Open Access

Diagnosis of rheumatic carditis in Mongolian children

Critical Ultrasound Journal20113:72

https://doi.org/10.1007/s13089-011-0072-5

Received: 24 October 2010

Accepted: 15 April 2011

Published: 5 May 2011

Abstract

Purpose

The aim of this study was to evaluate the clinical and echocardiographic findings in patients with acute rheumatic fever (ARF) and rheumatic heart diseases (RHD) and to compare echocardiographic findings with the clinical symptoms for the detection of subclinical carditis.

Methods

The study included 156 patients who meet the modified criteria of Jones. M-mode echocardiography was performed using a Sonos-1000 echo machine and 3.5-MHz transducer.

Results

Total of 156 patients with acute RF and RHD (median age 11.9, standard deviation 3.32, range 5–17, male to female ratio 1:1.4) were evaluated. All patients were divided into 2 groups according their diagnosis. The first group included 71 (45.5%) patients with a first onset of rheumatic fever (ARF), the second group—86 (54.5%) patients with a recurrent rheumatic fever (RHD). By echocardiography, 21 (20.1%) patients of first group, who had clinically isolated polyarthritis and chorea were diagnosed a first degree of mitral regurgitation and mitral valve thickening, which is the characteristic finding of rheumatic carditis. Out of all patients, mitral valve regurgitation was detected by 2D echocardiography in 146 (93.5%) patients. The cause of mitral valve regurgitation was annular dilatation in 48%, mitral valve prolapse in 10% and fibrotic change of valve in 42%.

Conclusion

Mitral regurgitation is the most common finding on Doppler color imaging in patients with the rheumatic carditis. In patients clinically manifesting only polyarthritis and/or chorea, we should exclude the subclinical carditis that can be easily detected by echocardiography. The presence of subclinical carditis should be accepted as an evidence of carditis.

Keywords

Rheumatic carditisMitral regurgitationSubclinical rheumatic carditisRheumatic heart disease

Introduction

Rheumatic fever (RF) is a delayed sequel of group A streptococcal throat infection and continues to be a common health problem in developing countries. About 30% of RF patients develop rheumatic heart disease (RHD), with high morbidity and cost to the public health system [16].

The major complication of acute rheumatic fever (ARF) is the appearance of carditis and subsequent development of a chronic valvular heart disease [2, 711]. Accurate detection of carditis is important because the chronic valvular disease rarely develops in patients without carditis [7, 9, 12]. Echocardiography has a leading role in diagnosis of rheumatic carditis and RHD [7, 1319]. The diagnosis of carditis in an ARF traditionally depends on characteristic auscultatory findings [20]. Using color and pulsed Doppler echocardiography minor degrees of pathological regurgitation without the characteristic clinical findings can be detected [14]. With the availability of echocardiogram as an investigative tool, a new subset of carditis is being recognized, namely subclinical carditis [2123]. The only physical finding which can be considered as being essential for diagnostic of rheumatic carditis is the presence of mitral or aortic valve regurgitation in an acute attack of RF [2426]. If a murmur of mitral or aortic valve regurgitation is not made out clinically, the patient is labeled as not having carditis [20, 27, 29]. Utilizing echocardiographic evaluation, a very sensitive investigation, presence of mitral valve disease not audible clinically, that is, subclinical carditis has been recognized [2830].

Purpose

The aim of this study was to evaluate the clinical and echocardiographic findings in ARF and RHD patients and compare these findings with the clinical symptoms.

Methods

The study included 156 patients with ARF and RHD who were diagnosed and treated in 2000–2009 at the Cardiology Division of the Maternal and Child Research Medical Center in Ulaanbaatar, Mongolia. In all cases, the diagnosis of ARF was made according to the modified criteria of Jones. M-mode echocardiography was performed in all cases using a Sonos-1000 echo machine and 3.5-MHz transducer. The following measurements were made and evaluated by application of the recommendations of the American Society of Echocardiography.

The statistical analysis was performed using the SPSS 16.0 statistical package.

Results

The study included 156 patients with acute RF and RHD (median age 11.9, standard deviation 3.32, range 5–17, male to female ratio 1:1.4). All patients were divided into 2 groups according their diagnosis. The first group included 71 (45.5%) patients with a first attack of acute rheumatic fever (ARF), the second group 86 (54.5%) patients with recurrent rheumatic fever (RHD). ARF and RHD were diagnosed in all patients by using modified Jones criteria. The patients’ clinical profiles according to the Jones criteria are shown in the Table 1. By clinical examination, the rheumatic carditis was diagnosed in 45 (28.8%) patients and the isolated polyarthritis and chorea in 26 (16.7%) patients of first group. The tachycardia, decreased first heart sound in apex, holosystolic and diastolic murmur, cardiomegaly and pericardial rub were accepted as a clinical symptom of rheumatic carditis.
Table 1

Clinical profile of patients by Jones criteria

 

ARF

RHD

x²

d

p

Carditis

66

93%

85

100%

6.1

1

0.013

Polyarthritis

45

63.4%

36

42.4%

6.8

1

0.009

Chorea

10

14.1%

2

2.4%

7.4

1

0.006

Subcutaneous nodule

4

5.6%

0

0

4.9

1

0.027

Erythema marginatum

3

4.2%

1

1%

1.4

1

0.23

In second group all patients had clinical symptom of rheumatic carditis and previous history of an ARF.

By echocardiography, 21 (20.1%) patients of first group, who had clinically isolated polyarthritis and chorea were diagnosed a first degree of mitral regurgitation and mitral valve thickening, which is the characteristic finding of rheumatic carditis. In both groups, as found by 2D echocardiography 108 (69.2%) patients had mitral regurgitation (MR), 1 (0.6%) patient had isolated mitral stenosis, 8 (5.1%) patients had mitral regurgitation and mitral stenosis, 1 (0.6%) patient had aortic regurgitation, 10 (6.4%) patients had combined mitral and aortic regurgitation, 13 (8.3%) patients had mitral and tricuspid regurgitation, 5 (3.2%) patients had combined mitral valve disease and aortic regurgitation and 2 (1.3%) patients had mitral, aortic and tricuspid regurgitation.

Among 108 patients, who had MR the following distribution was observed, as shown in Fig. 1: 84 patients (64.2%) MR grade 1, 46 patients (29.8%) MR grade 2 17 patients (6%) MR grade 3. Total 146 (93.5%) patients were diagnosed with mitral valve disease by echocardiography (Fig. 2).
Fig. 1

Mitral regurgitation in patients with rheumatic carditis

Fig. 2

Patient Ts. 12 years old, female. 2D echocardiography picture of III grade of mitral regurgitation

The cause of mitral valve regurgitation was annular dilatation in 48%, mitral valve prolapse in 10%, fibrotic change of valve in 42% (Fig. 3).
Fig. 3

The cause of mitral valve regurgitation in patients with rheumatic carditis

The left atrial dilatation was found in 36 (23.1%) patients and left ventricle dilatation in 88 (56.4%) patients while left ventricular systolic function was decreased in 54 (51.4%) patients. The paradoxical motion of ventricular septum was detected in 8 (22.8%) patients and hypokinetic motion in 1 (2.85%) patient. Clinically, those patients had clinically, heart failure symptoms of varying degrees.

Discussion

Carditis is the single most important prognostic factor in rheumatic fever [1, 3, 11]; only valvulitis leads to permanent damage and its presence determines the prophylactic strategy [31]. The clinical diagnosis of carditis in an index attack of rheumatic fever is based on the presence of significant murmurs (suggestive of mitral and aortic regurgitation), pericardial rub or unexplained cardiomegaly with congestive heart failure. Even careful clinical auscultation can miss mild valvular regurgitation [15, 32]. Two dimensional echo-Doppler and colour flow Doppler echocardiography are most sensitive for detecting structural abnormality, abnormal blood flow and valvular regurgitation [13, 3335]. This method can detect all valvular regurgitations; where as some of them can be not audible or difficult to hear.

The rheumatic process mostly involves mitral valve, most (93.5%) cases of which develop mitral regurgitation. The causes of mitral regurgitation in children are ventricular dilatation, mitral valve prolapse and leaflet mobility due to the fibrotic change. Unlike in adults the calcification of the valve leaflets is a rare observation [3538]. Clinically, all patients with left atrial dilatation had the heart failure symptoms of varying degrees. So that left atrial dilatation observed by echocardiography indicates decompensation of heart function. This could be accepted as an echocardiographic criterion of heart failure.

By echocardiography, 21 (20.1%) patients of first group, who had clinically isolated polyarthritis and chorea were diagnosed a pathological mitral regurgitation and signs of carditis.

A rheumatic heart disease develops only in patients with carditis so that those patients with subclinical carditis should be considered as candidates for developing chronic valvular heart disease. Patients with subclinical rheumatic carditis need a more stronger treatment option and longer secondary antibiotic prophylaxis to avoid a recurrent attack and development of a severe rheumatic heart disease. Echocardiography is more sensitive than clinical assessment for detection of the carditis in the acute rheumatic fever.

Conclusion

Mitral regurgitation is a most common finding (93.5%) in patients with rheumatic carditis on the Doppler color flow imaging and is related to ventricular dilatation and/or restriction of leaflet mobility due to the fibrotic change.

Subclinical carditis can be easily detected by echocardiography and should be accepted as an evidence of carditis.

All patients with clinical manifestation of polyarthritis and/or chorea should be evaluated by echocardiography in order to detect subclinical carditis.

Declarations

Conflict of interest

The authors state that they have no conflict. None of the authors have any financial interest in any organization providing support for this study.

Authors’ Affiliations

(1)
Maternal and Child Health Research Medical Center
(2)
Division of Pediatrics, Health Science University

References

  1. World Health Organization: The current evidence of the burden of group A streptococcal diseases. Available at http://www.int/child-adolescenthealth/publications/CHILD_HEALTH/DP/TOPIC2/paper
  2. Eisenberg MJ (1993) Rheumatic heart disease in the developing world: prevalence prevention and control. Eur Heart J 14:122–128PubMedView ArticleGoogle Scholar
  3. McLaren MJ, Markowitz M, Gerber MA (1994) Rheumatic heart disease in developing countries: the consequence of inadequate prevention. Ann Int Med 120:243–245PubMedView ArticleGoogle Scholar
  4. Chopra P, Bhatia ML (1992) Chronic rheumatic heart disease in India: a reappraisal of pathologic changes. J Heart Valve Dis 1:92–101PubMedGoogle Scholar
  5. Chopra P, Gulvwani H (2007) Pathology and pathogenesis of rheumatic disease. Indian J Pathol Microbiol 50:685–697PubMedGoogle Scholar
  6. Abbas MI, Person DA (2008) The pacific island health care project (PIHCP): experience with rheumatic heart disease (RHD) from 1998 to 2006. Hawaii Med J 67:326–329PubMedGoogle Scholar
  7. Figueroa F, Fernandez M (2001) Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease. Heart 85:407–410PubMedPubMed CentralView ArticleGoogle Scholar
  8. Carapetis JR (2007) Rheumatic heart disease in developing countries. N Engl J Med 357:439–441PubMedView ArticleGoogle Scholar
  9. Narula J, Chandrasekhar Y, Rahimtoola S (1999) Daignosis of active rheumatic carditis. The echoes of change. Circulation 100:1576–1581PubMedView ArticleGoogle Scholar
  10. Wilson NJ, Neutze JM (1994) Echocardiographic diagnosis of mitral insufficiency. J Pediatr 125(4):673–674PubMedView ArticleGoogle Scholar
  11. Abernethy M, Bass N (2008) Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever. Int Med J 24:530–535Google Scholar
  12. Ahsan B, Masood S (2008) Subclinical valvulitis in children with acute rheumatic fever. Pediatr Cardiol 29:1432–1971Google Scholar
  13. Vasan RS, Narang R, Lister BC, Narula J (1996) Echocardiographic evaluation of patients with acute rheumatic fever and rheumatic carditis. Circulation 94:73–82PubMedView ArticleGoogle Scholar
  14. Folger GM, Hajar R, Robida A (1992) Occurrence of valvular heart disease in acute rheumatic fever without clinical evident carditis: colour-flow Doppler identification. Br Heart J 67:434–438PubMedPubMed CentralView ArticleGoogle Scholar
  15. Vardi P, Markiewicz W, Weiss Y, Levi J, Benderly A (1983) Clinical-echocardiographic correlations in acute rheumatic fever. Pediatrics 71:830–834PubMedGoogle Scholar
  16. The WHO global programme for the prevention of RF/RHD (2000) Report of a consultation to review progress and develop future activities. World Health Organization, Geneva (WHO/CVD/00.1)Google Scholar
  17. Ozkutlu S, Ayabakan C, Saraclar M (2001) Can subclinical valvulitis detected by echocardiography be accepted as a evidence of carditis in the diagnosis of acute rheumatic fever. Cardiol Young 11:255–260PubMedView ArticleGoogle Scholar
  18. Williamson L, Bowness P, Mowat A, Ostman-Smith I (2000) Difficulties in diagnosing acute rheumatic fever-arthritis may be short lived and carditis silent. BMJ 320:362–365PubMedPubMed CentralView ArticleGoogle Scholar
  19. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M et al (2008) Prevention of infective endocarditis: guidelines from the American Heart Association. J Am Dent Assoc 139:1–35View ArticleGoogle Scholar
  20. Gururaj AK, Choo KE, Ariffin WA, Sharifan A (1990) A clinical, laboratory and echocardiographic profile of children with acute rheumatic fever. Singapore Med J 31:364–367PubMedGoogle Scholar
  21. Sergent JS (1993) Acute rheumatic fever. Trans Am Clin Climatol Assoc 104:15–23PubMedPubMed CentralGoogle Scholar
  22. David JS, Anthony D, Joseph K, Arthur W (1978) Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 58:1072–1083View ArticleGoogle Scholar
  23. Canan A, Suheyla O, Ayhan K (2003) The Doppler echocardiographic assessment of valvular regurgitation in normal children. Turk J Pediatr 45:102–107Google Scholar
  24. Abraham B, Shaul D, Andre K (1992) The prevalence of valvular regurgitation in children with structurally normal hearts: a color Doppler echocardiographic study. Am Heart J 123:177–180View ArticleGoogle Scholar
  25. Nidorf SM, Picard Mh, Triulzi MO, Thomas JD, Newell J, King, King Weyman AE et al (1992) New perspectives in the assessment of cardiac chamber dimensions during development and adulthood. J Am Coll Cardiol 19:983–988PubMedView ArticleGoogle Scholar
  26. Nancy AA, Wanda M, Derek AF, Stevenson JG, David JS, Luciana TY, Luann LM, Thomas RK, Tal G, Frank CS, Jack R (2005) Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric aquired or congenital heart disease. J Am Soc Echocardiogr 18:91–98View ArticleGoogle Scholar
  27. Stephen PS (2003) Echocardiography. Wolters Kluwer, Philadelphia, pp 159–180Google Scholar
  28. Hisham D, Ranjita S, Rajnikant P, Nasser L (2007) Usefullness of right ventricular tissue Doppler imaging to predict outcome in left ventricular heart failure independent of left ventricular diastolic function. Am J Cardol 99:961–965View ArticleGoogle Scholar
  29. Zile MR, Gaasch WH, Carroll JD, Levine HJ (1984) Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol 3:235–242PubMedView ArticleGoogle Scholar
  30. Charles WU, James WC, Edmund HS, John R, Eugene B (1968) Myocardial mechanics in aortic and mitral valvular regurgitation: the concept of instantaneous impedance as a determinant of the performance of the intact heart. J Clin Invest 47:867–876View ArticleGoogle Scholar
  31. Folger GM, Hajar R, Robida A, Hajar HA (1992) Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour-flow Doppler identification. BMJ 67:434–438Google Scholar
  32. Folger GM, Hajar R (1989) Doppler echocardiographic findings of mitral and aortic valvular regurgitation in children manifesting only rheumatic arthritis. Am J Cardiol 63:1278–1280PubMedView ArticleGoogle Scholar
  33. Saxena A (2000) Diagnosis of rheumatic fever: current status of Jones criteria and role of echocardiography. Indian J Ped 67:283–285View ArticleGoogle Scholar
  34. Marcus RH, Sareli P, Pocock WA, Meyer TE, Magalhaes MP, Grieve T, Antunes MJ, Barlow JB (1989) Functional anatomy of severe mitral regurgitation in active rheumatic carditis. Am J Cardiol 63:577–584PubMedView ArticleGoogle Scholar
  35. Stewart WJ, Currie PJ, Salcedo EE, Klein AL, Marwick T, Agler DA, Homa D, Cosgrove DM (1992) Evaluation of mitral leaflet motion by echocardiography and jet direction by Doppler color flow mapping to determine the mechanisms of mitral regurgitation. J Am Coll Cardiol 20:1353–1361PubMedView ArticleGoogle Scholar
  36. Otto CM (2001) Evaluation and management of chronic mitral regurgitation. N Engl J Med 345:740–745PubMedView ArticleGoogle Scholar
  37. Perloff JK, Roberts WC (1972) The mitral apparatus: functional anatomy of mitral regurgitation. Circulation 46:227–239PubMedView ArticleGoogle Scholar
  38. Agricola E, Galderisi M, Oppizzi M, Schinkel AF, Maisano F, Bonis MD, Margonato A, Maseri A, Alfieri O (2004) Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart 90:406–410PubMedPubMed CentralView ArticleGoogle Scholar

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