Rheumatic fever medical therapy


 * Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: ;

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

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

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

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

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

Aggressive use of inflammed joints should be avoided to prevent permanent damage of joints.

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

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

Valve defects
Mitral regurgitation or stenosis may develop in patients with rheumatic fever. Patients with mild MR may remain asymptomatic, but should be followed regularly yearly. Patients with moderate MR should be assessed with echocardiogram yearly or when symptoms develop. Patients with severe MR should undergo serial echocardiographic studies every 6 to 12 months to assess left ventricular size and ejection fraction which is important for timing of surgery. There is no specific medical therapy for treatment of asymptomatic valvular disease secondary to rheumatic fever. In rheumatic fever induced aortic stenosis, antibiotic prophylaxis against recurrent rheumatic fever is indicated with cautious use of antihypertyensives in treatment of co-existing systemic hypertension.

====2008 ACC/AHA Guidelines for Management of Valvular Heart Disease ==== {{cquote|

Class I
1. Percutaneous or surgical mitral valve commissurotomy is indicated when anatomically possible for treatment of severe mitral stenosis, when clinically indicated. (Level of Evidence: C)}}

Bacterial Endocarditis
Prophylaxis against infective endocarditis is not recommended in patients with rheumatic heart disease unless the patient has prothetic valves or prothetic materials used for valve repair, has history of previous episodes of endocarditis or certain congenital heart disease. In patients requiring endocarditis prophylaxis, it is recommended that an antibiotic from another class be administered. The chronic antibiotic dose is usually lower than what is required for prevention of endocarditis. Furthermore, these individuals often are colonized with viridans group streptococci in their oral that are relatively resistant to either penicillin or amoxicillin. In high risk patients, eitherclindamycin, azithromycin, or clarithromycin are recommended for prophylaxis prior to a dental procedure. As there is the potential for cross-resistance among strep viridans groups, cephalosporins, are not recommended. Finally, if possible it is recommended that elective procedures be delayed for 10 days to allow for recolonization with the usual flora.

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

Single dose intramuscular benzathine penicillin G (preferable) or oral penicillin V for 10 days (intravenous penicillin not needed; oral erythromycin may be used if patient allergic to penicillin)

Arthritis and fever


 * Paracetamol (first-line) or codeine until diagnosis confirmed
 * Aspirin (first-line) or naproxen once diagnosis confirmed, if arthritis or severe arthralgia present
 * Mild arthralgia and fever may respond to paracetamol alone
 * Influenza vaccine for children receiving aspirin during the influenza season (autumn/winter)

Chorea


 * No treatment for most cases
 * Carbamazepine or valproic acid if treatment is necessary

Carditis/heart failure
 * Bed-rest
 * Urgent echocardiogram
 * Anti-heart failure medication
 * Diuretics/fluid restriction for mild to moderate heart failure
 * ACE inhibitors for more severe heart failure, particularly if aortic regurgitation present
 * Glucocorticoids optional for severe carditis (consider treating for possible opportunistic infections)
 * Digoxin if atrial fibrillation present
 * Valve surgery for life-threatening acute carditis (rare)

Long-term preventive measures


 * Give first dose of secondary prophylaxis
 * Notify case for recording in ARF/RHD register, if available
 * Contact local health staff to ensure follow-up
 * Provide culturally appropriate education to patient and family
 * Arrange dental review and ongoing dental care to reduce risk of endocarditis