Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health

The social determinants of health (SDH), such as access to income, education, housing and healthcare, strongly shape the occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) at the household, community and national levels. The SDH are systemic factors that privilege some more than others and result in poverty and inequitable access to resources to support health and well-being. Primordial prevention is the modification of SDH to improve health and reduce the risk of disease acquisition and the subsequent progression to RHD. Modifying these determinants using primordial prevention strategies can reduce the risk of exposure to Group A Streptococcus, a causative agent of throat and skin infections, thereby lowering the risk of initiating ARF and its subsequent progression to RHD.This report summarises the findings of the Primordial Prevention Working Group-SDH, which was convened in November 2021 by the National Heart, Lung, and Blood Institute to assess how SDH influence the risk of developing RHD. Working group members identified a series of knowledge gaps and proposed research priorities, while recognising that community engagement and partnerships with those with lived experience will be integral to the success of these activities. Specifically, members emphasised the need for: (1) global analysis of disease incidence, prevalence and SDH characteristics concurrently to inform policy and interventions, (2) global assessment of legacy primordial prevention programmes to help inform the co-design of interventions alongside affected communities, (3) research to develop, implement and evaluate scalable primordial prevention interventions in diverse settings and (4) research to improve access to and equity of services across the RHD continuum. Addressing SDH, through the implementation of primordial prevention strategies, could have broader implications, not only improving RHD-related health outcomes but also impacting other neglected diseases in low-resource settings.

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.

Prothymosin Alpha: A Novel Contributor to Estradiol Receptor Alpha-Mediated CD8+ T-Cell Pathogenic Responses and Recognition of Type 1 Collagen in Rheumatic Heart Valve Disease

BACKGROUND

Rheumatic heart valve disease (RHVD) is a leading cause of cardiovascular death in low- and middle-income countries and affects predominantly women. The underlying mechanisms of chronic valvular damage remain unexplored and regulators of sex predisposition are unknown.

METHODS

Proteomics analysis of human heart valves (nondiseased aortic valves, nondiseased mitral valves [NDMVs], valves from patients with rheumatic aortic valve disease, and valves from patients with rheumatic mitral valve disease; n=30) followed by system biology analysis identified ProTα (prothymosin alpha) as a protein associated with RHVD. Histology, multiparameter flow cytometry, and enzyme-linked immunosorbent assay confirmed the expression of ProTα. In vitro experiments using peripheral mononuclear cells and valvular interstitial cells were performed using multiparameter flow cytometry and quantitative polymerase chain reaction. In silico analysis of the RHVD and Streptococcuspyogenes proteomes were used to identify mimic epitopes.

RESULTS

A comparison of NDMV and nondiseased aortic valve proteomes established the baseline differences between nondiseased aortic and mitral valves. Thirteen unique proteins were enriched in NDMVs. Comparison of NDMVs versus valves from patients with rheumatic mitral valve disease and nondiseased aortic valves versus valves from patients with rheumatic aortic valve disease identified 213 proteins enriched in rheumatic valves. The expression of the 13 NDMV-enriched proteins was evaluated across the 213 proteins enriched in diseased valves, resulting in the discovery of ProTα common to valves from patients with rheumatic mitral valve disease and valves from patients with rheumatic aortic valve disease. ProTα plasma levels were significantly higher in patients with RHVD than in healthy individuals. Immunoreactive ProTα colocalized with CD8⁺ T cells in RHVD. Expression of ProTα and estrogen receptor alpha correlated strongly in circulating CD8⁺ T cells from patients with RHVD. Recombinant ProTα induced expression of the lytic proteins perforin and granzyme B by CD8⁺ T cells as well as higher estrogen receptor alpha expression. In addition, recombinant ProTα increased human leukocyte antigen class I levels in valvular interstitial cells. Treatment of CD8⁺ T cells with specific estrogen receptor alpha antagonist reduced the cytotoxic potential promoted by ProTα. In silico analysis of RHVD and Spyogenes proteomes revealed molecular mimicry between human type 1 collagen epitope and bacterial collagen-like protein, which induced CD8⁺ T-cell activation in vitro.

CONCLUSIONS

ProTα-dependent CD8⁺ T-cell cytotoxicity was associated with estrogen receptor alpha activity, implicating ProTα as a potential regulator of sex predisposition in RHVD. ProTα facilitated recognition of type 1 collagen mimic epitopes by CD8⁺ T cells, suggesting mechanisms provoking autoimmunity.

Circulating follicular T helper cells and humoral reactivity in rheumatic heart disease

AIMS

This study aimed to profile circulating T follicular helper cells (cTfh) and their effect on B cells in rheumatic heart disease (RHD).

MATERIALS AND METHODS

Participants were divided into healthy control (HC, n = 30) and RHD (n = 30) groups. Percentages of cTfh subpopulations, based on CD4, CXCR5, CXCR3, CCR6, Foxp3, Ki67, and PD-1 cell markers, and of CD19⁺ B cell subgroups were measured by flow cytometry and compared between the groups. Also, IL-21 concentration in plasma and mitral valve were quantitated by cytometric bead array, immunofluorescence, and western blotting.

KEY FINDINGS

The PD-1⁺ cTfh, B cells (naive B cells, plasmablasts, and plasma B cells) proportion and cTfh17/cTfh ratios in RHD group were significantly increased, compared to HC (p < 0.01 in all cases), while different types of memory B cells were diminished (p < 0.001). In RHD patients, percentages of PD-1⁺ cTfh and switched memory B cells were negatively correlated (r = -0.565, p = 0.009); meanwhile, percentages of plasmablasts and PD-1⁺ cTfh cells were positively correlated (r = 0.594, p = 0.005). Additionally, IL-21 levels in plasma and mitral valve of RHD group were higher than those in HC. Also, IL-21 levels correlated with PD-1⁺ cTfh(r = 0.557, p = 0.010), cTfh17 (r = 0.567, p = 0.009), and plasmablast (r = -0.5957, p = 0.005) cell proportions, and (cTh2 + cTh17)/cTfh1 ratio (r = -0.547, p = 0.013).

SIGNIFICANCE

The activation of PD-1⁺ cTfh and cTfh17 subtype was highly correlated with plasmablast maturation and IL-21 production in rheumatic heart disease. Thus indicating the prominent role of cTfh and humoral reactivity in the immune pathogenesis of RHD.

High burden and seasonal variation of paediatric scabies and pyoderma prevalence in The Gambia: A cross-sectional study

BACKGROUND

Scabies is a WHO neglected tropical disease common in children in low- and middle-income countries. Excoriation of scabies lesions can lead to secondary pyoderma infection, most commonly by Staphyloccocus aureus and Streptococcus pyogenes (group A streptococcus, GAS), with the latter linked to acute post-streptococcal glomerulonephritis (APSGN) and potentially rheumatic heart disease (RHD). There is a paucity of data on the prevalence of these skin infections and their bacterial aetiology from Africa.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study, conducted over a four-month period that included the dry and rainy season, was conducted to determine the prevalence of common skin infections in Sukuta, a peri-urban settlement in western Gambia, in children <5 years. Swabs from pyoderma lesions were cultured for S. aureus and GAS. Of 1441 children examined, 15.9% had scabies (95% CI 12.2-20.4), 17.4% had pyoderma (95% CI 10.4-27.7) and 9.7% had fungal infections (95% CI 6.6-14.0). Scabies was significantly associated with pyoderma (aOR 2.74, 95% CI 1.61-4.67). Of 250 pyoderma swabs, 80.8% were culture-positive for S. aureus, and 50.8% for GAS. Participants examined after the first rains were significantly more likely to have pyoderma than those examined before (aRR 2.42, 95% CI 1.38-4.23), whereas no difference in scabies prevalence was seen (aRR 1.08, 95% CI 0.70-1.67). Swab positivity was not affected by the season.

CONCLUSIONS/SIGNIFICANCE

High prevalence of scabies and pyoderma were observed. Pyoderma increased significantly during the rainy season. Given the high prevalence of GAS pyoderma among children, further research on the association with RHD in West Africa is warranted.

A population pharmacokinetic study of benzathine benzylpenicillin G administration in children and adolescents with rheumatic heart disease: new insights for improved secondary prophylaxis strategies

BACKGROUND

Benzathine benzylpenicillin G (BPG) is recommended as secondary prophylaxis to prevent recurrence of acute rheumatic fever and subsequent rheumatic heart disease (RHD). Following intramuscular injection, BPG is hydrolysed to benzylpenicillin. Little is known of the pharmacokinetics of benzylpenicillin following BPG in populations at risk of RHD.

METHODS

We conducted a longitudinal pharmacokinetic study of children and adolescents receiving secondary prophylaxis throughout six monthly cycles of BPG. Dried blood spot samples were assayed with LC-MS/MS. Benzylpenicillin concentrations were analysed using non-linear mixed-effects modelling with subsequent simulations based on published BMI-for-age and weight-for-age data.

RESULTS

Eighteen participants contributed 256 concentrations for analysis. None had benzylpenicillin concentrations >0.02 mg/L for the full time between doses. The median duration above this target was 9.8 days for those with a lower BMI (<25 kg/m2), who also had lower weights, and 0 days for those with a higher BMI (≥25 kg/m2). Although fat-free mass was a key determinant of benzylpenicillin exposure after a standard dose of BPG, having a higher BMI influenced absorption and almost doubled (increase of 86%) the observed t½.

CONCLUSIONS

Few children and adolescents receiving BPG as secondary prophylaxis will achieve concentrations >0.02 mg/L for the majority of the time between injections. The discordance of this observation with reported efficacy of BPG to prevent rheumatic fever implies a major knowledge gap relating to pharmacokinetic/pharmacodynamic relationships between benzylpenicillin exposure and clinical outcomes.

School-based surveillance for detection of children with acute pharyngitis, rheumatic fever/rheumatic heart disease in Shimla district, Himachal Pradesh, India-A cluster randomized controlled trial

Background

The lack of surveillance system is a major barrier in prevention and control of rheumatic fever/rheumatic heart disease (RF/RHD). Efficacy of school-based surveillance was evaluated for detection of acute pharyngitis and RF/RHD in Shimla district, HP.

Methods

The schools in district Shimla were randomly assigned to intervention and controlled arm (442 vs. 441 schools). The trained nodal teachers reported children with symptoms of acute pharyngitis and or RF/RHD in intervention arm and children taken to hospitals by parents for symptoms of acute pharyngitis and or RF/RHD under control arm through mobile phone to coordinating centre. Final outcome for presence of RF/RHD or other heart Diseases was recorded after examination at nearest primary health centers and/or at Indira Gandhi Medical College Hospital, Shimla. Difference in detection rate between intervention arm and control arm was compared using Z test.

Results

The number of school children reported from intervention group was significantly higher than in control due to suspected symptoms of acute pharyngitis and or RF/RHD were 65 (2.84/1000) and 15 (0.60/1000), respectively (p < 0.01). Only 4 children in each arm were found to have heart diseases, with prevalence of (0.17/1000 and 0.16/1000), respectively, after clinical and echocardiography evaluation. In intervention arm, one child had RHD while three had congenital heart disease; in control arm, one child had congenital heart disease and three had RHD.

Conclusions

School based surveillance had higher rate of suspecting children with acute pharyngitis and or RF/RHD although with low specificity. There is a need of future studies to demonstrate the effectiveness of the proposed intervention in endemic regions of the state.

Acute rheumatic fever

Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.

Poststreptococcal Illness: Recognition and Management

Group A beta-hemolytic streptococcus can cause several postinfectious, nonsuppurative immune- mediated diseases including acute rheumatic fever, poststreptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders, and poststreptococcal glomerulonephritis. Except for sporadic outbreaks, poststreptococcal autoimmune syndromes occur most commonly in sub-Saharan Africa, India, Australia, and New Zealand. Children younger than three years are rarely affected by group A streptococcus pharyngitis or rheumatic fever, and usually do not require testing. Rheumatic fever is a rare condition that presents as a febrile illness characterized by arthritis, carditis or valvulitis, and neurologic and cutaneous disease, followed many years later by acquired valvular disease. Recurrence rates are high. In addition to evidence of recent streptococcal infection, two major or one major and two minor Jones criteria are required for diagnosis. Electrocardiography, chest radiography, erythrocyte sedimentation rate, and an antistreptolysin O titer are the most useful initial tests. Echocardiography is recommended to identify patients with subclinical carditis. The arthritis usually responds within three days to nonsteroidal anti-inflammatory drugs. Poststreptococcal reactive arthritis is nonmigratory, can affect any joint, and typically does not respond to aspirin. Pediatric autoimmune neuropsychiatric disorders affect the basal ganglia and are manifested by obsessive-compulsive and tic disorders. The presentation of poststreptococcal glomerulonephritis ranges from asymptomatic microscopic hematuria to gross hematuria, edema, hypertension, proteinuria, and elevated serum creatinine levels.

An Ineffective Differential Diagnosis of Infective Endocarditis and Rheumatic Heart Disease after Streptococcal Skin and Soft Tissue Infection

We herein report the case of a 68-year-old woman with a skin and soft tissue infection at her extremities. The blood culture results were positive for Streptococcus pyogenes, and we started treatment using ampicillin and clindamycin, although subsequent auscultation revealed a new-onset heart murmur. We therefore suspected rheumatic heart disease and infective endocarditis. The case met both the Jones criteria and the modified Duke criteria. Transesophageal echocardiography revealed vegetation on the aortic valve, although the pathological findings were also compatible with both rheumatic heart disease and infective endocarditis. The present findings suggest that these two diseases can coexist in some cases.

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.

Post-infectious group A streptococcal autoimmune syndromes and the heart

There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.

COMPLEMENTARY TECHNIQUES OF PERCUTANEOUS CLOSURE OF DUCTUS ARTERIOSUS USING DETACHABLE COOK COILS AND AMPLATZER DEVICES

BACKGROUND

Patent Ductus Arteriosus (PDA) is a commoncardiac malformation whose treatment locally has been surgical ligation via a lateral thoracotomy. Device closure of the ductus was first performed at the Mater hospital in 1999 in a ten year old male using a five millilitre detachable cook coil. In 2000 the Amplatzer device was introduced to close larger ducts. Subsequently these devices have been used interchangeably to close both small and large ducts. We report this single centre experience of percutaneous PDA closure in a resource-limited setting; utilising the two techniques.

OBJECTIVE

To describe our experience of trans-catheter closure of small and large ducts using either the detachable Cook coils or the Amplatzer occluders at the Mater Hospital Nairobi.

DESIGN

A descriptive retrospective cohort study. Setting: The Mater Hospital, Nairobi, Kenya.

SUBJECTS

Patients with clinical and echo-cardiographic features of patent ductus arteriosus who underwent cardiac catheterisation and angiography followed by device embolisation of the ductus.

RESULTS

From April 1999 to October 2009 a total of ninety eight subjects were recruited. into the study. Sixty nine (70%) of these subjects had the ducts closed using the Amplatzer devices, while twenty nine (30%) were embolised using the cook detachable coils. Three of the subjects in the coil group had the ducts embolised using the double technique while the rest were embolised using single coils. Various coil sizes four to eight millimetres were used in patients with small to medium ducts (two to seven millimetres) whereas the Amplatzer duct occluder was successfully used in all the duct sizes. The Amplatzer atrial septal occluder device was used to close very large ducts in two of the patients. The overall success rate was 93.1%, but the coil group had higher failure rate of 6.9% compared to the Amplatzer group of 3%. One patient in the Amplatzer group had a late embolisation requiring surgical retrieval at one month post occlusion. There were no mortalities.

CONCLUSION

Transcatheter device occlusion of PDA is a safe and alternative to

Socioeconomic and environmental risk factors among rheumatic heart disease patients in Uganda

BACKGROUND

Although low socioeconomic status, and environmental factors are known risk factors for rheumatic heart disease in other societies, risk factors for rheumatic heart disease remain less well described in Uganda.

AIMS AND OBJECTIVE

The objective of this study was to investigate the role of socio-economic and environmental factors in the pathogenesis of rheumatic heart disease in Ugandan patients.

METHODS

This was a case control study in which rheumatic heart disease cases and normal controls aged 5-60 years were recruited and investigated for socioeconomic and environmental risk factors such as income status, employment status, distance from the nearest health centre, number of people per house and space area per person.

RESULTS

486 participants (243 cases and 243 controls) took part in the study. Average age was 32.37+/-14.6 years for cases and 35.75+/-12.6 years for controls. At univariate level, Cases tended to be more overcrowded than controls; 8.0+/-3.0 versus 6.0+/-3.0 persons per house. Controls were better spaced at 25.2 square feet versus 16.9 for cases. More controls than cases were employed; 45.3% versus 21.1%. Controls lived closer to health centers than the cases; 4.8+/-3.8 versus 3.3+/-12.9 kilometers. At multivariate level, the odds of rheumatic heart disease was 1.7 times higher for unemployment status (OR = 1.7, 95% CI = 1.05-8.19) and 1.3 times higher for overcrowding (OR = 1.35, 95% CI = 1.1-1.56). There was interaction between overcrowding and longer distance from the nearest health centre (OR = 1.20, 95% CI = 1.05-1.42).

CONCLUSION

The major findings of this study were that there was a trend towards increased risk of rheumatic heart disease in association with overcrowding and unemployment. There was interaction between overcrowding and distance from the nearest health center, suggesting that the effect of overcrowding on the risk of acquiring rheumatic heart disease increases with every kilometer increase from the nearest health center.

Disease appearance and evolution against a background of climate change and reduced resources

Global health continues to face increasing challenges owing to a variety of reasons that include the almost constant changes in disease appearance and evolution. Most, but not all, of these changes affect low-income countries and are influenced by climate change. Tracking the recent and anticipated changes in the demographics and global distribution of these changes is essential for evolving effective new methods for dealing with the problems. The recent recognition by the United Nations of the importance of non-communicable diseases is a major positive step. For the sake of this paper, the following diseases were chosen: dengue and malaria, to highlight the role of climate change on vector-borne diseases. Drug-resistant tuberculosis illustrates the role of globalization and reduced resources on disease evolution. The continuing rise in cardiovascular mortality and morbidity, particularly in resource-poor countries is largely attributed to lack of preventive and therapeutic measures against such conditions as hypertension, diabetes, atherosclerosis and congenital heart disease as well as neglected diseases, of which Chagas and rheumatic heart disease will be discussed further.

Rheumatic heart disease: mediation by complex immune events

Rheumatic fever (RF) is an autoimmune disease caused by the Gram-positive bacteria Streptococcus pyogenes following an untreated throat infection in susceptible children. Rheumatic heart disease (RHD), the most serious complication, occurs in 30-45% of RF patients and leads to chronic valvular lesions. Here, we focus on the genes that confer susceptibility for developing this disease. Molecular mimicry mediates the cross-reactions between streptococcal antigens and human proteins. Several autoantigens have been identified, including cardiac myosin epitopes, vimentin, and other intracellular proteins. In heart tissue, antigen-driven oligoclonal T cell expansions probably cause the rheumatic heart lesions. These cells are CD4+ and produce inflammatory cytokines (TNF alpha and IFN gamma). IL-4+ cells are found in the myocardium; however, these cells are very scarce in the valve lesions of RHD patients. IL-4 is a Th2-type cytokine and plays a regulatory role in the inflammatory response mediated by Th1 cytokines. Our findings indicate that the Th1/Th2 cytokine balance has a role in healing myocarditis while the low numbers of IL-4-producing cells in the valves probably induced the progressive and permanent valve damage.

Rheumatic valvular heart disease in thalassaemic patients: a summary of reported Thai cases

Thalassaemia is a serious inherited disorder with a high prevalence in south-east Asian countries, including Thailand. Several complications of thalassaemia have been documented. Infection is a major problem and the leading cause of death, particularly in E-beta thalassaemia.

Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002)

BACKGROUND

Rheumatic fever (RF) and rheumatic heart disease (RHD) are still major medical and public health problems mainly in developing countries. Pilot studies conducted during the last five decades in developed and developing countries indicated that the prevention and control of RF/RHD is possible. During the 1970s and 1980s, epidemiological studies were carried out in selected areas of Cuba in order to determine the prevalence and characteristics of RF/RHD, and to test several long-term strategies for prevention of the diseases.

METHODS

Between 1986 and 1996 we carried out a comprehensive 10-year prevention programme in the Cuban province of Pinar del Rio and evaluated its efficacy five years later. The project included primary and secondary prevention of RF/RHD, training of personnel, health education, dissemination of information, community involvement and epidemiological surveillance. Permanent local and provincial RF/RHD registers were established at all hospitals, policlinics and family physicians in the province. Educational activities and training workshops were organised at provincial, local and health facility level. Thousands of pamphlets and hundreds of posters were distributed, and special programmes were broadcast on the public media to advertise the project.

RESULTS

There was a progressive decline in the occurrence and severity of acute RF and RHD, with a marked decrease in the prevalence of RHD in school children from 2.27 patients per 1,000 children in 1986 to 0.24 per 1,000 in 1996. A marked and progressive decline was also seen in the incidence and severity of acute RF in five- to 25-year-olds, from 18.6 patients per 100,000 in 1986 to 2.5 per 100,000 in 1996. There was an even more marked reduction in recurrent attacks of RF from 6.4 to 0.4 patients per 100,000, as well as in the number and severity of patients requiring hospitalisation and surgical care. Regular compliance with secondary prophylaxis increased progressively and the direct costs related to treatment of RF/RHD decreased with time. The implementation of the programme did not incur much additional cost for healthcare. Five years after the project ended, most of the measures initiated at the start of the programme were still in place and occurrence of RF/RHD was low.

A case of rheumatic fever with multiple recurrences of carditis

Rheumatic fever is still one of the major public health problems in developing countries. Recurrences have been reported during continuous regular prophylaxis. Here, we describe a 13-year-old girl who had four apparent recurrences of carditis while on a regimen of intramuscular benzathine penicillin G (BPG) every three weeks. The interesting and special features of this case were the presence of frequent recurrences of carditis with no evidence of arthritis despite regular BPG injections every three weeks, the requirement of long-term corticosteroid therapy due to these recurrences, and the shortness of time periods between attacks after withdrawal of steroid therapy. In this case, the administration of supraphysiologic doses of glucocorticoids caused iatrogenic Cushing syndrome with decreased bone mineral density and bilateral avascular tibial necrosis mimicking the symptoms of arthritis. Thus, this is a rare case. In similar cases with recurrences of either arthritis or carditis, instead of long-term corticosteroid therapy, we suggest a regimen of BPG prophylaxis every two weeks rather than every three weeks or monthly BPG injections because of the superiority of the every two weeks schedule in the adequate control of rheumatic fever recurrences, as shown in some previous studies.

Molecular mimicry in the autoimmune pathogenesis of rheumatic heart disease

Molecular mimicry is a hallmark of the pathogenesis of rheumatic fever where the streptococcal group A carbohydrate epitope, N-acetyl glucosamine, and the a-helical coiled-coil streptococcal M protein structurally mimic cardiac myosin in the human disease, rheumatic carditis, and in animal models immunized with streptococcal M protein and cardiac myosin. Recent studies have unraveled the potential pathogenic mechanisms by which the immune response against the group A streptococcus attacks the rheumatic valve leading to chronic rheumatic heart disease. Both B- and T-cell responses are involved in the process, and evidence for the hypotheses of molecular mimicry and epitope spreading are reviewed.

Towards a vaccine against rheumatic fever

Rheumatic fever (RF) is an autoimmune disease which affects more than 20 million children in developing countries. It is triggered by Streptococcus pyogenes throat infection in untreated susceptible individuals. Carditis, the most serious manifestation of the disease, leads to severe and permanent valvular lesions, causing chronic rheumatic heart disease (RHD). We have been studying the mechanisms leading to pathological autoimmunity in RF/RHD for the last 15 years. Our studies allowed us a better understanding of the cellular and molecular pathogenesis of RHD, paving the way for the development of a safe vaccine for a post-infection autoimmune disease. We have focused on the search for protective T and B cell epitopes by testing 620 human blood samples against overlapping peptides spanning 99 residues of the C-terminal portion of the M protein, differing by one amino acid residue. We identified T and B cell epitopes with 22 and 25 amino acid residues, respectively. Although these epitopes were from different regions of the C-terminal portion of the M protein, they showed an identical core of 16 amino acid residues. Antibodies against the B cell epitope inhibited bacterial invasion/adhesion in vitro. Our results strongly indicated that the selected T and B cell epitopes could potentially be protective against S. pyogenes.

Advances in potential M-protein peptide-based vaccines for preventing rheumatic fever and rheumatic heart disease

Rheumatic fever (RF) and rheumatic heart disease (RHD) are postinfectious complications of an infection (or repeated infection) with the Gram-positive bacterium, Streptococcus pyogenes (also known as group A streptococcus, GAS). RF and RHD are global problems and affect many indigenous populations of developed countries and many developing countries. However, RF and RHD are only part of a larger spectrum of diseases caused by this organism. The development of a vaccine against GAS has primarily targeted the abundant cell-surface protein called the M-protein. This review focuses on different M-protein-based-subunit vaccine approaches and the different delivery technologies used to administer these vaccine candidates in preclinical studies.

[The history of the disease of Taras Hryhorovych Shevchenko]

Differential diagnostics of T. H. Shevchenko's disease was presented in the article. The authors attempted to clarify the reasons of the writers's death. Diagnostic and treatment level provided to T. H. Shevchenko have been assessed in terms of practical achievements of XIX century medicine.

Oxidative stress and antioxidant status in cardiovascular diseases in population of western Nepal

OBJECTIVES

To observe if there is any connectivity between oxidative stress and cardiovascular diseases (CVDs).

MATERIALS AND METHODS

Patients suffering from different cardiovascular diseases (hypertension, ischemic heart disease, rheumatic heart disease) attending Manipal Teaching Hospital, Pokhara and strictly matched controls were selected for this study. Oxidative stress (OS) was measured by plasma thiobarbituric acid reacting substances (TBARS) where as antioxidant status was measured by estimating vitamin E, vitamin C and total antioxidant activity (TAA) in plasma.

RESULTS

The mean level of TBARS, TAA, vitamin C and E were 2.20+0.43 nmol/ml, 547+98 mol/l, 0.88+0.15 mg/dl and 0.75+0.20 mg/dl respectively in patients. The respective values in controls were 1.86+0.43 nmol/ml, 859+139 mol/l, 0.94+0.15 mg/dl and 1.10+0.30 mg/dl. Although the OS seems to be raised in patients, is practically insufficient to oxidize biomolecules and induce CVDs. Despite vitamin C and E levels being well within normal limits, the TAA was significantly and considerably lower in patients. This is a highly interesting observation suggesting that dietary antioxidants other than these vitamins were preferentially consumed to control OS because procedure for TAA used in this study practically measures only total dietary antioxidants.

CONCLUSION

OS does not appear to be an etiological factor for the cardiovascular diseases; rather slightly raised OS in patients seems to be a consequence. Further the raised OS was not due to lower nutrient antioxidant (vit. C and vit. E) in the local population studied herein.

Rheumatic fever: how S. pyogenes-primed peripheral T cells trigger heart valve lesions

The pathogenesis of rheumatic fever (RF) is related to autoimmune humoral and cellular responses against human tissues triggered by Streptococcus pyogenes. CD4(+) T cells are the ultimate effectors of chronic heart lesions in rheumatic heart disease (RHD). Heart-infiltrating CD4(+) T cell clones are able to recognize heart tissue and streptococcal antigens by molecular mimicry. The streptococcal M5(81-103) region, an immunodominant region, was recognized by both intralesional and peripheral T cell clones (62% and 38%, respectively). Peripheral T lymphocytes from Brazilian patients with severe RHD preferentially recognized the M5(81-96) peptide, in the context of HLA-DR7(+) and DR53(+) molecules. HLA-DR7 seems to be related to the development of multiple valvular lesions in RHD patients from different countries. In addition, the fact that peripheral and intralesional T cells recognized the M5(81-103) region points to this region as one of the streptococcal triggers of autoimmune reactions in RHD. T cell repertoire analysis from peripheral and intralesional T cell lines derived from RHD patients showed several oligoclonal expansions of BV families. Major expansions were found in the heart lesions, suggesting that such T cell populations preferentially migrate from the periphery to the heart. Some cross-reactive intralesional T cell clones displayed the same T cell receptor (TCR) BVBJ and CDR3 sequences, showing a degenerate pattern of antigen recognition. Heart tissue-infiltrating cells from myocardium and valvular tissue produced TNF-alpha, IFN-gamma, IL-10, and IL-4, whereas few cells from valvular tissue produced IL-4, showing that the lack of regulation in the valves could be responsible for the permanent and progressive valvular lesions.

Rheumatic heart disease in children: from clinical assessment to therapeutical management

Rheumatic heart disease is still a relevant problem in children, adolescents and young adults. Molecular mimicry between streptococcal and human proteins has been proposed as the triggering factor leading to autoimmunity and tissue damage in rheumatic heart disease. Despite the widespread application of Jones' criteria, carditis is either underdiagnosed or overdiagnosed. Endocarditis leading to mitral and/or aortic regurgitation influences morbidity and mortality of rheumatic heart disease, whilst myocarditis and pericarditis are less significant in determining adverse outcomes in the long-term. Strategy available for disease control remains mainly secondary prophylaxis with the long-acting penicillin G-benzathine.

Rheumatic and nonrheumatic valvular heart disease: epidemiology, management, and prevention in Africa

BACKGROUND

Unlike the Western world, valvular disease ranks among the major cardiovascular afflictions in Africa. Acute rheumatic fever and chronic rheumatic valvular disease in their most virulent form are still commonly encountered and impose a huge burden on limited healthcare resources.

METHODS AND RESULTS

We performed a systematic review of the literature with PubMed using rheumatic fever, rheumatic heart disease, valvular disease, warfarin anticoagulation, and pregnancy as search items. Literature emanating from Africa was emphasized. Epidemiology, current concepts on pathogenesis, and aspects of the medical and surgical management of this disease as seen from an African perspective are presented. The association of pregnancy with mitral stenosis is common and may be fatal if not managed appropriately. A practical approach to these patients is presented to optimize maternal and fetal outcome. Pregnant patients with mechanical valves require careful attention to ensure maternal survival and prevent fetal warfarin embryopathy. Prolonged subcutaneous heparin and frequent monitoring of the partial thromboplastin time are impractical in this setting, and the merits of different anticoagulation regimens are discussed. Congenital submitral aneurysms are a unique cause of mitral regurgitation, with the vast majority of cases originating from sub-Saharan Africa. Although the precise etiology is as yet unclear, the clinical and echocardiographic features are sufficiently characteristic to allow a preoperative diagnosis to be made. Transesophageal echocardiography allows much better definition of the size and anatomic relationships of the aneurysm. Surgical resection can be difficult but is usually curative. Mitral valve prolapse and endocarditis constitute the remaining frequent causes of valvular disease and are discussed briefly.

CONCLUSIONS

The spectrum and presentation of valvular disease in Africa are uniquely different from elsewhere. Together with socioeconomic issues and the HIV pandemic, this fact makes it imperative that further epidemiological and clinical studies be undertaken and guidelines developed that are appropriate to the practice of medicine on the African continent.

[Asymptomatic myocarditis after infection of the upper respiratory tract]

HISTORY AND CLINICAL FINDINGS

A 20-year-old patient was hospitalized with persistent high fever after tonsillitis and swelling of the talocalcanean joint.

INVESTIGATIONS

The ECG showed a partial right bundle branch block pattern and pathological T inversions on the left precordial leads. Cardiac Troponin I levels were slightly elevated and echocardiography revealed a dyscinetic area at the right ventricular apex. The anti-streptolysin titer was elevated.

DIAGNOSIS

Post-streptococcal rheumatic myocarditis. THERAPY AND FOLLOW-UP: Antibiotic therapy for 2 weeks. The patient showed subjective full recovery after 6 weeks. The anti-streptolysin titer further increases. Nuclear spin tomography of the heart reveal postinflammatory alterations at the apex of the right ventricle.

CONCLUSION

Rheumatoid fever is a rare diagnosis in developed countries. This case, however, illustrates that the true prevalence of rheumatoid carditis might be underestimated in the presence of only minimal heart-and joint-specific symptoms.

Maternal and perinatal outcome of pregnancies complicated by cardiac disease

OBJECTIVE

The aim of this study was to assess the maternal and perinatal outcome of pregnancies complicated by cardiac disease in a tertiary care center in Egypt.

METHODS

During a 1-year period, a total of 86 pregnant women with cardiac disease were admitted. Maternal and perinatal morbidity and mortality were calculated and compared with a control group.

RESULTS

Seventy-seven (89.5%) patients were due to rheumatic affection, and 60 patients were classified as NYHA classes I-II. There was one case of maternal mortality (1.16%), and 10 other cases developed life-threatening complications. Two perinatal mortalities (2.32%) occurred in this series. Birth weight of babies born to mothers with functional classes III and IV were significantly lower than those of functional classes I-II and control group.

CONCLUSION

Rheumatic heart disease with pregnancy is still predominant in Egypt. Maternal and perinatal morbidity and mortality are strongly correlated to maternal cardiac functional classification.

Rheumatoid disease and the heart: from epidemiology to echocardiography

Rheumatoid disease (RD) is a common chronic inflammatory condition associated with progressive joint destruction. Sufferers of RD experience reduced life expectancy, reflected in the increased standardised mortality rates reported in several studies over the last 50 years. Most studies indicate that the increased mortality affecting this population is mainly due to cardio-vascular disease. Epidemiological data have revealed an increased risk of developing ischaemic heart disease and heart failure in RD. The increased risk of ischaemic heart disease may result from traditional risk factors but data suggest that RD may confer risk independently. Although pericardial involvement, valvopathy and myocarditis are the most well-recognised cardiac manifestations of RD, and constitute a rheumatoid heart disease, these features are relatively benign. The current prevalence of rheumatoid heart disease in the era of early administration of disease-modifying therapy requires evaluation.

Pathogenesis of acute rheumatic fever and rheumatic heart disease: evasive after half a century of clinical, epidemiological, and laboratory investigation

Rheumatic fever and rheumatic heart disease continue to be a problem for medical and public health communities--the fact that penicillin has failed to eradicate this disease process is irrefutable proof of the need for more laboratory, epidemiological, and clinical research.

[Epidemiology of poststreptococcal, non-suppurative, late complications, in a Moldavian area (Romania) during the last decade]

The ubiquity of the acute infections caused by the group A beta-haemolytic streptococcus (ABHS) requires the continuation of the screening strategies of the risk to develop nonsuppurative late complications. The aim of this study was to assess the poststreptococcal pathologic evolution in an area where, during the last 10 years, there were recorded high values of the morbidity due to acute infections determined by ABHS. Using methods of retrospective data collecting, in Galaţi district, during 1990-2003, they monitored the dynamics of the case incidence and general and hospitalized morbidity, according to various age and home environment categories, for acute rheumatic fever (RF), carditis (CR), and acute poststreptococcal glomerulonephritis (APSG). The results emphasized the need to re-launch some targeted prevention programs, in order to lower the still high morbidity, due to these complications and, implicitly, to limit the deriving invalidity or social economical loss.

Henoch schonlein purpura with rheumatic carditis

Henoch Schonlein Purpura with acute rheumatic carditis is a rare entity and only few cases have been reported. An 8 year-old-girl presented with abdominal pain, arthralgia and rashes and was diagnosed as a case of Henoch Schonlein Purpura. She was managed conservatively and discharged. She was readmitted after 1 week with abdominal pain, fever and cough. She developed tachycardia with gallop rhythm on the third day of admission and pansystolic murmur of mitral regurgitation. Echocardiography showed features of myopericarditis, mild pericardial effusion and mitral regurgitation. She was diagnosed and managed as a case of acute rheumatic carditis.

Evidence for rheumatic valve disease in patients with severe tricuspid regurgitation long after mitral valve surgery: the role of 3D echo reconstruction

BACKGROUND AND AIM OF THE STUDY

Although severe tricuspid regurgitation (TR) is a well-recognized, long-term complication of rheumatic mitral valve replacement that impairs the functional results of surgery, its exact basis remains unclear and its management is unsatisfactory. The study aim was to obtain a detailed assessment of tricuspid valve morphology and function using 2D transesophageal echocardiography (TEE) with 3D reconstruction, and to determine long-term clinical outcome in patients after surgery for rheumatic mitral valve disease.

METHODS

A total of 42 patients (mean age 50 +/- 10 years) was followed up; 39 patients had mitral replacement and three had valvotomy. Thirty patients had developed impaired exercise tolerance, fluid retention and echocardiographic evidence of severe TR at 8.2 +/- 2.6 years after surgery; the remainder had mild regurgitation.

RESULTS

Follow up showed greater mortality in the severe TR group, with approximately 50% survival at 60 months after diagnosis compared with mild TR. None of the patients with severe TR had a dysfunctional mitral prosthesis. In these patients, transthoracic echo-Doppler showed enlarged right atrium and right ventricle, a mean transtricuspid retrograde pressure drop of 15 +/- 4 mmHg and apparently normal leaflet anatomy. Twenty patients (15 with severe TR) underwent a TEE and 3D reconstruction study for further evaluation. Abnormal leaflet anatomy was demonstrated in all patients with severe TR, with restricted leaflet motion in 10, leaflet shortening and thickening in the remainder, and dilatation of tricuspid valve annular insertion suggestive of rheumatic involvement. Although diastolic transtricuspid velocities were increased (peak flow 0.8 +/- 0.1 m/s) in these patients due to increased stroke volume, significant tricuspid stenosis was present in only two cases (mean gradient 4 and 3 mmHg respectively). Histopathology confirmed the presence of leaflet vascularization and extensive fibrosis in two patients who underwent tricuspid valve replacement.

CONCLUSION

Rheumatic leaflet involvement contributes to severe TR occurring long after mitral valve replacement, though overt stenosis is uncommon. Knowledge of the structural basis of this condition may thus improve its long-term management, possibly with early tricuspid valve repair.

Hydatid cyst of the right atrium and rheumatic mitral disease: a fortuitous association

Ecchinococcal infestation of the heart accounts for only 0.5-2% of ecchinococcosis cases. A case is reported of right atrial hydatid cyst associated with rheumatic mitral valve disease in a 43-year-old woman. Physical examination and chest X-radiography revealed mitral disease. Transthoracic and transesophageal echocardiography demonstrated a single, large cystic mass of 4 x 4 cm located in the right atrium, and heavily calcified mitral rheumatic disease with commissural fusion. Confirmatory computed tomography and magnetic resonance imaging excluded other extracardiac locations. Radioisotopic lung perfusion scanning and angiographic scanning excluded pulmonary embolism. The patient underwent mitral valve replacement and the hydatid cyst was excised. An intraoperative examination and subsequent pathology confirmed a diagnosis of hydatid cyst.

[Modern views on rheumatic fever]

Submitted in the paper are modern conceptions on etiology, pathophysiology, diagnosis and treatment of acute inflammatory rheumatism (IR). Some aspects of IR course in different age groups are highlighted, high informative value of new laboratory methods of diagnosis of its latent forms are validated. The place of interferons and selective inhibitors of COG-2 in the treatment of IR is determined.

Transjugular percutaneous inoue balloon mitral commissurotomy in a patient with inferior vena cava obstruction after liver transplantation

Percutaneous transvenous mitral commissurotomy was performed successfully via the transjugular approach in a patient with severe rheumatic mitral stenosis and obstruction of the inferior vena cava due to prior liver transplantation. This case demonstrates the advantage of the jugular approach in patients with difficult anatomy.