Rheumatic Fever Is Still Relevant According to New Research

The prevalence of rheumatic fever (RF) has been on a steady decline in the western world, although, according to investigators there's been evidence published regarding disease resurgence in developed countries. New research provided the largest study of pediatric rheumatic fever to be conducted in a developed country, spanning 25 years.

Rheumatic fever and rheumatic heart disease (RHD) present a significant strain on global health with an estimated 470,000 new cases of acute rheumatic fever each year. RF leads to rheumatic heart disease in 60% of cases and continues to be the most common cause of acquired heart disease in developing countries.

With a minimal amount of evidence on the topic, investigators, led by Rotem Tal, Pediatric Rheumatology Unit, Schneider Children’s Medical Center of Israel, conducted a retrospective review. The aim was to clinically and epidemiologically characterize rhematic fever in Israel, where acute rheumatic fever is endemic.

The 25 Year Retrospective Review

Investigators reviewed medical files in a tertiary pediatric hospital for all children (up to 18 years of age) who presented with rheumatic fever between 1993-2017. Primary outcomes included patient and disease related characteristics, incidence trends, risk factors, disease course, relapse rates and secondary prophylaxis.

The charts were checked for adherence to the revised 2015 Jones criteria which stratified populations into low, medium and high risk for acute rheumatic fever and included echocardiographic definitions of carditis. According to investigators, the revised guidelines set more lenient criteria for the medium-high risk populations in an effort to decrease RF underestimations.

A total of 402 patient files were examined and 307 were included in the respective cohort study. A family history of RF or RHD was observed in 23% of patients. The study population resided in larger households with a median of 6 family members compared with 3.4 in the general public. This relationship displayed a significant association with increased rate of acute RF.

Is Rheumatic Fever Still Relevant?

Results showed that rheumatic fever and rheumatic heart disease are still prominent causes of morbidity and mortality, even in developed countries.

Arthritis was observed in 64% of patients, and included hips and small joints of hands and feet at presentation. 52% of patients had carditis. This progressed to severe carditis in 19.5% of patients; 13.2% of carditis patients experienced heart failure and 5 patients required intensive care with 1 recent death.

Of the patients with rheumatic fever, 10% relapsed. Among all cardiac patients, 3.6% had a cardiac relapse. From the initial presentation of RF, the recurrence rate increased continually for up to 9 years.

"Presentation of small joints as well as hips should not exclude the diagnosis," investigators concluded. "Initial hip arthritis was associated with less cardiac involvement. Only one patient with carditis at relapse did not have carditis at initial presentation. The findings emphasize that acute RF and RHD remain an important cause of morbidity and mortality, with relapses continuing after 9 years, highlighting the need for prolonged prophylaxis."

The study, "Rheumatic fever in a developed country - is it still relevant? A retrospective, 25 years follow-up" was published in Pediatric Rheumatology.