Complications of physician misdiagnosis/treatment of rheumatic fever in the United States

Abstract

Rheumatic fever is an auto-immune disease caused by exposure to Streptococcus pyogenes. Over the last 50 years, reports of rheumatic fever within the United States have diminished. The decrease was attributed to the advent of penicillin in the treatment of streptococcus infections. We propose that current diagnostic and treatment methodologies may adversely increase the morbidity rate of rheumatic fever within the United States. Publication rates and interest in rheumatic fever has diminished over the last 30 years. Because of this decline, many physicians are only vaguely aware of the disorder. Additionally, the fear of antibiotic resistance has influenced the Center of Disease Control to suggest a significant decrease in the use of antibiotics by physicians. Although extremely valid for the future health and well-being of the population, such policies must be examined for each individual case carefully. The American Heart Association prescribes long-term antibiotic prophylaxis as the only current treatment; however literature reviews indicate that such therapy is rarely used. Therefore individuals diagnosed with rheumatic fever are not being treated. Additionally, because many physicians are not routinely testing for streptococcus or early signs of endocarditis, it is likely that cases of rheumatic fever will increase in the future, and many individuals may not be diagnosed until sever damage or morbidity occurs. Physician education and clear revised guide-lines are necessary to ensure adequate treatment of individuals with rheumatic fever. Misunderstandings of the disease and how it should be treated by first responders (i.e. primary care providers and pediatricians) are discussed.

In Search of the Holy Grail: A Specific Diagnostic Test for Rheumatic Fever

“…They were developed to avoid confusion and misdiagnosis of acute ARF/RHD and provide a rational basis to develop programs for prevention and patient care. Since then, the additions and modifications made to the original criteria, which now form the "Revised Jones Criteria" (4, 5) still do not prevent misdiagnosis (6)(7)(8)(9).…”

“…Of the laboratory tests, in addition to a positive throat culture and elevated or rising titre of anti-streptolysin O (ASOT) which were described by Jones we have now added anti-DNase titre. However, these are non-specific laboratory tests that are used to determine an exposure to streptococcal infection and are of little use in the definitive diagnosis of ARF/RHD, particularly in regions where streptococcal infection is endemic (6)(7)(8)(9). Therefore, a robust specific diagnostic test that can be used in the laboratory setting is required to overcome misdiagnosis of ARF/RHD.…”

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

“…In the present report, the use of BPG as secondary prophylaxis for ARF did not reduce the risk of developing ARF related sequelae. Indeed, the treatment of existing GABHS infections may decrease the overall damage from that episode, but it will not eliminate or stop the progression of damage from the initial infection [79]. Furthermore, one-third of ARF episodes results from non-symptomatic GABHS infections that go unnoticed and untreated [29].…”

“…The delivery of secondary antibiotic prophylaxis should be performed by a dedicated health care team. Physician attention and informed discussions regarding treatment efficacy and life events empower people to take responsibility for their own wellbeing and contribute to better patient adherence [79]. Maintaining adherence to BPG secondary prophylaxis might be prevented by physicians seeking to limit penicillin use in order to alleviate the development of antibiotic resistance.…”