Treatment of Rheumatic Fever

Treatment of acute rheumatic fever can be separated into 4 approaches:

• Treatment of streptococcal infection that caused the disease. This is a standard practice, although it was never proven to improve the 1-year outcome. Despite that, at least this stops the spread of rheumatogenic strains of streptococcus.
• General treatment of acute inflammation:

o   Anti-inflammatory agents are administered to alleviate the symptoms of arthritis, reduce fever, and deal with other acute symptoms. Salicylates are primarily used, although other NSAIDs are also effective. Steroidal anti-inflammatory drugs can also be used; however, they should be reserved for patients who do not respond to NSAIDs. None of the anti-inflammatory agents, however, have been proved to reduce the chances of rheumatic heart disease.

o   Bed rest is essential for all patients with acute rheumatic fever, especially those with carditis. During the acute phase of the disease, the patients are advised to rest. Then, gradually, they may increase their activity.

o   Intravenous immunoglobulin is also sometimes used; however, there are no studies that prove its effectiveness at preventing rheumatic heart disease.

o   If the patient develops chorea, it is usually managed by placing the patient into a quiet non stimulating environment. Valproic acid is usually used for sedation. Plasmapheresis, steroids, and intravenous immunoglobulin are also used in refractory chorea; however, there is little evidence for their efficacy.

• Cardiac management. It is crucial for patients with cardiac involvement to have complete bed rest. Severe carditis is sometimes treated using corticosteroid; however, the data supporting its efficacy are scant. Patients who develop heart failure should be treated using diuretics to prevent the accumulation of liquid within the body. The patient with acute carditis should also be constantly monitored for arrhythmias and treated accordingly.
• Antibiotic treatment. Patients with acute rheumatic fever are treated using antibiotics irrespective of whether the throat culture was positive or negative. This therapy might not reduce the risk of complications, but it reduces the spread of the infection.

o   Primary prophylaxis of streptococcal pharyngitis using antibiotics is essential for preventing rheumatic fever.

o   Secondary prevention is necessary to reduce the risk of additional streptococcal infections. Moreover, patients with a history of acute rheumatic fever are at a much greater risk of having recurrent acute rheumatic fever.

• Patients who had rheumatic fever with carditis which resulted in significant residual heart disease should undergo an antibiotic treatment for at least 10 years after that last episode (or until the patient is at least 40-45 years old). There were concerns that such treatment may create resistant strains of Streptococcus; however, latest studies have found no evidence for this hypothesis.
• Patients with carditis that resulted in mild mitral regurgitation should receive antibiotic prophylaxis for 10 year or until they reach the age of 25 (whichever is longer).
• Patients without carditis should receive antibiotic prophylaxis for 5 years or until they reach the age of 18-21 (whichever is longer).

Complications

Immediate complications include:

• Pancarditis – inflammation of the whole heart including epicardium, myocardium, and endocardium.
• Heart blocks – first-degree AV block is the most common; however, some patients may develop second- and third-degree AV blocks.
• Pericardial effusion – accumulation of fluid in the pericardial space. This condition should be treated immediately, as it can quickly result in death. The first symptoms of pericardial effusion include light-headedness and syncope, chest pain and discomfort, cough, hoarseness, dyspnea, anxiety and confusion.
• Chorea – is a sign of the involvement of the central nervous system in the inflammatory process. Chorea appears after several months after the onset of rheumatic fever if it is left untreated. The consequences of this complication can be debilitating.

Long-term complications include:

• Valvular stenosis – most commonly affecting the mitral valve. After years, this condition can lead to hypertrophy of the left atrium and then as a result to heart failure.

Prognosis

The prognosis for acute rheumatic fever was improved greatly through the use of secondary prophylaxis using antibiotics. The ultimate prognosis for the patient is directly linked to the severity of carditis caused by rheumatic fever.

In approximately 60% of cases, the patients show signs of improvement after having carditis. About 6% of the patients with no carditis will develop heart murmurs (which are a sign of valvular heart disease) in the next 10 years.