|Year : 2021 | Volume
| Issue : 1 | Page : 379-383
Recurrent attacks of rheumatic fever among school-age children (6–12 years)
Hala M El-Moselhy Shaheen1, Seham M Rgab2, Noura A Khalel1, Dina E. A. Saleh3
1 Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Family Medicine, Ministry of Health, El Mahallat, Egypt
|Date of Submission||27-Aug-2019|
|Date of Decision||07-Sep-2019|
|Date of Acceptance||14-Sep-2019|
|Date of Web Publication||27-Mar-2021|
Dina E. A. Saleh
Department of Family Medicine, Ministry of Health, El Mahalla, Gharbeya 31951
Source of Support: None, Conflict of Interest: None
To assess factors related to recurrence of rheumatic fever attacks among school-age children (6–12 years) in El-Mahala El-Kobra City, Gharbiya Governorate.
Recurrent episodes of acute rheumatic fever (ARF) can lead to rheumatic heart disease with considerable morbidity and mortality in children.
Patients and methods
A cross-sectional study was conducted in a center for follow-up of patients with rheumatic fever and rheumatic heart diseases in El-Mahala El-Kobra City, Gharbiya Governorate. There were 237 cases aged 6–12 years attending the selected center during the years of the study (first of November 2015 to end of October 2017). All cases that attended the center for follow-up (after either single attack or recurrent attacks of rheumatic fever) were recruited in the study. Participants were interviewed using a self-designed questionnaire filled by the researcher to assess socioeconomic characteristics and family and dietary history. Laboratory investigations included erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O titer, and hemoglobin percent, and also ECG and echocardiography were collected from patients' files.
There was a significant association between recurrence of rheumatic fever attacks and age of the patient, tonsillectomy, regimen of taking long-acting penicillin, and lack of adherence to treatment.
The study revealed that among 237 studied rheumatic cases, 104 (43.9%) had recurrent attacks of ARF. The most significant factor associated with recurrent ARF was the age of the patient, negative history for tonsillectomy, a regimen of taking long-acting penicillin, and lack of adherence to its use.
Keywords: children, recurrence, rheumatic fever, school age
|How to cite this article:|
El-Moselhy Shaheen HM, Rgab SM, Khalel NA, Saleh DE. Recurrent attacks of rheumatic fever among school-age children (6–12 years). Menoufia Med J 2021;34:379-83
|How to cite this URL:|
El-Moselhy Shaheen HM, Rgab SM, Khalel NA, Saleh DE. Recurrent attacks of rheumatic fever among school-age children (6–12 years). Menoufia Med J [serial online] 2021 [cited 2021 May 12];34:379-83. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/379/312047
| Introduction|| |
Acute rheumatic fever (ARF) results from the body's autoimmune response to a throat infection caused by Streptococcus pyogenes, also known as the group A Streptococcus bacteria. Rheumatic heart disease (RHD) refers to the long-term cardiac damage caused by either a single severe episode or multiple recurrent episodes of ARF. RHD remains a significant worldwide cause of morbidity and mortality, particularly in resource-poor settings. Although ARF and RHD were once common across all populations, improved living conditions and widespread treatment of superficial S. pyogenes infections have caused these diseases to become comparatively rare in developed areas . Rheumatic fever is diagnosed by positive culture result of the throat and/or rising streptococcal antibody titer. Major criteria are polyarthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules. Minor criteria are fever, arthralgia, elevated erythrocyte sedimentation rate or C-reactive protein, and prolonged PR interval on the electrocardiogram  Echocardiography confirms the diagnosis of ARF, allowing the diagnosis of important valve lesions and exclusion of nonrheumatic causes of valvular involvement . ARF is the result of a hyperimmune response to group A streptococcal infection in the susceptible host. The resulting valvular damage or RHD is the only long-term complication of ARF. An absence of primary prevention (treatment of group A streptococcal infections) and absence of screening programs to detect early RHD will lead to late disease presentation, with most patients only seeking medical treatment owing to symptoms associated with complications of the disease . The incidence of group A streptococcal pharyngeal infections varies between countries and also within the same country depending on several factors including season (usually winter), age group, socioeconomic conditions, environmental conditions, level of primary health care, and overcrowding . The first goal of treating an ARF episode is to eradicate streptococcal organisms and bacterial antigens from the pharyngeal region. Penicillin is the drug of choice in persons who do not have allergic reaction. A single parenteral injection of benzathine penicillin can enhance compliance. Oral cephalosporin, more than erythromycin, is recommended as an alternative in patients who are allergic to penicillin . Children given penicillin G benzathine at a dose of 1.2 million unit intramuscular every 4 weeks experienced a recurrence rate of 0.4 cases per 100 patients. ARF recurrence rates have been found to be even lower if penicillin is administered every 3 weeks instead of every 4 weeks. This regimen may be appropriate in patients with severe RHD. If we compare the benefits of a 3-week regimen against patient compliance and cost, compliance is often poor to start with, at least partially owing to the pain of the injections . RHD program was implemented in Egypt; the program has opened in 30 centers throughout the country, equipping them with 60 echocardiograms and ECG data information units. It has also trained 300 cardiologists and 1500 primary health care physicians in RHD management and established a referral system between primary care centers and RHD centers .
The aim of the work was to improve health of primary school-age children (6–12 years).
| Patients and methods|| |
A cross-sectional study was conducted in a center for follow-up of patients with rheumatic fever and RHDs in El-Mahala El-Kobra city, Gharbiya Governorate. There were 237 cases aged 6–12 years attending the selected center during 2 years (first of November 2015 to end of October 2017). All cases that attended the center for follow-up (after either single attack or recurrent attacks of rheumatic fever) were recruited in the study. Data were collected 3 days per week (they were selected randomly). Patients with ARF were subjected to a structured validated self-designed questionnaire to collect personal data, sociodemographic characteristics, and assessment of risk factors for ARF, which includes age, sex, the age of father, the age of mother, etc., and compliance to treatment. Socioeconomic level was determined according to Fahmy et al. . Proper aeration of the house was determined by the presence of a window in all rooms. Moreover, full history was taken related to recurrent attacks of rheumatic fever, such as the history of taking long-acting penicillin (LAP), regularity of taking LAP, and adherence to LAP, and also medical history such as chronic tonsillitis, tonsillectomy, and history of chronic diseases, for example, asthma, thalassemia, and diabetes mellitus, as well as family history of rheumatic fever.
The Menoufia Faculty of Medicine committee for medical research ethics formally approved the study. A written consent form was obtained from all participants, after a simple and clear explanation of the research object, procedure, and the liberty to drop out. The data were collected, tabulated, and analyzed statistically using IBM personal computer with a statically package for social science (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA). Qualitative data were expressed as number and percentage and analyzed by applying the χ2 test.
| Results|| |
The study revealed that among the total 237 rheumatic fever cases that participated in the study, ∼104 (44%) patients experience recurrent rheumatic fever attacks, whereas 133 (56%) patients had a single attack [Figure 1]. Regarding demographic data, there was no statistically significant difference between both single-attack and recurrent-attack groups regarding sex (P = 0.381). There was a statistically significant difference regarding age (mean ± SD), and it was significantly higher (10.13 ± 1.755) among the group with a recurrent attack of rheumatic fever versus (9.27 ± 2.368) (P < 0.001) in a single-attack rheumatic fever group. There was no statistically significant difference between both single-attack and recurrent attack groups regarding mother's age and father's age (P = 0.748 and 0.592, respectively). Moreover, there was no statistically significant difference between both single-attack and recurrent-attack groups regarding socioeconomic status (P = 0.374). There was no statistically significant difference between both single-attack and recurrent-attack groups.
|Figure 1: Frequency of participants with recurrent attacks of rheumatic fever.|
Click here to view
Regarding proper aeration of the house and ventilation devices, there was no significant difference (P = 0.308 and 0.664, respectively) [Table 1]. In this study, a recurrence rate of rheumatic fever episodes was significantly higher among cases with chronic tonsillitis (54.7%) and negative history for tonsillectomy (74.1%). However, there was no statistically significant difference between both single-attack and recurrent-attack groups regarding chronic tonsillitis (P = 0.009). There was a statistically significant difference between both single-attack and recurrent-attack groups regarding tonsillectomy (P < 0.001). There was no statistically significant difference between both single-attack and recurrent-attack groups regarding family history of rheumatic fever and history of chronic diseases (P = 0.291 and 0.419, respectively) [Table 2]. There was a significant difference between recurrence of rheumatic fever episodes and treatment regimen with LAP, as 54 (87%) patients who had irregular intake of LAP had recurrent attacks of rheumatic fever (P < 0.001). There was a significant difference between recurrence of rheumatic fever episodes and adherence to treatment regimen with LAP (P < 0.001), as ∼22% of the patients who took LAP every 2 weeks had recurrent attacks of rheumatic fever, 86% of the patients who took LAP every 3 weeks had recurrent attacks of rheumatic fever, and 67% of the patients who took LAP every 4 weeks had recurrent attacks of rheumatic fever [Table 3].
|Table 1: Relationship between sociodemographic criteria and recurrence of rheumatic fever|
Click here to view
|Table 2: The relationship between medical history and recurrence of rheumatic fever|
Click here to view
|Table 3: Relationship between regimen of taking long-acting penicillin and recurrence of rheumatic fever|
Click here to view
| Discussion|| |
ARF is a postinfectious nonsuppurative result of pharyngeal infection with S. pyogenes or group A β hemolytic streptococcus. Only damage to the valve tissue within the heart, or RHD, can become a chronic condition leading to congestive heart failure, strokes, endocarditis, and death. Although the incidence and prevalence of ARF and RHD have been decreasing in developed nations since the early 1900s, they continued to be major causes of morbidity and mortality among young people in developing countries. ARF affects children between the ages of 5 and 14 years, and initial episode of ARF can affect children younger than this . Recurrent episodes generally affect older children and can occur in young children. Risk factors for ARF and RHD include age, sex, and many environmental factors . Repeated episodes of RF become an important mechanism for worsening of RHD. Recurrent outbreaks are associated with increased frequency of carditis and are the most severe cases of cardiac involvement . The study revealed that among total cases that participated in the study, ∼44% of the patients experienced recurrent rheumatic fever attacks, and this result agreed with a study done by Rayamajhi et al. , which found that 49% of the rheumatic case sample had recurrent attacks, and disagreed with a study carried out in Brazil, where the recurrence rate was described as 21% by Meira et al. . The incidence of rheumatic fever recurrence has been reported between 15 and 34% by Costa et al. . In our study, age was significantly higher among the group with a recurrent attack of rheumatic fever (10.13 ± 1.755 years) versus 9.27 ± 2.368 a single-attack rheumatic fever group. Median age was ∼10 years among the group with recurrent attacks of rheumatic fever. This result agreed with Al Qurashi , which showed the patients' ages at the time of recurrence ranged from 5 to 13 years (median, 10 years). In this study, a recurrence rate of rheumatic fever episode was significantly higher among cases with chronic tonsillitis (54.7%) and negative history for tonsillectomy (74%). There was a statistically significant difference between both studied groups regarding tonsillectomy. This agreed with a recent systematic review of randomized trials in children, which estimated that tonsillectomy reduced the incidence of episodes of a sore throat by 1.2 episodes a year and reduced school absence associated with a sore throat by 2.8 days a year; the differences regarded by Van Staaij et al.  were clinically insignificant. This also agreed with a study done by Bharti et al.  which showed that tonsillectomy led to a significant decrease in the levels of raised antistreptolysin O titer in patients with chronic tonsillitis. It also reduced the chances of recurrence of disease. Moreover, it agreed with El-Magd et al.  which showed 30% of patients who were complaining of a recurrent sore throat improved after tonsillectomy. Another review study by Choi et al.  concluded that the frequencies of sore throat episodes and upper respiratory infections became lower over time whether or not a tonsillectomy was performed. Manyemba and Mayosi  reported that penicillin reduces the risk of recurrence of rheumatic fever by 55%, and this agreed with our study which showed recurrence rate of 87% in cases that had irregular intake of LAP, whereas this rate decreased to 28% in cases that had regular intake of LAP. On the contrary, Seckeler and Hoke  reported the recurrence rate of RF in penicillin-treated group as 38%. Spinetto et al.  reported that patients with nonadherence to treatment accounted for 55% of recurrences. El Dayem et al. . Some authors have recommended a 2-weekly regimen, and these recommendations are in agreement with findings from our study, where patients who followed 3-weekly regimen of LAP have recurrence rate of 86%, whereas patients who followed 2-weekly regimen of LAP have recurrence rate of 22%. This indicated the effectiveness of LAP in the prevention of repeated attacks of RF. Oran et al.  suggested that the interval between injections should be 15 days during the first 2 years after the acute episode of RF and 21 days during the subsequent years.
| Conclusion|| |
Recurrent ARF is a great problem that occurs owing to irregular intake of LAP and LAP injection, with 2-week interval being more effective than 3-week interval. Tonsillectomy decreased recurrent attacks of acute rheumatic fever.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham A, et al
. Disease manifestations and pathogenic mechanisms of group A streptococcus. Clin Microbiol Rev 2014; 27
Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al
. Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation 2015; 131
Shivaram P, Ahmed MI, Kariyanna PT, Sabbineni H, Avula UM. Doppler echocardiography imaging in detecting multi-valvular lesions: a clinical evaluation in children with acute rheumatic fever. PLoS One 2013; 8
Okello E, Wanzhu Z, Musoke C, Kakande B, Mondo CK, Freers J, et al
. Cardiovascular complications in newly diagnosed rheumatic heart disease patients at Mulago Hospital, Uganda. Cardiovasc J Afr 2013; 24
Sorour KA. Rheumatic heart disease in Egypt: gloomy past and promising future. Egypt Soc Cardiol 2014; 66
Wallace MR, Ravishankar J. Rheumatic fever treatment and management
. USA: Drugs and Disease; 2015.
Webb RH, Grant C, Harnden A. Acute rheumatic fever. BMJ 2015; 351
RHD. Implementation of Egyptian RHD program: rheumatic heart diseaseaction. 2016. Available at: https://rhdaction.org/what-rhd
. [Last Accessed on 2019 Aug 15].
Fahmy SI, Nofal LM, Shehata SF, El Kady HM, Ibrahim HK. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90
Lawrence JG, Carapetis JR, Griffiths K, Edwards K, Condon JR. Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia 1997-2010. Circulation 2013; 128
Carapetis JR, Beaton A, Cunningham MW, Guilherme L, Karthikeyan G, Mayosi BM, et al
. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers 2016; 2
Mota CCC, Meira ZMA, Graciano RN, Graciano FF, AraÃojo FDR. Rheumatic fever prevention program: long-term evolution and outcomes. Front Pediatr 2015; 2
Rayamajhi A, Sharma D, Shakya U. First-episode versus recurrent acute rheumatic fever: Is it different?. Pediatr Int 2009; 51
Meira ZM, Goulart EM, Araújo FD, Influence of outbreaks of rheumatic fever recurrence in the development of valvular heart diseasein children and adolescents. Rev Méd Minas Gerais 2008; 18
Costa LP, Domiciano DS, Pereira RM. Demographic characteristics, laboratory and radiological findings of rheumatic fever in Brazil: Review systematic. Rev Brasil Reumat 2009; 49
Al Qurashi M. The pattern of acute rheumatic fever in children: experience at the children's hospital, Riyadh, Saudi Arabia. J Saudi Heart Assoc 2009; 21
Van Staaij BK, Van den Akker EH, Van der Heijden GJ, Schilder AG, Hoes AW. Adenotonsillectomy for upper respiratory infections: evidence-based?. Arch Dis Child 2005; 90
Bharti P, Mohindroo S, Mohindroo NK, Sharma D, Kanga A. Tonsillectomy and its effect on ASO titer. Int J Res Med Sci 2017; 5
El-Magd EAA, Meguid MA, El Tahan AER. The value of high antistreptolysin o titre as an indicator of tonsillectomy in Upper Egypt. Int J Otolaryngol Head Neck Surg 2016; 5
Choi HG, Park B, Sim S, Ahn SH. Tonsillectomy does not reduce upper respiratory infections: a national cohort study. PloS One 2016; 11
Manyemba J, Mayosi BM. Penicillin for secondary prevention of rheumatic fever. Cochrane Database Syst Rev 2002; 3
Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol 2011; 3
Spinetto H, Lennon D, Horsburgh M Rheumatic fever recurrence prevention: a nurse-led programme of 28-day penicillin in an area of high endemicity. J Pediatr Child health 2011; 47
El Dayem SM, Hamza H, Helal S, Mohamed A, Hassan H. Evaluation of the policy of secondary prevention against rheumatic fever among Egyptian children. Indian Heart J 2014; 66
Oran B, Taştekin A, Karaaslan S, Baş L, Ayçiçek A, Çeri A, et al
. Prophylactic efficiency of 3-weekly benzathine penicillin G in rheumatic fever. Indian J Pediatr 2000; 67
[Table 1], [Table 2], [Table 3]