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Stop penicillin therapy
9%
3/33
Stop penicillin therapy in 4 years
18%
6/33
Decrease frequency of injections to bimonthly
0%
0/33
Switch to intramuscular cefotaxime, which has fewer side effects
Continue intramuscular penicillin therapy
64%
21/33
Select Answer to see Preferred Response
This patient's clinical presentation is consistent with rheumatic heart disease with valvular involvement. Patients with this condition should receive penicillin prophylaxis for 10 years, or until age 40 (whichever is longer). Rheumatic heart disease results from autoantigens that form in the setting of oropharyngeal infection with group A streptococcus. Cardiac tissue is one of the major autoantigen targets, which can lead to carditis and valvular abnormalities after resolution of the oropharyngeal, joint, and dermatological symptoms of acute rheumatic fever. Penicillin prophylaxis is recommended to prevent future infections with group A streptococcus, and the duration of treatment is dependent on the presence of carditis and valvular abnormalities. Shipton and Wahba review valvular heart disease. They note that the incidence of rheumatic heart disease has decreased significantly due to careful treatment of rheumatic fever. Although mitral stenosis is the most common valvular abnormality noted in rheumatic heart disease, mitral and aortic regurgitation also occur. Marijon et al. review the use of echocardiography as a screening tool for rheumatic heart disease in Cambodia and Mozambique. While clinical screening showed a 0.2-0.3% prevalence of rheumatic heart disease, echocardiography screening showed a prevalence of 2-3% in the same group. They conclude that echocardiography screening may be a useful tool for diagnosis of rheumatic heart disease in high-risk populations. Illustration A demonstrates the transition from strep infection to rheumatic fever to rheumatic heart disease. Incorrect Answers: Answer 1: If this patient did not have evidence of carditis or valvular involvement, it would be appropriate to discontinue penicillin therapy after 5 years of treatment or until age 21 (whichever is longer). Answer 2: If this patient had a history of carditis without valvular involvement, it would be appropriate to discontinue penicillin therapy after 10 years of treatment or until age 21 (whichever is longer). Answer 3: Decreasing the frequency of injections may increase the likelihood of developing penicillin-resistant infections. Answer 4: Penicillin is generally well tolerated, and this patient does not report side effects from the treatment.
4.0
(4)
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