Background Acute rheumatic fever (ARF) is a delayed, inflammatory sequela of pharyngitis secondary to Group A Streptococcus infection. ARF remains one of the most important causes of cardiovascular morbidity and mortality in developing countries. Although it is mainly known as a childhood disease, it is also encountered in adult clinics in developing countries.

Objectives To investigate the clinical and laboratory characteristics of patients who were diagnosed with ARF in two rheumatology outpatient clinics from June 2015 to January 2017.

Methods The data of 20 patients (12 female; median age 29.5 (21–40) years) were evaluated. The diagnosis of ARF was based on the 2015 Jones criteria. The data collected included patient age, gender, arthralgia, arthritis, erythema marginatum (EM), subcutaneous nodules (SN), ECG/ Doppler transthoracic echocardiography findings, and other rare findings. The erythrocyte sedimentation rate (ESR), antistreptolysin O (ASO) and CRP levels of the patients and the drugs initiated were also recorded. Anti-streptolysin O (ASO) test or throat culture were used for the evidence of preceding Streptococcus infection. Patients with post-streptococcal reactive arthritis were differentiated and excluded by clinically. Patients with positive rheumatoid factor or ACPA were also excluded. Joint fluid examination was done to exclude septic arthritis in patients with monoarthritis.

Results All patients were referred to rheumatology for arthralgia or arthritis. Patients were taking some sort of nonsteroidal antiinflammatory (NSAI) drugs before the referral. The median follow-up time was 9 months (0–18). Sixteen out of 20 patients had mono-, oligo- or poliarthritis (25%, 25% and 30%, respectively). Knees and ankles were the most common involved joints. The median duration of arthritis was 1 week (1–50 weeks). Six out 20 patients had subclinical carditis (30%). Nine out of 20 patients had a history of ARF attack previously. Three patients had chronic rheumatic mitral valve thickening without any severe insufficiency. EM and SN were observed in 15% and 60% of patients, respectively. Chorea was diagnosed in one patient. NSAI drugs were given to all patients with maximum dosages. High dose salicylate therapy were not given to patients due to intolerance or side effects. Nine patients were given prednisolone therapy (5–20 mg/d). The median duration of prednisolone therapy was 2 weeks (0–6 weeks). Sulfasalazine was given to two patients for the prolonged arthritis. All patients received secondary prophylaxis with penicillin.

Conclusions ARF should be considered in the differential diagnosis of arthritis in young adults in developing countries. Arthritis of ARF in adults seems to be resistant to classical NSAI drugs. Our data show that steroid therapy can be given safely instead of salicylates in carditis or arthritis.

References

1. GewitzMH,BaltimoreRS,TaniLY,etal. AmericanHeart Association Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease of the Council on Cardiovascu- lar Disease in the Young. Revision of the Jones criteria for the diagnosis of the rheumatic fever in the era of Doppler echocardiography: a scientific statement of the American Heart Association. Circulation 2015; 131: 1806–18.

2. He VY, Condon JR, Ralph AP, et al. Long-Term Outcomes From Acute Rheumatic Fever and Rheumatic Heart Disease: A Data-Linkage and Survival Analysis Approach. Circulation. 2016 Jul 19;134(3):222–32.

References

Disclosure of Interest None declared