What follow-up is needed in adulthood for a patient with a history of Acute Rheumatic Fever (ARF) in childhood?

From the Guidelines

Adults with a history of rheumatic fever in childhood require lifelong cardiac follow-up, primarily focusing on monitoring for valvular heart disease, with the most recent guidelines suggesting that patients with rheumatic heart disease should continue prophylaxis for at least 10 years after the last episode or until age 40 (whichever is longer) 1. The follow-up care should include regular clinical evaluations with a cardiologist, including echocardiograms to assess valve function, particularly the mitral and aortic valves which are commonly affected.

• The frequency of these evaluations typically ranges from annual to every 2-5 years, depending on the presence and severity of any cardiac involvement.
• Secondary prophylaxis with antibiotics is crucial for those with evidence of rheumatic heart disease to prevent recurrent episodes of rheumatic fever.
• This typically involves penicillin G benzathine 1.2 million units intramuscularly every 3-4 weeks, or daily oral penicillin V 250 mg twice daily, or sulfadiazine 1 g daily, or erythromycin 250 mg twice daily for penicillin-allergic patients. The duration of prophylaxis depends on several factors, including the presence of residual heart damage (valvular disease) and the patient's risk of exposure to streptococcal infections.
• Patients who have had rheumatic carditis, with or without valvular disease, are at a relatively high risk for recurrences of carditis and are likely to sustain increasingly severe cardiac involvement with each recurrence.
• For patients without persistent valvular disease, prophylaxis should continue for 10 years or until the patient is 21 years of age, whichever is longer 1. Additionally, all patients require antibiotic prophylaxis before dental or invasive procedures to prevent infective endocarditis if they have residual valve damage. This vigilant follow-up is necessary because rheumatic fever can cause progressive valve damage even decades after the initial illness, as highlighted by the World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Bicillin L-A and other antibacterial drugs, Bicillin L-A should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria Medical Conditions in which Penicillin G Benzathine Therapy is indicated as Prophylaxis: Rheumatic fever and/or chorea—Prophylaxis with penicillin G benzathine has proven effective in preventing recurrence of these conditions. It has also been used as follow-up prophylactic therapy for rheumatic heart disease and acute glomerulonephritis. Following an acute attack, penicillin G benzathine (parenteral) may be given in doses of 1,200,000 units once a month or 600,000 units every 2 weeks.

The follow-up needed in adulthood for a history of rheumatic fever in childhood is prophylaxis with penicillin G benzathine to prevent recurrence of rheumatic fever and/or chorea, and as follow-up prophylactic therapy for rheumatic heart disease and acute glomerulonephritis. The recommended dosage is 1,200,000 units once a month or 600,000 units every 2 weeks 2 2.

• Key points:
  • Prophylaxis with penicillin G benzathine is effective in preventing recurrence of rheumatic fever and/or chorea
  • Follow-up prophylactic therapy is also used for rheumatic heart disease and acute glomerulonephritis
  • Recommended dosage: 1,200,000 units once a month or 600,000 units every 2 weeks

From the Research

Follow-up in Adulthood for Rheumatic Fever in Childhood

• Regular follow-up is necessary for individuals with a history of rheumatic fever in childhood to monitor for potential cardiac complications, such as rheumatic heart disease (RHD) 3, 4.
• The follow-up should include regular echocardiography and/or color Doppler to assess cardiac valvular function and detect any potential problems early on 3, 5.
• Patients with a history of rheumatic fever should also receive regular benzathine penicillin prophylaxis to prevent recurrent infections and reduce the risk of developing RHD 3, 6.
• In addition to medical follow-up, patients with RHD may require surgical intervention, such as valvular repair or replacement, to manage severe valve disease 4, 7.
• Ongoing research is focused on developing new diagnostic and therapeutic strategies, including immunotherapy and vaccine development, to improve outcomes for individuals with rheumatic fever and RHD 4, 6.

Key Considerations

• Regular follow-up and adherence to prophylactic treatment are crucial to preventing long-term cardiac complications 3, 6.
• Access to specialized care and surgical intervention can be limited in regions with high prevalence of rheumatic fever and RHD, highlighting the need for improved healthcare infrastructure and access to care 7, 5.
• Ongoing education and awareness efforts are necessary to ensure that individuals with a history of rheumatic fever are aware of the potential risks and benefits of follow-up care 6, 5.