Rheumatic fever medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]
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[1].
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[2][3]. 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.
Sydenham’s chorea
Sydenham’s chorea is usually self limiting, resolving within few weeks[4]. 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. Anti-inflammatories such as glucocorticoids and aspirin have no effect on Sydenham's chorea[5].
Heart failure
Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure: diuretics and digoxin. Unlike normal heart failure, rheumatic heart failure responds well to corticosteroids.
National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand Treatment Guidelines[6]
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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)
Long-term preventive measures
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References
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ BYWATERS EG, THOMAS GT (1961). "Bed rest, salicylates, and steroid in rheumatic fever". Br Med J. 1 (5240): 1628–34. PMC 1954279. PMID 13689614.
- ↑ DORFMAN A, GROSS JI, LORINCZ AE (1961). "The treatment of acute rheumatic fever". Pediatrics. 27: 692–706. PMID 13723875.
- ↑ LESSOF MH, BYWATERS EG (1956). "The duration of chorea". Br Med J. 1 (4982): 1520–3. PMC 1980122. PMID 13316200.
- ↑ Markowitz, M. & Gordis, L., Rheumatic Fever, 2nd ed. 1972. W.B. Saunders: Philadelphia
- ↑ Carapetis JR, Brown A, Wilson NJ, Edwards KN, Rheumatic Fever Guidelines Writing Group (2007). "An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline". Med J Aust. 186 (11): 581–6. PMID 17547548.