Rheumatic Fever: An Old Foe Returns

Untreated strep infections can cause acute rheumatic fever and rheumatic heart disease in children. That complication has become rare in the continental US, but a new CDC report finds a resurgence in the American territory of Samoa and in people of Samoan descent living in the state of Hawaii.

Acute rheumatic fever no longer has to be reported in the US. Once a widely feared and fairly common childhood ailment, the illness is a consequence of untreated strep throat, now easily prevented if the strep is cured with antibiotics.

Untreated it can cause permanent cardiac valve damage and rheumatic heart disease.

According to a report from the US Centers for Disease Control and Prevention, the disease is seeing a resurgence in the American territory of American Samoa and in persons of Samoan background living in Hawaii.

Thought there are fewer than 0.06 cases per 1,000 in US children living on the mainland, the incidence in Samoa has been as high as 1.5 cases per 1,000.

Reporting in the May 29 edition of Morbidity and Mortality Weekly Report James Marrone, MD of the Lyndon B. Johnson Tropical Medical Center in American Samoa and colleagues at the CDC and other institutions found that 49% of those children stricken with rheumatic fever—usually due to missed strep diagnosis—went on to develop rheumatic heart disease.

The team called for establishment of a coordinated acute rheumatic fever and rheumatic heart disease control program to “improve diagnosis, treatment, and patient compliance” with therapy. One obstacle is that “in American Samoa families often choose traditional remedies over medical care” and that hospitals physicians “often rely on clinical, rather than laboratory, diagnosis of pharyngitis.” That means they might miss a case of strep throat.

Even if strep goes undiagnosed at first, and antibiotics are not given within 9 days of symptom onset, it’s not too late to prevent complications. Long-term injections of benzathine penicillin G can prevent recurrent acute rheumatic fever. But they need to be given every 3 or 4 weeks for 10 years (or until the child reaches adulthood at 21) to be fully effective in preventing rheumatic heart disease.

In addition to rheumatic heart disease, strep can cause pyoderma, toxic shock syndrome and necrotizing fasciitis and other post-infection syndromes.

“Damage to heart valves can be irreversible and is worsened by repeat episodes of acute rheumatic fever,” the researchers noted.

The highest rheumatic heart disease in children is in sub-Saharan Africa where it occurs in 5.7 children in 1,000.