Acute rheumatic fever: Treatment and prevention
- Andrew Steer, MBBS, PhD, FRACP
Andrew Steer, MBBS, PhD, FRACP
- Associate Professor
- Pediatric Infectious Diseases Physician
- Royal Children's Hospital Melbourne
- Allan Gibofsky, MD, JD, FACP, FCLM
Allan Gibofsky, MD, JD, FACP, FCLM
- Professor of Medicine and Public Health
- Weill Medical College of Cornell University
- Section Editors
- Robert Sundel, MD
Robert Sundel, MD
- Section Editor — Pediatric Rheumatology
- Associate Professor of Pediatrics
- Harvard Medical School
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Acute rheumatic fever (ARF) is a nonsuppurative complication of pharyngeal infection with group A Streptococcus (GAS). Signs and symptoms of ARF develop two to three weeks following pharyngitis and include arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum .
Treatment and secondary prevention of rheumatic fever are reviewed here. Primary prevention (eg, treatment of streptococcal tonsillopharyngitis) and the epidemiology, pathogenesis, clinical manifestations, and diagnosis of ARF are discussed in detail separately. (See "Treatment and prevention of streptococcal tonsillopharyngitis" and "Acute rheumatic fever: Epidemiology and pathogenesis" and "Acute rheumatic fever: Clinical manifestations and diagnosis".)
Treatment of ARF consists of anti-inflammatory therapy, antibiotic therapy, and heart failure management [2,3].
Goals of treatment — The four major goals of treatment are:
●Symptomatic relief of acute disease manifestations (eg, arthritis)
- RAMMELKAMP CH Jr, STOLZER BL. The latent period before the onset of acute rheumatic fever. Yale J Biol Med 1961; 34:386.
- Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2009; 119:1541.
- Webb RH, Grant C, Harnden A. Acute rheumatic fever. BMJ 2015; 351:h3443.
- Bicillin-LA (benzathine penicillin G) shortage. http://www.cdc.gov/std/treatment/drugnotices/bicillinshortage.htm (Accessed on October 31, 2016).
- United Kingdom and United States Joint Report: The treatment of acute rheumatic fever in children. Cooperative clinical trial of ACTH, cortisone and aspirin. Circulation 1955; 11:343.
- ILLINGWORTH RS, LORBER J, HOLT KS, RENDLE-SHORT J. Acute rheumatic fever in children; a comparison of six forms of treatment in 200 cases. Lancet 1957; 273:653.
- BYWATERS EG, THOMAS GT. Bed rest, salicylates, and steroid in rheumatic fever. Br Med J 1961; 1:1628.
- Hashkes PJ, Tauber T, Somekh E, et al. Naproxen as an alternative to aspirin for the treatment of arthritis of rheumatic fever: a randomized trial. J Pediatr 2003; 143:399.
- Albert DA, Harel L, Karrison T. The treatment of rheumatic carditis: a review and meta-analysis. Medicine (Baltimore) 1995; 74:1.
- Cilliers A, Adler AJ, Saloojee H. Anti-inflammatory treatment for carditis in acute rheumatic fever. Cochrane Database Syst Rev 2015; :CD003176.
- DORFMAN A, GROSS JI, LORINCZ AE. The treatment of acute rheumatic fever. Pediatrics 1961; 27:692.
- BYWATERS EG, THOMAS GT. Treatment of rheumatic fever with 12-week courses of cortisone or salicylate. Br Med J 1962; 2:221.
- Skoularigis J, Sinovich V, Joubert G, Sareli P. Evaluation of the long-term results of mitral valve repair in 254 young patients with rheumatic mitral regurgitation. Circulation 1994; 90:II167.
- National Heart Foundation of Australia (RF/RHD guideline development working group) and the Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia -- an evidence based review. 2006. Available at: www.heartfoundation.com.au/downloads/ARF_RHD_PP-590_Diag-Mgnt_Evidence-Review_0606.pdf (Accessed on December 07, 2006).
- Walker KG, Wilmshurst JM. An update on the treatment of Sydenham's chorea: the evidence for established and evolving interventions. Ther Adv Neurol Disord 2010; 3:301.
- The natural history of rheumatic fever and rheumatic heart disease. Ten-year report of a cooperative clinical trial of ACTH, cortisone, and aspirin. Circulation 1965; 32:457.
- BLAND EF, DUCKETT JONES T. Rheumatic fever and rheumatic heart disease; a twenty year report on 1000 patients followed since childhood. Circulation 1951; 4:836.
- Majeed HA, Yousof AM, Khuffash FA, et al. The natural history of acute rheumatic fever in Kuwait: a prospective six year follow-up report. J Chronic Dis 1986; 39:361.
- Gordis L, Lilienfeld A, Rodriguez R. Studies in the epidemiology and preventability of rheumatic fever. II. Socio-economic factors and the incidence of acute attacks. J Chronic Dis 1969; 21:655.
- Stollerman GH. Rheumatic fever. Lancet 1997; 349:935.
- STOLLERMAN GH. The use of antibiotics for the prevention of rheumatic fever. Am J Med 1954; 17:757.
- DENNY FW, WANNAMAKER LW, BRINK WR, et al. Prevention of rheumatic fever; treatment of the preceding streptococcic infection. J Am Med Assoc 1950; 143:151.
- Dajani AS. Current status of nonsuppurative complications of group A streptococci. Pediatr Infect Dis J 1991; 10:S25.
- Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 1987; 316:421.
- World Health Organization. Rheumatic fever and rheumatic heart disease: report of a WHO expert consultation. Geneva. WHO, 20 Oct to 1 Nov, 2001. WHO Tech Rep Ser 2001; 923.
- Rammelkamp CH Jr. Epidemiology of streptococcal infections. Harvey Lect 1955- 1956; 51:113.
- Berrios X, del Campo E, Guzman B, Bisno AL. Discontinuing rheumatic fever prophylaxis in selected adolescents and young adults. A prospective study. Ann Intern Med 1993; 118:401.
- STOLLERMAN GH, RUSOFF JH. Prophylaxis against group A streptococcal infections in rheumatic fever patients; use of new repository penicillin preparation. J Am Med Assoc 1952; 150:1571.
- Broderick MP, Hansen CJ, Faix DJ. Factors associated with loss of penicillin G concentrations in serum after intramuscular benzathine penicillin G injection: a meta-analysis. Pediatr Infect Dis J 2012; 31:722.
- Parnaby MG, Carapetis JR. Rheumatic fever in indigenous Australian children. J Paediatr Child Health 2010; 46:527.
- Allergic reactions to long-term benzathine penicillin prophylaxis for rheumatic fever. International Rheumatic Fever Study Group. Lancet 1991; 337:1308.
- FEINSTEIN AR, WOOD HF, EPSTEIN JA, et al. A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis. N Engl J Med 1959; 260:697.
- CREA MA, MORTIMER EA Jr. The nature of scarlatinal arthritis. Pediatrics 1959; 23:879.
- Ahmed S, Ayoub EM, Scornik JC, et al. Poststreptococcal reactive arthritis: clinical characteristics and association with HLA-DR alleles. Arthritis Rheum 1998; 41:1096.
- Goals of treatment
- Eradication of GAS carriage
- - GAS pharyngitis
- - GAS pyoderma
- - Household contacts
- Arthritis management
- Carditis management
- - Severe carditis
- - Indications for valve surgery
- Sydenham chorea management
- RISK FACTORS FOR RECURRENT DISEASE
- Primary prevention
- Secondary prevention (antibiotic prophylaxis)
- - Duration
- - Antibiotic selection
- - Administration of parenteral prophylaxis
- - Case reporting and prevention programs
- - Education
- POSTSTREPTOCOCCAL REACTIVE ARTHRITIS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS