Characteristics of Children with Acute Rheumatic Carditis from a High-Incidence Region: Importance of Unexplained Worsening of Functional Class

Abstract

Background: Acute rheumatic fever (ARF) and acute rheumatic carditis (ARC) continue to be a major public health problem in developing countries. Objective: To study the characteristics of children with ARC being treated at a tertiary centre. Methods and Results: We studied 126 children (mean age 10.4 ± 2.3 years, range 5-15 years, 60% males) diagnosed with ARC by treating cardiologists. Most had lower socioeconomic status. Fifty of 126 (40%) presented with a first episode of ARC. Joint symptoms were present in 29% and fever in 25%. Only 2.4% had subcutaneous nodules and none had erythema marginatum or chorea. Fifty-one percent presented in NYHA class II and 29% in NYHA class III or IV. Tachycardia and heart failure were present in 53% and 21%, respectively. Recent worsening of NYHA class (dyspnoea) was the commonest feature (48%). Laboratory investigations showed raised antistreptolysin O titres (> 333 units) in only 36.7% of patients. Raised C-reactive protein (CRP) was present in 70%, while raised erythrocyte sedimentation rate was found in only 37% of patients. On the basis of above findings, the modified Jones criteria (2015) for the diagnosis of ARF were satisfied only in 46% of children. Echocardiography showed mitral valve thickening in 77% and small nodules on the tip of the leaflets in 43% (27 and 8%, respectively for aortic valve). Left ventricular ejection fraction was < 50% in only 3 patients. The dominant valve lesion was mitral regurgitation (MR) (present in 95% of patients; severe in 78%, moderate in 15%), while aortic regurgitation was present in 44% (severe in 14%). Conclusions: The criteria are often not satisfied by patients being treated for ARC. Recent unexplained worsening of dyspnoea, young age, significant MR, echocardiographic nodules, and elevated CRP are important indicators.

Acute rheumatic fever: a single center experience

“…In previous studies, joint pain has been reported as the most common complaint. 16,26,27 Considering the physical examination findings, in our study, arthritis was the most common, followed by carditis, which is consistent with the literature findings. Similar to my study, in most studies with a small number of patients, except for one, erythema marginatum and subcutaneous nodules were not encountered.…”

Rheumatic Fever Licks at the Joints, but Bites at the Heart

“…In this issue of Cardiology , Narang et al [4] report the clinical presentation of 126 children with acute rheumatic fever who were treated in a tertiary medical center (60 patients had a previous history of rheumatic fever). Joint symptoms were present in 29% and fever in only 25% of the patients; 2.4% of the patients had subcutaneous nodules and there were no patients with erythema marginatum or chorea.…”