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Cardiology Follow-Up and Penicillin Prophylaxis are Necessary for Patients with Poststreptococcal Reactive Arthritis

Question

  • JC is a 15 year old male recently diagnosed with Poststreptococcal Reactive Arthritis (PSRA). Do patients with PSRA need cardiology follow-up? Are they more likely to develop ARF or carditis with recurrent strep infections? Should they receive penicillin prophylaxis?

Clinical Bottom Lines

  1. Patients with PSRA may have delayed-onset carditis and should be observed carefully for several months for subsequent development of carditis.
  2. In addition, patients with PSRA are at risk of developing rheumatic carditis with recurrent GAS infection, and should receive prophylactic penicillin therapy.


Summary of Key Evidence

  1. Studies: Two cohort studies to determine prognosis. (1, 2)
  2. Subjects: Children 4-17 years old with either serologic or culture evidence of GAS infection who also had joint symptoms but did not meet Jones criteria for acute rheumatic fever (ARF)
  3. Methods: Retrospective chart review
  4. Main results: Of 12 patients with PSRA who were treated but not given penicillin prophylaxis followed for a mean of 17 months, 1 (8%) developed acute rheumatic fever (ARF) after repeat GAS infection within 18 months of her initial episode. Four of four patients with PSRA in a more recent study have received penicillin prophylaxis and have not developed carditis, even with repeat GAS infection, in an average of 36 months of follow-up.
  5. Validity: Fair, due to difficulty defining the illness, the rarity of the illness, and confusion regarding appropriate length of follow-up.  

Additional Comments

  • Key biological mechanisms at issue include organism and host factors that determine patient's likelihood to develop ARF or PSRA. Examples include repeated episodes of PSRA, family members with ARF, first few years after PSRA, infection with certain GAS serotypes.
  • Although this is not a randomized, double-blind, placebo-controlled trial, one could state that risk of developing carditis after PSRA w/o prophlaxis is 8% in 18 months while risk of carditis after PSRA w/ prophylaxis is 0% in 36 months. The absolute risk reduction would be 8% and NNT would be 12.5 patients, but this is a blatant distortion of the use of this statistic.
  • Despite paucity of data, given the cost and risk-benefit ratio, these studies do affect the management of the patient. As a result of these studies I would arrange cardiology follow-up and prophylax my patient.

Citation

  1. Moon RY, Greene MG, et al. Poststreptococcal reactive arthritis in children: a potential predecessor of rheumatic heart disease. J Rheumatol 1995; 22: 529-32.
  2. De Cunto CL, Giannini EH, et al. Prognosis of children with poststreptococcal reactive arthritis. Pediatr Infect Dis J 1988; 7: 683-6.

CAT Author: Julia Warren-Ulanch, MD

CAT Appraisers: Jon Fliegel, MD

Date appraised: December 11, 2000

Last updated June 15, 2003
Department of Pediatrics and Communicable Diseases
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