Management of acute rheumatic fever and prevention of recurrence
THE CONTEXT
Management aims to limit cardiac damage and relieve symptoms, while antibiotic prophylaxis prevents further attacks.
Bed rest and recovery
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Bed rest reduces joint pain and cardiac workload.
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Its duration should be guided by symptoms, temperature, leucocyte count and erythrocyte sedimentation rate (ESR), and it should continue until these have settled.
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Normal physical activity can resume after full recovery.
Heart failure and conduction abnormalities
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Heart failure may result from valve dysfunction, usually severe mitral and/or aortic regurgitation.
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Valve replacement may be necessary if heart failure does not respond to medical treatment.
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Atrioventricular block occasionally occurs and usually resolves spontaneously; pacemaker insertion is rarely required.
Eradication of residual infection
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At diagnosis, give a single intramuscular dose of benzathine benzylpenicillin, 1.2 million units, or oral phenoxymethylpenicillin, 250 mg four times daily for 10 days, to eliminate residual streptococcal infection.
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Erythromycin or a cephalosporin can be used in patients allergic to penicillin.
Long-term antibiotic prophylaxis
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Another streptococcal infection can trigger a further attack of rheumatic fever, so long-term prophylaxis should be given.
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Prophylaxis uses oral phenoxymethylpenicillin, 250 mg twice daily, or intramuscular benzathine benzylpenicillin, 1.2 million units monthly, if adherence is in doubt.
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Sulfadiazine or erythromycin may be used for prophylaxis in patients allergic to penicillin.
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Further attacks are unusual after age 21, when prophylaxis can usually stop. It may continue with recurrent infection, residence in a high-prevalence area or high risk of recurrent streptococcal exposure, such as in school teachers or carers.
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With residual heart disease, continue prophylaxis until 10 years after the last episode or age 40, whichever is later.
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Long-term antibiotic prophylaxis prevents further attacks of acute rheumatic fever but does not protect against infective endocarditis.
Aspirin for arthritis
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Aspirin usually relieves arthritis rapidly; improvement within 24 hours helps confirm the diagnosis.
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The stated dose is 60 mg/kg body weight/day, divided into six doses.
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Continue aspirin until the ESR has fallen, then gradually reduce it.