Can rheumatic fever occur for the first time in older adults?

Rheumatic Fever Can Occur for the First Time in Older Adults

Yes, rheumatic fever can occur for the first time in older adults, although it is much less common than in children and young adults. Evidence from clinical studies shows that approximately 39% of adults with an average age of 56 years can experience their initial attack of acute rheumatic fever 1.

Epidemiology and Risk Factors

• Primary occurrence of rheumatic fever is most common in children aged 5-15 years 2
• In adults over 45 years, rheumatic fever can present as either:
  • First-time occurrence (39% of cases) 1
  • Recurrence after a long latent period (average interval of 20.5 years between attacks) 1
• Risk factors specific to older adults include:
  • Contact with young children (significant predisposing factor) 1
  • Overcrowding and poor socioeconomic conditions 2
  • Exposure to group A streptococcal infections in high-risk settings

Clinical Presentation in Older Adults

The clinical presentation of rheumatic fever differs between adults and children:

• In adults over 45 years:

  • Arthritis (83%) and carditis (35%) are the predominant major criteria 1
  • All patients typically present with at least 3 minor criteria 1
  • Laboratory findings include elevated ESR (>50 mm/hr), anemia (70%), hyperglobulinemia (70%), and urinary sediment abnormalities (66%) 1

• In contrast to children:

  • Chorea, erythema marginatum, and subcutaneous nodules are rare in adults 1
  • Diagnosis may be more challenging due to atypical presentation

Diagnosis

Diagnosis of rheumatic fever in adults follows the modified Jones Criteria but requires heightened awareness:

• Evidence of preceding group A streptococcal infection is essential 3
• Throat culture remains the gold standard for diagnosis of group A streptococcal pharyngitis 4
• In adults with pre-existing rheumatic heart disease, unexplained cardiac deterioration should prompt investigation for acute rheumatic fever 1

Management and Prevention

1. Primary Prevention:

   • Proper identification and adequate antibiotic treatment of group A streptococcal pharyngitis 4
   • Full 10-day course of penicillin is required to prevent acute rheumatic fever 4

2. Secondary Prevention:

   • Continuous antimicrobial prophylaxis is essential for patients with a history of rheumatic fever 3
   • Duration depends on presence of carditis and residual heart disease:
     • With carditis and residual heart disease: 10 years or until age 40 (whichever is longer) 3
     • With carditis but no residual heart disease: 10 years or until age 21 (whichever is longer) 3
     • Without carditis: 5 years or until age 21 (whichever is longer) 3

3. Antibiotic Options for Secondary Prevention:

   • Penicillin G benzathine: 1.2 million units intramuscularly every 4 weeks 3
   • Penicillin V potassium: 250 mg orally twice daily 3
   • Sulfadiazine: 1 g orally once daily 3
   • Macrolide or azalide antibiotics for penicillin-allergic patients 3

Prognosis in Older Adults

The prognosis for older adults with first-time rheumatic fever is generally favorable:

• Response to treatment is typically good 1
• Only 1 in 13 patients developed a new valvular lesion in follow-up studies 1
• Death in the acute episode is rare and occurs only in patients with severe pre-existing valvular disease with congestive failure 1

Clinical Implications

Clinicians should maintain a high index of suspicion for rheumatic fever in older adults presenting with unexplained arthritis and cardiac symptoms, particularly when there is a history of contact with young children or evidence of recent streptococcal infection. Although less common than in children, prompt diagnosis and appropriate management can prevent long-term cardiac complications.