Main Treatment for Symptomatic Acute Rheumatic Fever
The correct answer is B: High dose oral acetyl salicylic acid is the main treatment for symptomatic acute rheumatic fever, specifically for controlling the inflammatory manifestations of arthritis and mild carditis. 1, 2
Understanding the Treatment Framework
The treatment of symptomatic acute rheumatic fever involves two distinct therapeutic goals that must not be confused:
Anti-Inflammatory Treatment (Primary Symptomatic Management)
- High-dose aspirin (acetylsalicylic acid) at 75-100 mg/kg/day for 4-6 weeks is the standard anti-inflammatory treatment for patients with arthritis and/or mild carditis 2
- The arthritis of rheumatic fever responds rapidly to acetylsalicylic acid, typically resolving within days of initiating therapy 3
- Treatment duration is typically 12 weeks total when combining aspirin with or without steroids 2
Antibiotic Treatment (Eradication of Streptococcus)
- A full 10-day course of penicillin is required to eradicate residual group A streptococcus, even if throat culture is negative at diagnosis 1
- This can be oral penicillin V or intramuscular benzathine penicillin G, but this addresses the underlying infection, not the symptomatic acute inflammatory process 1
Why the Other Options Are Incorrect
Option A (Intravenous ampicillin every 6 hours):
- This is not indicated for acute rheumatic fever treatment 1, 2
- Penicillin, not ampicillin, is the recommended antibiotic, and it addresses the streptococcal infection rather than the symptomatic inflammatory manifestations 1
Option C (Daily intravenous hydrocortisone):
- Corticosteroids are reserved for severe carditis with heart failure, not as the main treatment for symptomatic acute rheumatic fever 2
- The FDA label for hydrocortisone lists "acute rheumatic carditis" as an indication only as adjunctive therapy for short-term administration 4
Option D (Monthly intramuscular penicillin):
- This represents secondary prophylaxis to prevent recurrent attacks, not treatment of the acute symptomatic episode 1, 5
- The American Heart Association explicitly notes that monthly intramuscular penicillin is for preventing recurrences, not treating the acute attack 1
Important Clinical Considerations
Monitoring for Adverse Effects:
- Aspirin therapy causes hepatotoxicity in approximately 36.5% of patients, along with gastric irritation and salicylism 6
- Liver enzymes should be monitored, particularly in children under 11 years of age who have higher rates of hepatotoxicity (69% of those with elevated enzymes) 7
Alternative Anti-Inflammatory Agents:
- Ibuprofen has emerged as a safer alternative with comparable efficacy, causing hepatotoxicity in only 18% versus 62% with aspirin 7
- Tolmetin (25 mg/kg/day) has also shown equal efficacy to aspirin without the adverse effects 6
Common Pitfalls to Avoid
- Do not confuse primary treatment with secondary prophylaxis - monthly penicillin prevents recurrences but does not treat the acute inflammatory process 1
- Do not use broad-spectrum antibiotics like ampicillin when narrow-spectrum penicillin is appropriate 1
- Do not delay anti-inflammatory therapy while waiting for culture results, as the inflammatory process requires immediate treatment 2