Amongst Indigenous Māori: A Retrospective Cohort Study

BACKGROUND

Acute rheumatic fever (ARF) predominantly affects indigenous Māori schoolchildren in Bay of Plenty region, and more so male Māori students, especially when socioeconomically deprived. We evaluated the effectiveness of strategies for reducing ARF with group A streptococcal pharyngitis treatment in 2011-18.

METHODS

We retrospectively assessed outcomes of 3 open cohorts of Māori schoolchildren receiving different interventions: Eastern Bay rural Cohort 1, mean deprivation decile 9.80, received school-based sore-throat programs with nurse and general practice (GP) support; Eastern Whakatane township/surrounds Cohort 2, mean deprivation 7.25, GP management; Western Bay Cohort 3, mean deprivation 5.98, received predominantly GP care, but 3 highest-risk schools received school-based programs. Cases were identified from ICD10 ARF-coded hospital discharges, notifications to Ministry of Health, and a secondary-prevention penicillin database. Primary outcomes were first-presentation ARF cohorts' incidence preintervention (2000-10) and postintervention (2011-18) with cases over annual school rolls' Māori students-year denominators.

RESULTS

Overall, ARF in Maori schoolchildren declined in the cohorts with school-based programs. Cohort 1 saw a postintervention (2011-18) decline of 60%, 148 to 59/100,000/year, rate ratio (RR) = 0.40(CI 0.22-0.73) P = 0.002. Males' incidence declined 190 to 78 × 100,000/year RR = 0.41(CI 0.19-0.85) P = 0.013 and females too, narrowing gender disparities. Cohort 3 ARF incidence decreased 48%, 50 to 26/100,000/year RR = 0.52(CI 0.27-0.99) P = 0.044. In contrast, ARF doubled in Cohort 2 students with GP-only care without school-based programs increasing 30 to 69/100,000/year RR = 2.28(CI 0.99-5.27) P = 0.047, especially for males 39/100,000/year to 107/100,000/year RR = 2.71(CI 1.00-7.33) P = 0.0405.

CONCLUSIONS

School-based programs with indigenous Māori health workers' sore-throat swabbing and GP/Nurse support reduced first-presentation ARF incidence in Māori students in highest-risk settings.

Coexistence of acute poststreptococcal glomerulonephritis and acute rheumatic fever in a Japanese girl with primary Sjögren's syndrome

Although acute poststreptococcal glomerulonephritis (APSGN) and acute rheumatic fever (ARF) are well-known complications of group A streptococcus infection, concomitant occurrence of both diseases is rare. We report an 11-year-old Japanese girl with primary Sjögren's syndrome complicated by acute renal failure about 2 weeks after the onset of pharyngitis. Although histopathological findings of the kidney were not confirmative, APSGN was suggested by the spontaneous recovery of her renal function, typical latent period with high levels of antistreptolysin O and low serum levels of C3 but not of C4. In addition, cardiac hypomotility and regurgitation of the 4 valves progressed in the convalescent phase of APSGN, which was accompanied by elevation of serum C-reactive protein and plasma brain natriuretic peptide (BNP) levels. Myocarditis was suggested by delayed gadolinium-enhancement of cardiac walls on cardiac magnetic resonance imaging. She was diagnosed with APSGN and ARF and was treated with a combination of short course prednisolone and prophylactic penicillin G. There is no relapse of renal or cardiac symptoms during 6 years follow-up. Unexpected elevation of plasma BNP in a convalescent stage of APSGN suggests the development of ARF. Underlying Sjögren's syndrome (SS) may modify the histopathological findings and make it difficult to differentiate APSGN from CTD-associated nephritis such as lupus nephritis (LN) even by renal biopsy.

Incidence of acute rheumatic fever and rheumatic heart disease in Melbourne, Australia from 1937 to 2013

AIM

Acute rheumatic fever (ARF) most commonly presents in children aged 5-14 years old. Lifelong rheumatic heart disease (RHD) can result. This study investigated time trends in ARF and RHD using inpatient data from the Royal Children's Hospital, Melbourne (RCH).

METHODS

A retrospective cohort study covering the period 1937-2013 was conducted using records from RCH, a quaternary paediatric hospital in Melbourne, Victoria, Australia. Patient data were identified using RCH classification of diseases coding for ARF or RHD for years <1952. For the period 1952-1987, this system was used in addition to identifying International Classification of Disease (ICD) discharge codes that corresponded to ARF or RHD. From 1988-2013, only ICD codes were used to identify patient data. Descriptive epidemiological analyses were performed, including incidence rate calculations using historical census population denominator data. Analyses focussed on children in the peak age group.

RESULTS

Among children aged five to 14 years, a total of 4337 RCH admissions with ARF/RHD occurred for 3015 patients. A sharp decline in first ARF/RHD hospitalisations at RCH occurred from 1959, following a peak mean annual incidence rate during 1944-1947 of 40.1/100 000 children (95% confidence interval (CI): 36.6-43.9; P < 0.05). Over 1996-2013, the mean annual incidence rate was 1.6/100 000 (95% CI: 1.3-1.8) and reached 2.3/100 000 (95% CI: 1.3-3.7) in 2005.

CONCLUSION

The burden of ARF and RHD treated at RCH declined following the 1940s, mirroring changes seen in North America and Europe. Despite this, inpatient treatment for these conditions continued to be provided right up until the end of the study period.

Development and Evaluation of a New Triplex Immunoassay That Detects Group A Streptococcus Antibodies for the Diagnosis of Rheumatic Fever

Streptococcal serology is a cornerstone in the diagnosis of acute rheumatic fever (ARF), a postinfectious sequela associated with group A Streptococcus infection. Current tests that measure anti-streptolysin O (ASO) and anti-DNaseB (ADB) titers require parallel processing, with their predictive value limited by the low rate of decay in antibody response. Accordingly, our objective was to develop and assess the diagnostic potential of a triplex bead-based assay, which simultaneously quantifies ASO and ADB together with titers for a third antigen, SpnA. Our previous cytometric bead assay was transferred to the clinically appropriate Luminex platform by coupling streptolysin O, DNaseB, and SpnA to spectrally unique magnetic beads. Sera from more than 350 subjects, including 97 ARF patients, were used to validate the assay and explore immunokinetics. Operating parameters demonstrate that the triplex assay produces accurate and reproducible antibody titers which, for ASO and ADB, are highly correlative with existing assay methodology. When ARF patients were stratified by time (days following hospital admission), there was no difference in ASO and ADB between <28 and 28+ day groups. However, for anti-SpnA, there was a significant decrease (P < 0.05) in the 28+ day group, indicative of faster anti-SpnA antibody decay. Anti-SpnA immunokinetics support very recent group A Streptococcus infection and may assist in diagnostic classification of ARF. Further, bead-based assays enable streptococcal serology to be performed efficiently in a high-throughput manner.