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Rapid Responses: Rapid Responses published:
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Why not adding Bryonia ?
- harold j. bueno de mesquita (19 September 2003)
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How long do we need to treat with steroids ?
- Oommen John (19 September 2003)
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rheumatic fever as of now.
- manan vasenwala (19 September 2003)
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Need for Prevention of Acute Rheumatic Fever
- Anil Pandit (20 September 2003)
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Frustruations galore!
- Vijayashankara.c nanjegowda (21 September 2003)
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Treating recurrent rheumatic fever
- Friedrich Flachsbart (24 September 2003)
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Steroids and Rheumatic Fever
- Joseph F Cosgrove (30 September 2003)
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High doses of intravenous methylprednisolone is not better than oral corticosteroid to treat severe rheumatic carditis.
- Edmundo J Camara, Braga J, Alves-Silva, LS, Camara GF, Lopes AAS (31 October 2003)
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Why not Absolute Bed Rest For Acute Rheumatic Fever?
- Munir E Nassar, M.D., Ph.D. (11 January 2004)
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Acute Rheumatic Fever and Antiphospholipid Antibody Syndrome!
- Friedrich Flachsbart (2 February 2004)
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harold j. bueno de mesquita, family-physician JERUSALEM 93384
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Dear Sir, With so much doubt what is good or not,I would again suggest to look a liitle bit further,to the experience of other excellent clinicians,even if the "miracle-word" evidence based medicine may not be applicable here[yet] Well ,there has been ,as it seems,enough evidence for the late Dr.A. Vrijlandt from Holland to write the following:[translated by me from the Dutch]:" Whoever heals an acute rheumatic fever with Bryonia,does not have to fear for heart complications" Personally I can't judge this statement,but I do advise any patient,especially when there is rheumatic fever in the near family,to take with the slightest cold [and/or a minimal sore throat] Bryonia for a few days,as a homeopathic dilution [in the order of D6]. I also think that it has been shown by Dutch workers that rheumatic fever virtually always shows up after subclinical infections and virtually never after clear [fulminant] thraot infections. again,one has nothing to loose!! I think it is due time to add Bryonia to a clinical study,for those who does not respect the experience of other doctors,with a good name. Competing interests: None declared |
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Oommen John, Consultant Research Resource Centre, The Leprosy Mission, New Delhi 110 003.
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Dr. Cilliers has brought out the need for further research on the role of cortico-steroids and other non steroidal anti inflammatory agents in the prevention of carditis in Acute Rheumatic Fever. Despite pathologic evidence of myocardial inflammation, the significance of myocarditis in children with acute rheumatic carditis remains controversial1. It is this myocardial inflammation that is aimed at while using steroids. It is well established that valular lesions as a sequale to Acute Rheumatic Fever occurs aleast a decade later, so the duration of treatment with steroids may influence the outcome. Most of the Randomised control trails mentioned in the editorial have a treatment period ranging from 4-6 weeks, however if there is an ongoing inflammation that is “autoimmune” in nature ,there may be substantial benefit by prolonging the duration of treatment with steroids. Only few multi centric randomized clinical trials using varying does and duration of treatment with stereiods or NSIADs may help in establishing the real benefit. Dr Oommen John MD References: 1. Williams RV, Minich LL, et al. Evidence for lack of myocardial injury in children with acute rheumatic carditis. Cardiol Young. 2002 Dec;12(6):519-23. Competing interests: None declared |
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manan vasenwala, consultant-cardiologist (non-invasive) k.k.heart center, aligarh-202002.india
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it is true, despite a decade having gone by, the treatment of rheumatic fever remains empirical. it is not known which is better: steroids or aspirin. both modes of treatment brings about symptomatic relief without affecting the underlying disease which is self limiting till the next attack of rheumatic fever.the only consensus is in perhaps use of steroids in the presence of carditis with heart failure. here steroids either reduce the degree of inflammation or retard its progression. the minority view is that heart failure is secondary to vulvular disruption rather than myocarditis thus diminishing role of myocarditis per se in rheumatic carditis- it being more of endocarditis and pericarditis, rather than pan-carditis. also novel treatment with intravenous imunoglobulins did not alter the natural history of acute rheumatic fever.(1) on the positive side, the diagnostic work up for rheumatic fever is well established. the 1992 update on jones criteria is in this direction.(2) the current jones criteria is exclusively for acute attack of rheumatic fever and not recurrent rheumatic fever. also on the up-side is the recognition that arthritis may only involve a single joint(3) (labelled as arthralgia in the minor criteria). this has removed the main cause of under-diagnosis of rheumatic fever.further, over zealous use of salicylates by physicians for arthritis before establishing rheumatic fever can mask poly-arthritis and make itresemble a monoarthritis, a factor needed to be taken into account. echocardiography is also playing an important role in carditis with vulvular involvement. doppler is more sensitive than the human ear in detecting vulvular incompetence which is an important ingredient for diagnosis of carditis.Color flow Doppler imaging is a useful method of identifying subclinical mitral and aortic valvar disease at all stages of rheumatic fever when carditis cannot be otherwise detected clinically.(4) In some patients with arthritis with a high ASO titre do not meet jones criteria. this has been named post-streptococcal reactive arthritis(psra).(5)this condition does not respond dramatically to aspirin, has a prolonged course without any cardiac effects. whether rheumatic prophylaxis is needed in these cases in not known. finally, and most important, not mentioned in this article inadvertantly, is the role of rheumatic prophylaxis.one controversy is the dose of benzathine penicillin. there are cases where rheumatic fever has recurred despite rheumatic prophylaxis. there is a suggestion to reduce interval of penicillin to two weeks rather than four.(6) we currently follow a compromise of three weeks regimen. for how long should prophylaxis be continued is another thorny issue.current recommendations are 5yrs or till age 21yrs for simple rheumatic fever, rheumatic fever with carditis but no residual valve disease 10yrs, rheumatic fever with carditis and residual valve disease atleast 10yrs, or till 40yrs or even lifelong.(7). 1.Intravenous Immunoglobulin in Acute Rheumatic Fever : A Randomized Controlled Trial Circulation, Jan 2001; 103: 401 - 406. 2.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 Association JAMA, Oct 1992; 268: 2069 - 2073. 3.J R Carapetis and B J CurrieRheumatic fever in a high incidence population: the importance of monoarthritis and low grade fever.Arch. Dis. Child., Sep 2001; 85: 223 - 227. 4.GM Folger Jr, R Hajar, A Robida and HA Hajar Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour-flow Doppler identification. 5.JM Valtonen, S Koskimies, A Miettinen, and VV Valtonen. Various rheumatic syndromes in adult patients associated with high antistreptolysin O titres and their differential diagnosis with rheumatic fever.Ann. Rheum. Dis, Jul 1993; 52: 527 - 530. 6.AS Kassem, SR Zaher, H Abou Shleib, AG el-Kholy, AA Madkour, and EL Kaplan Rheumatic fever prophylaxis using benzathine penicillin G (BPG): two- week versus four-week regimens: comparison of two brands of BPG.Pediatrics, Jun 1996; 97: 992 - 995. 7.Dajani AS, Taubert k, Ferrieri P, et al: treatment of streptococcal phyaryngitis and prevention of rheumatic fever.paediatrics 96:758,1995. Competing interests: None declared |
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Anil Pandit, Resident MIDAT CLINIC, Langakhel , Patan, Nepal
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Acute Rheumatic fever is an important cause of acquired heart disease in developing countries where it is an endemic disease(1). It is well established fact that treatment regarding acute rheumatic fever and it's complications is very expensive one in developing and poor countries like Nepal with a gross national product of $220 per capita, and 45 per cent of the population living below the poverty line(2). In Nepal, the total amount of money spent by the government on each person health amounts to US $ 3 per year.(3) I totally agree with the author when he said further randomized controlled studies on treatment of acute rheumatic fever are warranted(4). However, I would like to stress that more research programs should be focussed for prevention and prophylaxis of acute rheumatic fever, which will substantially reduce the burden of morbidity and mortality of disease with infectious origin in country like ours. Dr Anil Pandit References: 1. Olivier C. Rheumatic fever—is it still a problem? J Antimicrob Chemother 2000;45(suppl 13): s13-21. 2. At a Glance: Nepal. UNICEF 2003, www.unicef.org 3. Budget of the Fiscal Year 2003/2004. Ministry of Finance, HMG, Nepal, 2003 4. Cillers A. Treating Acute Rheumatic fever. BMJ 2003;327:631-632 (20 September) Competing interests: None declared |
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Vijayashankara.c nanjegowda, professor of pediatrics SDUMC,Kolar,India. 563101
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Sir, Acute rheumatic fever with its cardiac complications has been a constant frustruating problem in India and other developing countries.Even after long years of research and with availability of various treatment modalities,there has been no decrease in the incidence of the disease.This is primarily due the poor living conditions and the lack of awreness for hygiene among the general population.Unless the governaments take appropriate actions,the treatment modalities alone will not help to bring down the misery of the people. Competing interests: None declared |
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Friedrich Flachsbart, General medicine 37085 Göttingen
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Dear Sir, acute rheumatic fever changed its pattern. We see ever and ever recurrent exacerbations of rheumatic fever. And we do not understand the pathogenesis. In my patients coagulation is the main problem. A possible link between the concept of autoimmunity and my concept of coagulation could be the Antiphospholipid Syndrome. In reaction to infection a thrombophilic state is induced. The prevalence in the general population is around 2-4 %. The correlation between the streptococci and this autoimmune-thrombophilia should be elucidated. Until we know more, penicillin and anticoagulation should be the treatment. Sincerely yours Friedrich Flachsbart Competing interests: None declared |
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Joseph F Cosgrove, Consultant in Anaesthesia and Adult Critical Care Freeman Hospital, Newcstle upon Tyne NE7 7DN
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Editor Dr Cillier discusses the pros and cons of steroid therapy in rheumatic fever (BMJ 2003; 327:631-632.) Similar debates are occuring re the role of steroids in sepsis and critical illness per se, with current usage of low dose steroid therapy being guided by the presence of low serum cortisol levels and/ or a poor response to a short synacthen test. Such patients have been noted to have poor outcomes. Could such methods be employed in determing whether or not to use steroids in the treatment of rheumatic fever? References. 1. Annane D, Sebille V et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002. 288(7). 862-871. 2. Carlet J. Steroid therapy during septic shock: a second birth? Advances in Sepsis. 2001. 1 (3). 93-6. [Review Article] 3. Ligtenberg JJM, Girbes ARJ, Beetjes JAM, et al. Hormones in the critically ill patient: to intervene or not? Intensive Care Medicine. 2001. 27: 1567-77. 4. Bourne R, Webbe S, Hutchinson S. Adrenal axis testing and corticosteroid replacement therapy in septic shock patients. Anaesthesia. 2003. 58. 6 591-6 5. Cooper MS, Stewart PM. Corticosteroid insufficiency inacutely ill patients. NEJM 2003; 348 (8):727-734. 6. Harry R, Auzinger G, Wendon J. The clinical importance of adrenal insufficiency inacute hepatic dysfunction. Hepatology 2002; 36: 395-402. Competing interests: None |
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Edmundo J Camara, M.D. Federal University of Bahia, Av. Reitor Miguel Calmon, s/n, Vale do Canela, 40.110-100, Salvador – B, Braga J, Alves-Silva, LS, Camara GF, Lopes AAS
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I have read this interesting Editorial about rheumatic fever treatment, written by Dr. Cilliers 1. Althought it has not been proved superiority of corticosteroids over aspirin to diminish lesions to the heart valves at follow-up, it seems to improve the short term prognosis and symptoms during severe acute rheumatic carditis, and the majority of cardiologists around the world, specially where the disease is frequent, usually treat that condition with corticosteroids. Dr. Cilliers mentioned that high dose methylprednisolone have been used to treat patients with acute rheumatic fever and that the outcomes have not been tested in a randomised and controlled manner. However, we have published a randomised study comparing high dose methylprednisolone with oral prednisone during severe acute rheumatic carditis in a Brazilian population 2. Using methylprednisolone (pulsetherapy) in the same manner and doses originally proposed by Couto et al. (1g per day, 3 consecutive days in the first and second weeks, 2 days in the third week and 1 day in the fourth week) 3 and prednisone in a dosage of 1.5mg/Kg/day, the therapeutic results were better in the prednisone group, according to NYHA functional class, heart rate, erythrocyte sedimentation rate, C-reactive protein, end-systolic left ventricular dimension and ejection fraction, reaching statistical significance. The groups were indeed similar and composed by children and teenagers (mean age/SD 11.1/3.7 y, range 4-18 y). This is the first randomised study comparing pulsetherapy with oral corticosteroid. In our opinion, the intermittence of pulsetherapy and the longer interval of days without medication between the pulses of methylprednisolone, may decrease the anti-inflammatory and immunomodulator effects, promoting only a partial control of the disease process. It is possible that pulsetherapy with intravenous high doses of methylprednisolone in association with oral corticosteroid could be beneficial to some patients, but it has not already been proved. Our data do not support the suggestion of using pulsetherapy with high doses endovenous methylprednisolone as the sole therapy insteady of oral corticosteroid to treat severe acute rheumatic carditis. References 1. Cilliers A. Treating acute rheumatic fever. BMJ 2003;327(7416):631 -632. 2. Camara EJ, Braga JC, Alves-Silva LS, Camara GF, da Silva Lopes AA. Comparison of an intravenous pulse of methylprednisolone versus oral corticosteroid in severe acute rheumatic carditis: a randomized clinical trial. Cardiol Young 2002;12(2):119-24. 3. Couto AA, Martins JCS, Mansur EM. Metilprednisolona em altas doses (pulsoterapia): possível solução terapeutica para a febre reumática ativa com cardite grave. Arquivos Brasileiros de Cardiologia 1984;43:97-101. Competing interests: None declared |
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Munir E Nassar, M.D., Ph.D., Consultant 17 Cobblefield Way, Pittsford, NY 14534 USA
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Dear Editor: Permit me to make a few comments on the Editorial: Treatment of Acute Rheumatic Fever, by Dr A. Cilliers, BMJ 2003, 327 631-632. Although Dr Cilliers has elucidated quite well the controversy between the use of Corticosteroids or aspirin in the treatment of Acute Rheumatic Fever and that neither treatment approach really does prevent adequately and convincingly sometimes the late complications of Rheumatic Fever. Here I am old fashioned, I would like to stress the importance of absolute bed rest from the onset and during the duration of treatment(aspirin or steroids) of the imflammatory process of acute rheumatic fever( Paul Wood, Diseases of the Heart and Circulation 2nd Ed. pages 491-492 Lippincot Publisher). Futhermore, the activity of the inflammation is best monitored by the sedimentation rate levels and not by antistreptolysin o titer x2 which shows after the fact, a delayed response that b hemolytic streptococcus throat infection is the culprit. Of course all of the above is after the diagnosis has been established by throat culture. Now I would like to emphasize that prevention of acute rheumatic fever is the main key to the whole problem: It is distressing to find that several young doctors do not treat acute b hemolytic streptococcus sore throat seriously by giving only 5 day or seven day course of penicillin, whereas the correct treatment is a full 10 day course of penicillin treatment started as quickly and efficiently without delay. For those allergic to penicillin, erythomycin is the stand by. Also, lest we forget over- crowding in the home environment and that other siblings may harbor acute or carrier state of b hemolytic streptocococcus throat infection and those should be attended to as well, because carriers may be the cause of recurrence of the activity of the rheumatic process. Competing interests: None declared |
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Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen
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Dear Sir, the Mayo Clinic treated a 29-year-old man with a third episode of acute rheumatic fever. They postulate "that rheumatic pancarditis created an inflammatory, thrombogenic environment that facilitated coronary artery thrombosis secondary to APS, a novel association". This association is not a novel association, it is the central truth of acute rheumatic fever! And ARF is still with us. Treat sore throat with penicillin 10 days long - and vasculitis will vanish! Sincerely Yours
Ishevsky D, Maple JT, Ommen SR: Acute myocardial infarction: an unusual culmination of rheumatic pancarditis and antiphospholipid antibody syndrome. J Intern Med. 2004;255:296-8 Miner LJ et al.; THE POST-STREPTOCOCCAL SYMDROME STUDY TEAM: Molecular characterization of Streptococcus pyogenes isolates collected during periods of increased acute rheumatic fever activity in Utah. Pediatr Inf Dis J. 2004;23:56-61 Competing interests: None declared |
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