To the Editor. —
This letter is in response to the article “Rheumatic Fever in Children Younger Than 5 Years: Is the Presentation Different?” published in Pediatrics by Tani et al.1 The article alerts pediatricians to rheumatic fever (RF) in children <5 years old in the differential diagnosis, although the disease is uncommon in this age group.
Based on this study, we also reviewed our experience with the RF cases in the last 20 years. Data on 609 RF attacks seen in 564 patients seen from January 1982 through December 2001 were collected from the medical records. The diagnoses were based on revised Jones criteria before 1992 and on updated Jones criteria afterward. Age at presentation, gender, major Jones criteria fulfilled, and the severity of carditis (if present) were noted. The criteria used by Tani et al were applied to evaluate the severity of carditis. Isolated arthritis (arthritis without any other major finding of RF) and isolated carditis (carditis without any other major finding of RF) cases were determined. Regarding these features, the clinical presentation of the attacks that occurred in the first 5 years of life were compared with that of attacks that occurred after 5 years of age using χ2 or Fisher’s exact test. P < .05 was considered statistically significant.
Of 609 RF attacks, 16 (2.6%) had occurred in the first 5 years of life, with a mean age of 4.69 ± 0.48 (range: 43–59 months). The male/female ratio (1.0 [8 girls, 8 boys]), carditis and arthritis rates (50.1% and 62.5%), and isolated carditis and isolated arthritis rates (37.5% and 50%) did not differ from those of 593 attacks that occurred after 5 years of age (male/female: 1.0; carditis and arthritis rates: 46.2% and 61.4%; isolated carditis and isolated arthritis rates: 32.5% and 48.1%). The severity of carditis was also similar among cases with carditis in both groups (moderate to severe carditis: 28.6% of the 16 attacks occurring at a younger age vs 36.8% of the attacks occurring after the age of 5 years). Therefore, unlike the study by Tani et al, we cannot conclude that arthritis tends to be isolated, nor can we say that carditis tends to be moderate to severe in RF cases occurring at <5 years of age. In our study, the only difference between the 2 groups was regarding chorea, which was not seen in any of the 16 attacks, whereas 7.1% of the rest of the attacks involved chorea. In the mentioned study, 11% of the children <5 years of age had chorea, which was significantly lower than the chorea rate of older patients.
As Tani et al stated in their report, the occurrence rate of RF under the age of 5 years differs from 1 study to another.2–4 Although our sample size was as large as that of the Tani et al study, the rate we found is almost half the rate that they reported (2.6% vs 5%). Therefore, the inconsistent results in the literature do not seem to be resolved by making studies involving large series; rather, the awareness of pediatricians of RF in patients <5 years old determines these reported rates. No matter what the incidence is, studies such as ours show that RF occurs in these young children, and if it goes unnoticed, sequelae from reactivations caused by the lack of prophylaxis seem inevitable for these patients.
- Copyright © 2004 by the American Academy of Pediatrics
Massell BF, Fyler DC, Roy SB. The clinical picture of rheumatic fever. Diagnosis, immediate prognosis, course and therapeutic implications. Am J Cardiol. 1958. 1:436-39. [Medline].
Parks T, Smeesters PR, Steer AC. Streptococcal skin infection and rheumatic heart disease. Curr Opin Infect Dis. 2012 Apr. 25(2):145-53. [Medline].
Pickering LK. Rheumatic fever. 2009 Red Book: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 616-628.
Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med. 1987 Feb 19. 316(8):421-7. [Medline].
Breda L, Marzetti V, Gaspari S, Del Torto M, Chiarelli F, Altobelli E. Population-based study of incidence and clinical characteristics of rheumatic Fever in abruzzo, central Italy, 2000-2009. J Pediatr. 2012 May. 160(5):832-836.e1. [Medline].
Orün UA, Ceylan O, Bilici M, Karademir S, Ocal B, Senocak F. Acute rheumatic fever in the Central Anatolia Region of Turkey: a 30-year experience in a single center. Eur J Pediatr. 2012 Feb. 171(2):361-8. [Medline].
Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol. 2011 Feb 22. 3:67-84. [Medline]. [Full Text].
Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. 2007 Aug 2. 357(5):470-6. [Medline].
[Guideline] Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Asso. JAMA. 1992 Oct 21. 268(15):2069-73. [Medline].
Bas HD, Baser K, Yavuz E, Bolayir HA, Yaman B, Unlu S. A shift in the balance of regulatory T and T helper 17 cells in rheumatic heart disease. J Investig Med. 2014 Jan. 62(1):78-83. [Medline].
Eriksson JG, Kajantie E, Phillips DI, Osmond C, Thornburg KL, Barker DJ. The developmental origins of chronic rheumatic heart disease. Am J Hum Biol. 2013 Sep-Oct. 25(5):655-8. [Medline].
[Guideline] Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease--an evidence-based guideline. Nat Rev Cardiol. 2011. 9(5):297-309. [Medline].
Beaton A, Aliku T, Okello E, Lubega S, McCarter R, Lwabi P. The utility of handheld echocardiography for early diagnosis of rheumatic heart disease. J Am Soc Echocardiogr. 2014 Jan. 27(1):42-9. [Medline].
Godown J, Lu JC, Beaton A, Sable C, Mirembe G, Sanya R, et al. Handheld echocardiography versus auscultation for detection of rheumatic heart disease. Pediatrics. 2015 Apr. 135 (4):e939-44. [Medline].
Robertson KA, Volmink JA, Mayosi BM. Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis. BMC Cardiovasc Disord. 2005 May 31. 5(1):11. [Medline].
Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. 1997 Jul 1. 96(1):358-66. [Medline].
Rayamajhi A, Sharma D, Shakya U. First-episode versus recurrent acute rheumatic fever: is it different?. Pediatr Int. 2009 Apr. 51(2):269-75. [Medline].
Yakub MA, Dillon J, Krishna Moorthy PS, Pau KK, Nordin MN. Is rheumatic aetiology a predictor of poor outcome in the current era of mitral valve repair? Contemporary long-term results of mitral valve repair in rheumatic heart disease. Eur J Cardiothorac Surg. 2013 Oct. 44(4):673-81. [Medline].
[Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2008 Jan. 139 Suppl:3S-24S. [Medline].
Abernethy M, Bass N, Sharpe N, et al. Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever. Aust N Z J Med. 1994 Oct. 24(5):530-5. [Medline].
Asbahr FR, Garvey MA, Snider LA, et al. Obsessive-compulsive symptoms among patients with Sydenham chorea. Biol Psychiatry. 2005 May 1. 57(9):1073-6. [Medline].
Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15. 366(9480):155-68. [Medline].
Circulation. The natural history of rheumatic fever and rheumatic heart disease. Ten-year report of a cooperative clinical trial of ACTH, cortisone, and aspirin. Circulation. 1965 Sep. 32(3):457-76. [Medline].
Cotran RS, Kumar V, Collins T. Rheumatic fever. Robbins Pathologic Basis of Disease. 6th ed. WB Saunders Co; 1999. 570-73.
Dajani A, Taubert K, Ferrieri P, et al. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American. Pediatrics. 1995 Oct. 96(4 Pt 1):758-64. [Medline].
Ellis NM, Li Y, Hildebrand W, et al. T cell mimicry and epitope specificity of cross-reactive T cell clones from rheumatic heart disease. J Immunol. 2005 Oct 15. 175(8):5448-56. [Medline].
Fae KC, Oshiro SE, Toubert A, et al. How an autoimmune reaction triggered by molecular mimicry between streptococcal M protein and cardiac tissue proteins leads to heart lesions in rheumatic heart disease. J Autoimmun. 2005 Mar. 24(2):101-9. [Medline].
Guilherme L, Fae K, Oshiro SE, Kalil J. Molecular pathogenesis of rheumatic fever and rheumatic heart disease. Expert Rev Mol Med. 2005 Dec 8. 7(28):1-15. [Medline].
Guilherme L, Ramasawmy R, Kalil J. Rheumatic fever and rheumatic heart disease: genetics and pathogenesis. Scand J Immunol. 2007 Aug-Sep. 66(2-3):199-207. [Medline]. [Full Text].
Karademir S, OGuz D, Senocak F, et al. Tolmetin and salicylate therapy in acute rheumatic fever: Comparison of clinical efficacy and side-effects. Pediatr Int. 2003 Dec. 45(6):676-9. [Medline].
Mukhopadhyay S, Varma S, Gade S, Yusuf J, Trehan V, Tyagi S. Regulatory T-cell deficiency in rheumatic heart disease: a preliminary observational study. J Heart Valve Dis. 2013 Jan. 22(1):118-25. [Medline].
Narula J, Virmani R, Reddy KS. Rheumatic Fever. American Registry of Pathology. Washington, DC: 1999.
Swedo SE, Leonard HL, Garvey M, et al. A case of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Am J Psychiatry. 1998 Nov. 155(11):1592-8. [Medline].
Walker KG, Lawrenson J, Wilmshurst JM. Neuropsychiatric movement disorders following streptococcal infection. Dev Med Child Neurol. 2005 Nov. 47(11):771-5. [Medline].