The consequence of the first attack of acute rheumatic fever with subclinical carditis




Rheumatic fever, Rheumatic heart disease, Subclinical carditis, Echocardiography


Background: Immune mediated damage of RF occurs most prominently in the heart, joints, brain, skin and subcutaneous tissues, however RF leaves no lasting damage to the brain, joint or skin, it is the leading cause of acquired heart disease in children and adolescents worldwide, therefore carditis is the most important manifestation of RF. Echocardiography along with color; Doppler imaging is now worldwide used for early detection of cardiac involvement even in the absence of clinical evidence, which in this case is called subclinical carditis (SCC) and was reported to cause similar consequences to clinically evident carditis.

Methods: A retrospective study carried out on 35 patients already diagnosed to have RF and subclinical RHD and attending the cardiology clinic at Alexandria University Children’s Hospital (AUCH) from December 2015 to November 2016. Data collected from patients' files and then appropriately updated during subsequent follow-up visits.

Results: 35 children already diagnosed to have RF and subclinical RHD were included in the current study, 22 patients (66.6%) improved completely with no residual cardiac lesion, 10 patients (30.3%) had persistent lesion and one patient (3.1%) had worsened condition.

Conclusions: The most important predictors of poor prognosis according to the current study were recurrence and lack of regular compliance to long acting penicillin (LAP). Furthermore the outcome was not influenced by the treatment given in the initial attack.


Tani LY. Rheumatic fever and rheumatic heart disease in: Allen HD, Driscoll DJ, Shaddy RE, eds.Moss and Adams’ heart diseases in infant, children and adolescent. 7th ed. Baltimor: WolterKluwev; 2008: 1290-1320.

Rothenbühler M, O'Sullivan CJ, Stortecky S, Stefanini GG, Spitzer E, Estill J, et al. Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta-analysis of prevalence among children and adolescents. Lancet Glob Health. 2014;2(12):717-26.

Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005;366(9480):155-68.

Kassem AS, Rasmia Z, Zaher SR. Rheumatic fever and rheumatic heart disease in Alexandria, Egypt: Present status. Egypt Heart J. 1995;47:129-36.

Kassem AS, Zaher SR. An international comparison of the prevalence streptococcal infections and rheumatic fever in children. Pediatr Ann. 1992;21(12):835, 839-42.

Kumar RK, Rammohan R, Narula J, Kaplan E. Epidemiology of streptococcal pharyngitis, rheumatic fever, and rheumatic heart disease. In: Narula J, Virmani R, Reddy KS, Tandon R, eds.Rheumatic Fever. Washington, DC: American Registry of Pathology; 1999: 41-68.

Bisno AL. Group A streptococcal infections and acute rheumatic fever. New Engl J Med. 1991;325(11):783-93.

Pruksakorn S, Currie B, Brandt E, Phornphutkul C, Hunsakunachai S, Manmontri A, et al. Identification of T cell autoepitopes that cross-react with the C-terminal segment of the M protein of group A streptococci. Int Immunol. 1994;6(8):1235-44.

WHO. Rheumatic Fever and Rheumatic Heart Disease: Report of a WHO Expert Consultation, Geneva, 2001. Geneva: World Health Organization; 2004.

Tubridy-Clark M, Carapetis JR. Subclinical carditis in rheumatic fever: A systematic review. Int J Cardiol. 2007;119(1):54-8.

Narula J, Kaplan, EL. Echocardiographic diagnosis of rheumatic fever. Lancet. 2001;358:20002010.

Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease: an evidence-based guideline. Nat Rev Cardiol. 9(5):297-309.

Beg A, Sadiq M. Subclinical valvulitis in children with acute rheumatic fever. Pediatr Cardiol. 2008;29(3):619-23.

Nair B, Viswanathan S, Koshy AG, Gupta PN, Nair N and Thakkar A. Rheumatic heart disease in Kerala: a vanishing entity? An echo Doppler study in 5-15 years-old school children. Int J Rheumat. 2015;14:930790.

Paar JA, Berrios NM, Rose JD, Cáceres M, Peña R, Pérez W, et al. Prevalence of rheumatic heart disease in children and young adults in Nicaragua. Am J Cardiol. 2010;105(12):1809-14.

Sahin M, Yildirim I, Özkutlu S, Alehan D, Özer S, Karagözet T. Clinical features and mid-and long-term outcomes of pediatric patients with subclinical carditis. Turk J Pediatr. 2012;54(5):486-92.

da Rocha Araújo FD, de Andrade Goulart EM, Meira ZM. Use of Doppler echocardiography to support the decision to discontinue secondary prophylaxis for patients with rheumatic fever and normal cardiac auscultation. Pediatr Cardiol. 2013;34(5):1073-80.

Ozdemir O, Işık S, Abacı A, Hizli S, Akelma Az, Kislal F, et al. Silent enemy in acute rheumatic fever: subclinical carditis. Turk Kardiyoloji Dern Ars. 2011;39(1):41-6.

Bhaya M, Beniwal R, Panwar S, Panwar RB. Two years of follow-up validates the echocardiographic criteria for the diagnosis and screening of rheumatic heart disease in asymptomatic populations. Echocardiography. 2011;28(9):929-33.

Saxena A, Ramakrishnan S, Roy A. Prevalence and outcome of subclinical rheumatic heart disease in India: The RHEUMATIC (Rheumatic Heart Echo Utilisation and Monitoring Actuarial Trends in Indian Children) study. Heart. 2011;97(24):2018-22.

Beaton A, Okello E, Aliku T, Lubega S, Lwabi P, Mondo C, et al. Latent rheumatic heart disease: outcomes 2 years after echocardiographic detection. Pediatr Cardiol. 2014;35(7):1259-67.

Zühlke L, Engel ME, Lemmer CE, van de Wall M, Nkepu S, Meiring A, et al .The natural history of latent rheumatic heart disease in a 5 year follow-up study: a prospective observational study. BMC Cardiovascular Disorders. 2016;16:46.

Wilson NJ, Voss L, Morreau J, Stewart J, Lennon D. New Zealand guidelines for the diagnosis of acute rheumatic fever: small increase in the incidence of definite cases compared to the America Heart Association Jones criteria. N Z Med J. 2013;126(1379):50-9.

Figueroa FE, Fernández MS, Valdés P, Wilson C, Lanas F, Carrión F, et al. Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease. Heart. 2001;85(4):407-10.

Cann MP, Sive AA, Norton RE, McBride WJ, Ketheesan N. Clinical presentation of rheumatic fever in an endemic area. Arch Dis Child. 2010;95:455-7.

Meira ZM, Goulart EM, Colosimo EA, Mota CC. Long term follow up of rheumatic fever and predictors of severe rheumatic valvar disease in Brazilian children and adolescents. Heart. 2005;91(8):1019-22.

Karaaslan S, Demirören S, Oran B, Baysal T, Başpinar O, Uçar C. Criteria for judging the improvement in subclinical rheumatic valvitis. Cardiol Young. 2003;13(6):500-5.

Caldas AM, Terreri MT, Moises VA, Silva CM, Len CA, Carvalho AC, et al. What is the true frequency of carditis in acute rheumatic fever? A prospective clinical and Doppler blind study of 56 children with up to 60 months of follow-up evaluation. Pediatr Cardiol. 2008;29(60:1048-53.

Lanna CC, Tonelli E, Barros MV, Goulart EM, Mota CC. Subclinical rheumatic valvitis: a long-term follow-up. Cardiol Young. 2003;13(5):431-8.

Vijayalakshmi IB, Mithravinda J, Deva AN. The role of echocardiography in diagnosing carditis in the setting of acute rheumatic fever. Cardiol Young. 2005;15(6):583-8.

Ozer S, Hallioğlu O, Ozkutlu S, Celiker A, Alehan D, Karagöz T. Childhood acute rheumatic fever in Ankara, Turkey. Turk J Pediatr. 2005;47(2):120-4.

Ozkutlu S, Ayabakan C, Saraclar M. Can subclinical valvitis detected by echocardiography be accepted as evidence of carditis in the diagnosis of acute rheumatic fever? Cardiol Young. 2001;11(3):255-60.

Ozkutlu S, Hallioglu O, Ayabakan C. Evaluation of subclinical valvar disease in patients with rheumatic fever. Cardiol Young. 2003;13(6):495-9.

Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al. American Heart Association Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease of the Council on Cardiovascular Disease in the Young. Revision of the Jones criteria for the diagnosis of the rheumatic fever in the era of Doppler echocardiography: a scientific statement of the American Heart Association. Circulation. 2015;131(20):1806-18.

Eroğlu AG. Acute rheumatic fever 2015 Jones criteria. Turk Pediatri Ars 2016;51(1):1-7.




How to Cite

Heiba, D. A.-M. (2019). The consequence of the first attack of acute rheumatic fever with subclinical carditis. International Journal Of Community Medicine And Public Health, 6(8), 3203–3210.



Original Research Articles