Hello Jessica,

Your basic understanding of the concept of RF and RHD is correct. However, please keep in mind the following:

Rheumatic fever is not direct infection of the cardia. There is Streptococcal infection, away from the heart, generally in the throat, sometimes skin. There is only an immunological cross-reaction between the anti-streptococcal antibodies and proteins in the cardia. This results in cardiac inflammation. The clinical features of this inflammation are labelled "Rheumatic fever".

Have you heard of the saying "Rheumatic fever licks the joint, but bites the heart"? The inflammation is not just in the cardia, but also in the joints. That explains all the symptoms and signs of an acute rheumatic fever.

Most patients recover from this without problems.

Now let's see what happens in the heart after an episode of RF:

Fibrosis: A result of intense inflammation, especially in the endocardial layer. Remember that valves are also covered by a layer of endocardium. This fibrosis also affects the valves therefore. Can this fibrosis result in stenosis? Not yet! Generally one episode does not result in significant permanent changes in the heart.

Now let's look at this: RF usually occurs in persons (esp. children) living in developing countries. This means that they are repeatedly exposed to streptococcal infections. This recurrent infection results in gradually increasing "permanent" damage to the heart by progressive fibrosis. Every episode of acute RF worsens the permanent damage. (that's the reason it bites the heart)

Over time: This results in significant permanent damage which leads to stenosis/ regurgitation lesions in valves, especially mitral. This is called rheumatic heart disease (RHD).

Hope you are getting the concepts further cleared. Remember that recurrent infection is generraly the "keyword".

Now, your main question:
Can RF and RHD coexist? YES.

RHD is a chronic valvular heart disease produced by recurrent rheumatic fever. If RF can be recurrent before the onset of RHD, why can't it be afterwards? To give you a comparison, it's like a patient with cirrhosis of liver developing acute hepatitis.

If you have understood the "recurrent RF >> RHD" concept, you will understand why "rheumatic fever prophylaxis" has to be given for a longer duration. That is just to avoid any possibility of streptococcal infection and all related complications as described above.

Now don't confuse RF prophylaxis with IE prophylaxis.

Please do not hesitate to ask if you do not understand any of these clearly.

Rheumatic fever and Rheumatic heart disease are generally dealt with in detail in Pediatrics textbooks.

Textbook of Pediatrics by OP Ghai has one of the simplest and best descriptions of hemodynamics in RHD. You can also refer to Nelson's textbook of Pediatrics.

At a higher level, textbooks on cardiology like Braunwald's also deal with this condition in detail, but may be out of scope for an undergraduate student.

If you any other queries on this condition, you can ask here.

That's important. I did mention about that in my first reply in this thread...

There are TWO types of prophylaxis given to patients with RHD:

• 1. Rheumatic fever prophylaxis
• 2. Infective endocarditis prophylaxis

1. Rheumatic fever prophylaxis:
As explained above, this is given to all patients who develop an initial episode of rheumatic fever. Aim is to prevent recurrent infection with beta hemolytic streptococci. If not, they may develop recurrent Strep infections and develop RHD.
Therefore: Prevention of Strep. pneumoniae beta hemolytic streptococcal infection >> Prevention of subsequent rheumatic fever >> Prevention of RHD
Classical regimen: Benzathine penicillin IM once in 3-4 weeks.
Duration of prophylaxis: As long as the possibility of beta hemolytic streptococcal infection persists, ideally for life. If this is not practical, at least till the patient is well into middle age.

2. Infective endocarditis prophylaxis
This is different from rheumatic fever prophylaxis. Given to patients with established valvular heart disease (either due to RHD or other causes).
Patients with valvular heart disease are more prone to have bacterial endocarditis. Why? Their valves are abnormal. Whenever there is bacteremia, it is "easy" for the bacteria to "deposit" on the valves and initiate infection - infective endocarditis.
Whenever a patient with a valvular heart disease is likely to have bacteremia - dental extraction, other oral procedures, genitourinary procedures - they are given a course of antibiotics to suppress the bacteremia.
Classical regimen: Oral Amoxycillin for dental procedures. Ampicillin and Gentamycin for genitourinary procedures.
Duration of prophylaxis: Starts about 6 hours before a planned procedure and goes on up to 2 days after the procedure. NOT continuous like rheumatic fever prophylaxis.

...
16th June 2006: Edited the organism, typed by mistake, after Cindylxy pointed that out in a subsequent post. Thank you Cindy...

Hello cindy,

You meant Streptococci - A beta-hemolytic Streptococci right? Not Streptococcus pneumoniae...

Your doubt is very relevant. There are two terms to consider here:
1. Resistance
2. Tachyphylaxis

You know what is resistance so I will not go into it, but tachyphylaxis is when a person becomes tolerant to the drug and loses the efficacy of that medication (classical example: Salbutamol in bronchial asthma).

Some drugs taken on long term can have reduced efficacy due to tachyphylaxis, but that does not happen with antibiotics, at least with Penicillins. However, RESISTANCE is an issue.

Simple principles to avoid resistance are very useful here. These include the use of the right drug in the right dosage for the right duration...

As long as this is followed, drug resistance should not be a threat. If resistance does set in, it may be difficult, though Erythromycin might still be useful.

This is exactly the reason why antibiotic use for (simple) viral upper respiratory infections is widely discouraged. Cochrane Review: Antibiotics for the common cold and acute purulent rhinitis

...

You are welcome

Yes, rheumatic fever is caused by Group A beta hemolytic streptococci, and NOT S. pneumoniae.


Yes. Since Group A beta hemolytic streptococci are the cause of RF, Benzathine penicillin is used to eradicate them. But this drug also has activity against S. pneumoniae.

Resistance can develop amongst Group A beta hemolytic streptococci and that is what we are worried about in RHD-RF. Fortunately, resistance in  Group A beta hemolytic streptococci is less common than that amongst S. pneumoniae. However S. pneumoniae resistance is not directly relevant for RHD-RF.

Further Reading:

• Concepts related to Streptococci
• Rheumatic fever in 21st Century

but still having doubts....

1.benzathine penicillin given in RF is to eradicate Gr A beta hemolytic Strep, not really S.pneumoniae, 
   because A beta hemolytic strep are the cause of RF. rigth?

2.but based on the reply on 28th may, sir said that, prevention of S.pneumoniae infection>>prevents   
   subsequent RF>>prevents RHD... here sir used S.pneumoniae, why?

3. can we say that,we are preventing S.pneumoniae (which is commoon in URTI) to prevent RF because   
    RF is immunological mediated... so S.pneumoniae infection will cause antigenic eff same as A beta
    hemolytic Strep, and cause RF?

4. patient with RF need prophylaxis for RF.. but if they develop RHD,do we stil cont with this prophylaxis
    regimen, or we switch it to prophy for IE which can aff the valve in RHD, or we use both regimen?

thanku sir...