Intravenous Immunoglobulin in Acute Rheumatic Fever

Abstract

Background-Acute rheumatic fever (ARF) remains the leading cause of acquired heart disease in children worldwide. No therapeutic agent has been shown to alter the clinical outcome of the acute illness. Immunological mechanisms appear to be involved in the pathogenesis of ARF. Intravenous immunoglobulin (IVIG), a proven immunomodulator, may benefit cardiac conditions of an autoimmune nature. We investigated whether IVIG modified the natural history of ARF by reducing the extent and severity of carditis. Methods and Results-This prospective, double-blind, randomized, placebo-controlled trial evaluated IVIG in patients with a first episode of rheumatic fever, stratifying patients by the presence and severity of carditis before randomization. Patients were randomly allocated to receive 1 g/kg IVIG on days 1 and 2 and 0.4 g/kg on days 14 and 28, or they received a placebo infusion. Clinical, laboratory, and echocardiographic evaluation was performed at 0, 2, 4, 6, 26, and 52 weeks. Fifty-nine patients were treated, of whom 39 had carditis (including 4 subclinical) and/or migratory polyarthritis (nϭ39). There was no difference between groups in the rate of normalization of the erythrocyte sedimentation rate or acute-phase proteins at the 6-week follow-up. On echocardiography, 59% in the IVIG group and 69% in the placebo group had carditis at baseline. There was no significant difference in the cardiac outcome, including the proportion of valves involved, or in the severity of valvar regurgitation at 1 year. At 1 year, 41% of the IVIG and 50% of the placebo group had carditis. Conclusions-IVIG

Subclinical carditis in rheumatic fever: A systematic review

“…In summary, several articles reported cases of progressive valve dysfunction during follow-up [3,7,15,16]. Others reported improvement and even resolution [2,14,[17][18][19][20][21].…”

“…In a proportion of patients with ARF, pathological valvular regurgitation that is not evident clinically can be seen on echocardiography [2][3][4][5][6][7]. This has been termed subclinical carditis (SCC).…”

Rheumatic fever and long-term sequelae in children

“…There are also reports of using immunomodulators like intravenous gamma globulin in high doses for the treatment of rheumatic carditis. The results, however, are not encouraging [14].…”

Rheumatic Heart Disease in Indigenous Populations—New Zealand Experience

“…It was found that IVIG did not alter the clinical course or lead to reduction in echocardiographic evidence of acute valvular disease or chronic cardiac damage one year later [29]. We have also considered a larger, international study with echocardiographic endpoints to re-evaluate the potential benefits of corticosteroids [30] and other newer anti-inflammatory agents on acute rheumatic carditis and longer term cardiac outcome.…”