Treatment of Acute Rheumatic Fever Mimicking Pericarditis
The treatment for acute rheumatic fever (ARF) that mimics pericarditis requires a full therapeutic course of penicillin to eradicate Group A Streptococcus (GAS), followed by continuous antimicrobial prophylaxis, and anti-inflammatory therapy for symptom relief. 1
Initial Treatment Approach
- A full therapeutic course of penicillin should be administered to eradicate residual GAS, even if throat culture is negative at the time of diagnosis 1
- For symptomatic relief of pericarditis symptoms, high-dose aspirin is recommended as first-line anti-inflammatory therapy 2, 3
- In cases with severe inflammation or cardiac involvement, corticosteroids such as prednisone may be considered at 1-2 mg/kg/day for 1-2 weeks 1
- Continuous antimicrobial prophylaxis should be initiated as soon as ARF is diagnosed to prevent recurrences 1
Antimicrobial Regimens
Eradication Therapy
- Oral penicillin V: 250 mg twice daily for children, 500 mg 2-3 times daily for adolescents/adults for 10 days 4
- For penicillin-allergic patients: erythromycin or first-generation cephalosporins (if no immediate-type hypersensitivity) 4
Secondary Prophylaxis
- Intramuscular benzathine penicillin G: 1,200,000 units every 4 weeks (preferred regimen) 1, 5
- In high-risk populations or those with recurrences despite adherence to the 4-week regimen, administration every 3 weeks may be considered 1, 4
- For patients with non-severe or immediate penicillin hypersensitivity: oral erythromycin twice daily 6
Duration of Prophylaxis
The duration of prophylaxis depends on the presence of cardiac involvement:
- Patients with rheumatic carditis and residual heart disease: 10 years after the last episode or until 40 years of age (whichever is longer), sometimes lifelong 1
- Patients with rheumatic carditis but no residual heart disease: 10 years or until 21 years of age (whichever is longer) 1
- Patients without carditis: 5 years or until 21 years of age (whichever is longer) 1
Special Considerations for Pericarditis
- Echocardiography should be performed to assess for valvular involvement, as pericarditis may be part of a broader cardiac involvement 3, 7
- Anti-inflammatory treatment with high-dose aspirin has shown beneficial effects in rheumatic pericarditis 3
- In severe cases with significant cardiac involvement, intravenous methylprednisolone (1000 mg/day initially) may be considered, followed by oral prednisone 1
- Careful monitoring for development of heart failure is essential, as patients with rheumatic pericarditis may develop cardiac dysfunction 7
Important Caveats
- Even when GAS pharyngitis is treated optimally, rheumatic fever can still occur in susceptible individuals, highlighting the importance of continuous prophylaxis 4
- At least one-third of rheumatic fever cases result from asymptomatic GAS infections, making prevention challenging 4
- Prophylaxis should continue even after valve surgery, including prosthetic valve replacement 1
- Patients with rheumatic heart disease should receive appropriate endocarditis prophylaxis before undergoing high-risk dental or surgical procedures 6
- Family members of patients with current or previous rheumatic fever should have prompt treatment of streptococcal infections 1
By following this treatment approach, the risk of recurrent ARF and progression to rheumatic heart disease can be significantly reduced, improving long-term morbidity, mortality, and quality of life outcomes 8.