Initial clinical pattern of rheumatic fever in children hospitalized at Prapokklao Hospital.

Abstract

Objective : To review initial clinical pattern of children who presented with rheumatic fever.

Methods : From July 1995 through 2003, the patients who were under 15 years old and hospitalized with a diagnosis of rheumatic fever were included in this study.Their medical records were reviewed in terms of age, sex, reasons for hospitalization, initial clinical manifestation, results of complete white blood cell count, erythrocyte sedimentation rate, C-reactive protein, ASO-titer,throat swab culture, chest roentgenogram, electrocardiogram and color flow Doppler echocardiography. The results were presented by descriptive statistics.

Results : Of 46 patients with rheumatic fever, 26 were male and 20 were female; 35 (76.1 percent) were older than 9 years, 10 (21.7 percent) were between 5 and 9 years of age and 1 (2.2 percent) was under 5 years of age. There were 42 first-attack cases and 4 recurrent cases. The age range was 4.6-14.8 years (mean 11.4 ± 2.4). The reasons for hospitalization of most patients were cardiac symptoms and abnormal movement of the extremities (chorea).The overall number of the individual manifestation of major Jones criteria at presentation were carditis in 42 cases (91.3 percent), chorea in 11 cases (23.9 percent), and polyarthritis in 6 cases (13.0 percent). There were no cases presenting with subcutaneous nodules or erythema marginatum. Among the 42 cases who had clinical evidence of carditis, there were various types of cardiac involvement. Mitral valve involvement was found in all of the cases,in which regurgitation was the most common defect (97.6 percent). Aortic and tricuspid regurgitation were found in 21 cases (50.0 percent) and 19 cases (45.2 percent) respectively. Mitral stenosis occurred in 3 cases (7.2 percent) and all of them had history of recurrent attacks. Of the 42 patients with carditis,cardiomegaly and varying extent of congestive heart failure were found in 32 cases and 30 cases respectively. In addition, there were 3 cases with flail mitral leaflet, 2 cases with pericardial effusion and 1 case with prolapse of both aortic and mitral valves. Elevated ESR (100 percent), fever (88.2 percent), positive C-reactive protein (81.5 percent), leucocytosis (76.5 percent), rising ASO titer (70.6 percent), sinus tachycardia (90.3 percent) and left atrial enlargement(51.6 percent) were the minor Jones criteria and laboratory results commonly found among the cardiac symptom-presenting patients.

Conclusions : The clinical pattern of rheumatic fever in this study was based on forty-six children hospitalized between July 1995 and August 2003. They were mostly over 5 years old. Carditis was the most common major Jones criterion, followed by chorea and arthritis. Several patterns and varying severity of cardiac involvement, findings of minor Jones criteria and abnormalities in EKG tracings were more common in cardiac symptompresenting patients than in chorea-presenting patients.