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Amoxicillin for 1 year
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Annual cardiology evaluation and echocardiography only
Penicillin V for 5 years
Penicillin G for 10 years
Penicillin G for 30 years
Select Answer to see Preferred Response
This patient with migratory polyarthralgia, pericarditis (diffuse ST-segment elevations, pleuritic sharp chest pain), erythema marginatum (erythema in rings with central clearing), elevated ESR and CRP, and recent group A Streptococcus (GAS) infection most likely has acute rheumatic fever (ARF). Patients with ARF with carditis, but without evidence of valvular disease, should receive secondary prophylaxis with penicillin V for 10 years or until reaching 21 years of age. Acute rheumatic fever (ARF) is an inflammatory complication of pharyngeal infection with GAS. To prevent the development of ARF, patients with GAS infection should receive prompt treatment with penicillin V. Signs and symptoms of ARF include arthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. The treatment of ARF is with penicillin G. Patients with a history of ARF are at high risk for recurrence and require secondary prevention with antibiotic prophylaxis. Antibiotic prophylaxis should begin immediately after the course of antibiotics for acute rheumatic fever. The preferred agent is IM penicillin G benzathine every 4 weeks; alternatives include oral penicillin V and sulfadiazine. The duration of antibiotic therapy depends on the severity of the disease and should be continued for the longer of the following options. Patients with rheumatic fever without carditis should receive treatment for 5 years or until the patient reaches 21 years of age. Patients with rheumatic fever with carditis but without residual heart disease should receive treatment for 10 years or until the patient reaches 21 years of age. Patients with rheumatic fever with carditis and permanent valvular heart disease should receive treatment for 10 years or until the patient reaches 40 years of age. Beaton et al. discuss secondary antibiotic prophylaxis for latent rheumatic heart disease. This study screened 102200 children in Uganda by echocardiography for evidence of rheumatic heart disease, with 926 identified to have latent disease. Patients were then randomized to receive antibiotic prophylaxis or placebo for two years. Although the study found that secondary antibiotic prophylaxis reduced the risk of disease progression at two years, the authors ultimately do not believe this study justifies echocardiographic screening for latent rheumatic heart disease due to high cost.Figure/Illustration A shows the torso of a patient with erythema marginatum. This is classically described as an evanescent, nonpruritic, nontender rash with a pale-pink center (yellow arrow) surrounded by a slightly raised red outline (blue arrow) that can either be annular (purple circle) or have an irregular elongated shape (orange arrow). Incorrect Answers: Answer 1: Amoxicillin can be used in both the treatment and secondary prophylaxis of GAS infections. Although penicillin G is preferred, amoxicillin is equally efficacious in the secondary prophylaxis of ARF. However, the duration of prophylaxis in this patient with evidence of carditis without valvular disease should be 10 years, not 1 year. Answer 2: Annual cardiology evaluation and echocardiography are important in the follow-up of patients with mild to moderate cardiac complications from ARF. However, secondary antibiotic prophylaxis is also indicated in all patients with ARF. Answer 3: Penicillin V for 5 years is an insufficient length of secondary prophylaxis for a patient with ARF with carditis. Although once monthly IM penicillin G benzathine is the preferred agent for secondary prophylaxis in ARF, oral penicillin V can also be used. Regardless of the antibiotic, this patient should receive prophylaxis for 10 years due to ARF with carditis. Answer 5: Penicillin G for 30 years would be recommended for secondary prophylaxis of a patient with ARF with carditis and permanent valvular heart disease. For this patient with ARF with carditis, but without evidence of valvular disease, secondary prophylaxis for only 10 years would be required. Bullet Summary: Secondary prophylaxis with penicillin G should be initiated in all patients with acute rheumatic fever.
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