1 NURALIEVA ALTYNAY TOPCHUBAEVNA
2 SOYAB SOYAB
1 LECTURER, INTERNATIONAL MEDICAL FACULTY, OSH STATE UNIVERSITY, OSH KYRGYZ REPUBLIC.
2 STUDENT, INTERNATIONAL MEDICAL FACULTY, OSH STATE UNIVERSITY, OSH KYRGYZ REPUBLIC.
Abstract
Rheumatic fever is a systemic inflammatory disease that develops as a delayed autoimmune complication following infection with Group A β-hemolytic Streptococcus, particularly streptococcal pharyngitis. It remains a major public health problem in developing countries and contributes significantly to acquired cardiovascular morbidity among children and young adults. The present retrospective observational review aimed to evaluate the epidemiology, clinical manifestations, diagnostic criteria, complications, and management outcomes of rheumatic fever among pediatricand adolescent patients attending tertiary healthcare centers. Data from 150 patients diagnosed according to the revised Jones criteria over a five-year period were analyzed using hospital records, laboratory findings, echocardiographic reports, and treatment outcomes. The majority of patients belonged to the 5–15 years age group, with a slight male predominance. Fever, migratory polyarthritis, carditis, and elevated inflammatory markers were the most common findings. Mitral valve involvement was the predominant cardiac lesion detected on echocardiography. Elevated antistreptolysin-O titers and positive throat cultures supported recent streptococcal infection in most cases. Penicillin therapy, anti-inflammatory treatment, and long-term secondary prophylaxis formed the cornerstone of management. Early diagnosis and adherence to secondary prophylaxis significantly reduced recurrence and progression to rheumatic heart disease. Despite advances in healthcare, rheumatic fever continues to impose a substantial burden in low- and middle-income countries due to poverty, overcrowding, and inadequate access to healthcare services. Improved awareness, early treatment of streptococcal pharyngitis, and public health interventions are essential for prevention and reduction of disease burden.
Keywords
• Rheumatic Fever
• Rheumatic Heart Disease
• Streptococcal Pharyngitis
• Jones Criteria
• Carditis
• Group A Streptococcus
Introduction
Rheumatic fever (RF) is an acute, immune-mediated inflammatory disease that occurs following untreated or inadequately treated infection with Group A β-hemolyticStreococcus (GAS), mainly Streptococcus pyogenes. It primarily affects children and adolescents between 5 and 15 years of age and remains one of the leading causes of acquired heart disease in developing countries.
The disease develops due to molecular mimicry between streptococcal antigens and human tissues, resulting in autoimmune inflammation affecting the heart, joints, skin, and central nervous system. Rheumatic fever may progress to rheumatic heart disease (RHD), characterized by permanent valvular damage, especially involving the mitral and aortic valves.
Globally, approximately 39 million people are estimated to be living with rheumatic heart disease, with the highest burden occurring in South Asia, Sub-Saharan Africa, and Pacific regions. The incidence of acute rheumatic fever has declined substantially in developed countries because of improved living conditions and antibiotic therapy; however, it continues to pose major health challenges in low-resource settings.
Risk factors include overcrowding, poverty, malnutrition, limited healthcare access, and recurrent streptococcal infections. Delayed diagnosis and poor adherence to secondary prophylaxis contribute significantly to recurrent attacks and chronic valvular complications.
The diagnosis of rheumatic fever is primarily clinical and based on the revised Jones criteria, which incorporate major and minor manifestations along with evidence of preceding streptococcal infection. Major manifestations include carditis, migratory polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.
Early diagnosis and treatment are crucial to prevent progression to rheumatic heart disease and long-term cardiovascular complications.
The objectives of this study are:
1. To evaluate the demographic and clinical profile of patients with rheumatic fever.
2. To analyze laboratory and echocardiographic findings associated with the disease.
3. To assess management strategies and outcomes.
4. To highlight preventive measures and the importance of secondary prophylaxis.
Methodology
Study Design
A retrospective observational review study was conducted using hospital-based medical records and relevant published literature regarding rheumatic fever.
Study Population
The study included pediatric and adolescent patients diagnosed with rheumatic fever in tertiary healthcare institutions between January 2020 and December 2024.
Inclusion Criteria
• Patients diagnosed according to revised Jones criteria
• Age between 5 and 18 years
• Evidence of preceding streptococcal infection
• Complete clinical and laboratory records available
Exclusion Criteria
• Congenital heart disease
• Autoimmune arthritis unrelated to rheumatic fever
• Infective endocarditis
• Incomplete medical records
Sample Size
A total of 150 patients were included in the study for analysis.
Data Collection Methods
Data were collected from:
• Pediatric and cardiology department records
• Echocardiography reports
• Laboratory investigations
• Discharge summaries and follow-up records
The following variables were recorded:
• Age and gender distribution
• Clinical manifestations
• Laboratory findings
• Echocardiographic abnormalities
• Treatment modalities
• Complications and recurrence rates
Statistical Analysis
Data were entered into Microsoft Excel and analyzed using SPSS software version 25. Descriptive statistics including frequencies, percentages, mean, and standard deviation were used.
Ethical Considerations
Institutional ethical committee approval was obtained before the study. Patient confidentiality and anonymity were maintained according to the Declaration of Helsinki principles.
Results
Demographic Characteristics
Table 1: Age and Gender Distribution of Patients (n=150)
| Age Group (Years) | Male | Female | Total |
| 5–10 | 42 | 36 | 78 |
| 11–15 | 30 | 24 | 54 |
| 16–18 | 10 | 8 | 18 |
| Total | 82 | 68 | 150 |
Most patients belonged to the 5–10 years age group with slight male predominance.
Clinical Manifestations
Table 2: Clinical Features of Rheumatic Fever
| Clinical Feature | Number | Percentage |
| Fever | 130 | 86.6% |
| Migratory Polyarthritis | 112 | 74.6% |
| Carditis | 90 | 60% |
| Chorea | 18 | 12% |
| Subcutaneous Nodules | 10 | 6.6% |
| Erythema Marginatum | 6 | 4% |
Fever and migratory polyarthritis were the most common clinical manifestations.
Laboratory Findings
Table 3: Laboratory Investigations
| Investigation | Positive/Abnormal Cases | Percentage |
| Elevated ESR | 120 | 80% |
| Elevated CRP | 110 | 73.3% |
| Raised ASO Titer | 125 | 83.3% |
| Positive Throat Culture | 72 | 48% |
| Leukocytosis | 85 | 56.6% |
Raised antistreptolysin-O titers were observed in the majority of patients.
Echocardiographic Findings
Table 4: Cardiac Valve Involvement
| Valve Lesion | Number | Percentage |
| Mitral Regurgitation | 58 | 38.6% |
| Aortic Regurgitation | 20 | 13.3% |
| Combined Mitral and Aortic Lesions | 12 | 8% |
| No Cardiac Involvement | 60 | 40% |
Mitral regurgitation was the most common echocardiographic abnormality.
Treatment Modalities
Table 5: Treatment Approaches
| Treatment | Number | Percentage |
| Penicillin Therapy | 150 | 100% |
| NSAIDs/Aspirin | 120 | 80% |
| Corticosteroids | 45 | 30% |
| Secondary Prophylaxis | 140 | 93.3% |
| Heart Failure Management | 18 | 12% |
All patients received antibiotic therapy targeting streptococcal infection.
Discussion
Rheumatic fever remains a major cause of cardiovascular morbidity among children and young adults in developing countries despite substantial reduction in incidence in developed nations.The present study demonstrated that the disease predominantly affected children aged 5–15 years, which is consistent with global epidemiological data.
The pathogenesis of rheumatic fever involves an autoimmune response triggered by molecular mimicry between streptococcal M proteins and human tissue antigens. Antibodies directed against streptococcal antigens cross-react with cardiac myosin, synovial tissue, and neuronal tissue, leading to multisystem inflammation.
Migratory polyarthritis was the most common major manifestation observed in this study. Rheumatic arthritis typically affects large joints such as knees, ankles, elbows, and wrists and demonstrates dramatic response to salicylates.Similar findings have been reported in previous pediatric studies.
Carditis was identified in 60% of patients and remains the most serious manifestation because it can lead to chronic rheumatic heart disease. Pancarditis involving the endocardium, myocardium, and pericardium may occur during the acute phase. Mitral regurgitation was the most frequent valvular lesion observed, consistent with established literature.
Sydenham chorea occurred in a smaller proportion of patients. It results from autoimmune involvement of the basal ganglia and may present weeks to months after streptococcal infection.Emotional lability and involuntary movements are characteristic features.
Elevated ESR, CRP, and ASO titers reflected active inflammation and recent streptococcal infection. ASO titersremain one of the most commonly used serological markers in diagnosis. However, throat cultures may be negative because the primary infection often resolves before onset of rheumatic fever.
The revised Jones criteria remain the cornerstone of diagnosis. Recent updates emphasize the role of Doppler echocardiography in detecting subclinical carditis, especially in high-risk populations.
Penicillin remains the drug of choice for eradication of streptococcal infection. Long-term benzathine penicillin prophylaxis is essential to prevent recurrent attacks and progression to rheumatic heart disease. Poor compliance with secondary prophylaxis is strongly associated with recurrence and worsening valvular disease.
Anti-inflammatory therapy using aspirin or NSAIDs effectively reduces joint inflammation and fever.Corticosteroids are reserved for severe carditis and heart failure.
Public health measures including improved hygiene, early treatment of streptococcal pharyngitis, reduction of overcrowding, and school-based screening programs are crucial preventive strategies. The persistence of rheumatic fever in low-income regions reflects inequalities in healthcare access and socioeconomic conditions.
Suggestions / Recommendations
• Early diagnosis and treatment of streptococcal pharyngitis should be emphasized in primary healthcare settings.
• School-based screening programs should be implemented in high-risk populations.
• Long-term secondary prophylaxis with benzathine penicillin should be strictly monitored.
• Public health education regarding sore throat management and hygiene practices should be promoted.
• Echocardiographic screening should be encouraged for early detection of subclinical carditis.
• Improved access to healthcare facilities in rural and underserved regions is necessary.
• Further multicenter prospective studies are recommended to evaluate long-term outcomes and vaccine development.
• Healthcare workers should receive regular training regarding updated Jones criteria and management protocols.
Conclusion
Rheumatic fever is a preventable autoimmune inflammatory disease that continues to cause substantial morbidity among children and adolescents in developing countries. Fever, migratory polyarthritis, and carditis are the most common clinical manifestations, while mitral valve involvement remains the predominant cardiac lesion. Diagnosis is primarily based on the revised Jones criteria supported by laboratory and echocardiographic findings. Early antibiotic therapy, anti-inflammatory treatment, and long-term secondary prophylaxis are essential to prevent recurrent attacks and progression to rheumatic heart disease. Public health interventions focusing on early streptococcal infection treatment, improved living conditions, and awareness programs are crucial in reducing disease burden.
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