Treatment of Symptomatic Acute Rheumatic Fever
The main treatment for symptomatic acute rheumatic fever is high-dose oral acetylsalicylic acid (aspirin) for anti-inflammatory control of symptoms, though this does not prevent cardiac damage. The correct answer is B.
Understanding the Treatment Approach
The treatment of acute rheumatic fever (ARF) must be distinguished from its prevention. While penicillin is critical for eradicating the streptococcal infection and preventing recurrences, anti-inflammatory agents like aspirin are the mainstay for treating the acute symptomatic manifestations of ARF 1.
Anti-Inflammatory Therapy for Acute Symptoms
- High-dose aspirin (75-100 mg/kg/day) provides dramatic clinical improvement in the arthritis and other inflammatory manifestations of ARF 2.
- The arthritis of rheumatic fever is highly responsive to salicylate therapy, with symptoms typically resolving within days of treatment initiation 1, 2.
- Anti-inflammatory agents do NOT prevent the subsequent development of rheumatic heart disease, but they effectively control acute symptoms and reduce patient suffering 1.
Why the Other Options Are Incorrect
Option A (Intravenous ampicillin every 6 hours): This is not the primary treatment for symptomatic ARF. While eradicating group A streptococcus is important, a full therapeutic course of penicillin (not ampicillin) should be given to eliminate residual streptococci, but this addresses the infection, not the symptomatic inflammatory disease 3, 4.
Option C (Daily intravenous hydrocortisone): Corticosteroids remain controversial in ARF treatment. Controlled studies have failed to demonstrate improved long-term prognosis with corticosteroid therapy, and their role in treating carditis remains uncertain 1. They are not the main treatment for symptomatic ARF.
Option D (Monthly intramuscular penicillin): This represents secondary prophylaxis to prevent recurrent attacks of rheumatic fever, not treatment of the acute symptomatic episode 3. Monthly (or every 3-4 weeks) benzathine penicillin G is given long-term after ARF diagnosis to prevent recurrences 5.
Complete Treatment Algorithm
Acute Phase Management
- Initiate high-dose aspirin (75-100 mg/kg/day) divided into multiple doses for symptomatic relief of arthritis and inflammation 2.
- Administer a full 10-day course of penicillin to eradicate residual group A streptococcus, even if throat culture is negative at diagnosis 3, 4.
- Monitor for aspirin toxicity including hepatotoxicity (occurs in approximately 36.5% of patients), gastric irritation, and salicylism 2.
Important Clinical Caveats
- Aspirin therapy has significant side effects that may require temporary discontinuation, potentially prolonging hospitalization 2.
- Alternative NSAIDs like tolmetin may be equally effective with fewer adverse effects for patients with arthritis without carditis 2.
- No treatment has been proven to alter the likelihood or severity of rheumatic heart disease after an episode of ARF 6.
- The role of corticosteroids remains uncertain, with no proven benefit for long-term cardiac outcomes 1.
Transition to Secondary Prevention
- After completing acute treatment, immediately initiate continuous antimicrobial prophylaxis with benzathine penicillin G 1.2 million units intramuscularly every 4 weeks (or every 3 weeks in high-risk situations) 3, 5.
- Duration of prophylaxis depends on cardiac involvement: at least 10 years or until age 40 (whichever is longer) for those with persistent valvular disease 3.