Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations

Liesl J Zühlke, Andrea Beaton, Mark E Engel, Christopher T Hugo-Hamman, Ganesan Karthikeyan, Judith M Katzenellenbogen, Ntobeko Ntusi, Anna P Ralph, Anita Saxena, Pierre R Smeesters, David Watkins, Peter Zilla, Jonathan Carapetis, Liesl J Zühlke, Andrea Beaton, Mark E Engel, Christopher T Hugo-Hamman, Ganesan Karthikeyan, Judith M Katzenellenbogen, Ntobeko Ntusi, Anna P Ralph, Anita Saxena, Pierre R Smeesters, David Watkins, Peter Zilla, Jonathan Carapetis

Abstract

Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now includes the concept of low-risk versus medium-to-high risk populations. Initiation of secondary prophylaxis and the establishment of early medium to long-term care plans is a key aspect of the management of ARF. It is a requirement to identify high-risk individuals with RHD such as those with heart failure, pregnant women, and those with severe disease and multiple valve involvement. As penicillin is the mainstay of primary and secondary prevention, further research into penicillin supply chains, alternate preparations and modes of delivery is required.

Keywords: Acute rheumatic fever; Benzathine penicillin; Echocardiography; Global burden of disease; Group A streptococcus; Pathogenesis.

Conflict of interest statement

Conflict of Interest

Liesl J. Zühlke is funded through the Hamilton-Naki Netcare Physicians Trust.

Liesl J. Zühlke, Jonathan Carapetis, and David Watkins are funded by Medtronic Foundation to support the work of RhEACH and RHDAction.

Andrea Beaton is supported in RHD research through a mentored early career award from the American Heart Association and a grant from the Verizon Foundation, The Namibian national registry for Rheumatic Fever and Rheumatic Heart Disease is supported by the Harold and Ethyl Pupkewitz Heart Foundation.

Ntobeko Ntusi gratefully acknowledges funding support from the National Research Foundation and Medical Research Council of South Africa.

Anna P. Ralph is supported by an Australian National Health and Medical Research Council Fellowship 1084656.

Judith M. Katzenellenbogen is funded by the National Heart Foundation of Australia through the Future Leader Fellowship scheme.

David Watkins is funded by the Disease Control Priorities Network Grant from the Bill and Melinda Gates Foundation to the University of Washington.

Jonathan Carapetis receives funding from the Australian National Health and Medical Research Council to support RHD research, Novartis Institutes for Biomedical Research to support penicillin research.

Mark E. Engel, Christopher T. Hugo-Hamman, Ganesan Karthikeyan, Anita Saxena, Pierre R. Smeesters, and Peter Zilla each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Figures

Fig. 1
Fig. 1
Global prevalence and mortality rates. Source: data derived from Global Burden of Disease data 2010/2013.
Fig. 2
Fig. 2
Echocardiogram from a patient with severe mitral regurgitation secondary to a flail anterior mitral leaflet (arrow) (a). Color Doppler shows severe eccentric mitral regurgitation (b).
Fig. 3
Fig. 3
Echocardiogram from a patient with severe mitral stenosis showing thickened mitral valve with restricted opening (a) and commissural fusion (arrows) (b). Mitral valve area by planimetry is 0.73 cm2.

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