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Rheumatic Fever :

What you should know ?




Teddy Ontoseno
Division of Cardiology
Department of Child Health Dr Sutomo Hospital
Airlangga University, Surabaya
Philosophical - Practical consideration
Licks the joints and bites the heart.

BACKGROUND
Rheumatic fever (RF) :
1. Acquired heart disease in children and
young adults worldwide.
2. Still remains a major problem in developing
countries.
3. Severe cardiac dysfuction decades later
4. Premature death
5. Preventable and easily treatable



Epidemiology
* Ages 5-15 yrs
* <7 yrs : severe carditis
* Individual predisposition
(genetic ?, HLA antigen ?)
* Developing countries :
endemis, 25-45% of acquired
heart disease caused by RF.


R.F. can be presented in many ways:

a. Arthritis without cardiac involvement.
b. Rheumatic chorea without arthritis
nor carditis.
c. Carditis with or without arthritis.




R.F.What Pediatrician should know ?

R.F.What Pediatrician should know ?
Pathogenesis
* Recent concept : abnormal humoral (acute
phase) and cellular (chronic phase) immune
response occurs.

* Antigenic mimicry : there is certain amino
acid sequence that is similar btw GABHS and
human tissue in individuals with genetic
predisposition.

I mmunologically mediated inflammatory
Rheumatic
fever is a
classic
example of
molecular
mimicry
Rheumatic fever-
pathogenesis
Throat
Heart
Rheumatic Fever Pathogenesis:
TissueDamage
The Recent Concept :

HUMORAL and
CELLULAR
R.F.What Pediatrician should know ?

B. Rheumatogenic strains of
GABHS M types l, 3, 5,
6,18,19 & 24 have antigenic
domains similar to antigens
in components of the human
heart
A. Only infections
GABHS of the pharynx
initiate or reactivate RF.
1st Problem

* 50% of patients with pharyngitis will be treated
but will not be infected with GABHS

* 30% of patients with pharyngitis will not be
treated but will be infected with GABHS




GABHS pharyngitis and non-GABHS pharyngitis
Signs and symptoms overlap broadly
How do we diagnose it?

* A laboratory test

* A clinical diagnosis and offer presumptive
treatment.

so diagnosis remains a clinical decision !

Rationale Decission Making
The WHO Acute Respiratory Infections (ARI) :

* In the absence of laboratory diagnosis for
children under 15 years of age, acute
GABHS pharyngitis should be suspected and
presumptively treated when pharyngeal
exudate plus enlarged and tender cervical
lymph nodes are found.

Acute Pharyngitis: Clinical Features
Suggest Bacterial Suggest Viral
( GABHS )

* Sudden Onset Sore throat - Conjunctivitis
* Pain on Swallowing - Runny Nose
* Fever ( 101-104 F) - Cough
* Headache - Diarrhea
* Abdominal Pain - Hoarseness
* Cervical Nodes
* Pharyngeal / Tonsillar
Erythema & Exudates
Acute Pharyngitis
To treat or not to treat?.
That is the million dollar question.
WellSo what is the most
important goal of treatment?


Modified Centor Score & Management Approach
( McIsaac - JAMA 2007)

Criteria Points

*Temperature >38 C 1
*Absence of Cough 1
*Swollen Tender Cervical Node 1
*Tonsillar Swelling / Exudate 1
*Age: 3 - 14 years 1
15 44 years 0
45 years or older -1

Total Score : ( )
Management Approach:
SCORE: 0 - 1 No Further Testing or ABX Therapy.
2 - 3 Culture All
>4 Treat Empirically .
GABHS Pharyngitis:
Treatment Options
Four reasons to treat a GABHS pharyngitis
with antibiotics :
* To prevent rheumatic fever
* To prevent peritonsillar abscess
* To reduce symptoms there is a modest (~ 1
day) reduction in symptoms with early treatment
* To prevent transmission this is important in
pediatrics due to extensive exposures but not in
adults
2nd Problem
RHEUMATIC FEVER, DIAGNOSIS

It is difficult to give a satisfactory
clinical picture of the disease,
because the modes of onset are so
varied and the symptoms so diverse.
RF, Clinical Features:
* Acute Rheumatic Fever
- Acute Inflammatory Phase
- Heart Pancarditis (40-50%)
- Skin Erythema Marginatum/ S.nodule (10%)
- CNS Sydenham Chorea (15%)
- Migratory polyarthritis (75%)
* Chronic Rheumatic Fever
- Deforming fibrotic valvular disease.
RF, Clinical Features:
Polyarthritis low grade fever, large joints,
( > 75%), migratory, painful, warm and swollen
asymmetrical, no permanent dysfunction
Carditis - pericarditis, cardiomegaly, or
valvulitis (~ 50%) (valvulitis is the most serious
manifestation.)
Chorea late occurrence, 3 - 4 months after ( ~
10%) infection, self-limiting, resolves in 1- 3
months.
RF, Clinical Features:
Erythema Marginatum classic truncal
rash, ( ~ 10%) migratory - appears &
disappears within hours. (pink rash irregular
red edges clear center)

Subcutaneous Nodules late occurs
(1 - 2%) ( months after infection), painless small
nodules over bony prominences - elbows,
knees, spine.

Major criteria of Jones
Help to remember :
CAPOCHES
Carditis
Polyarthritis
Chorea
Erythema Marginatum
Subcutan nodule
The Jones Criteria for Rheumatic
Fever, Updated 2003
Major Criteria
Carditis
Migratory polyarthritis
Sydenham's chore
Subcutaneous nodules
Erythema marginatum
Minor Criteria
Clinical
fever
Arthralgia
Laboratory
Elevated acute phase
reactants
Prolonged PR interval
plus
Supporting evidence of a recent group A streptococcal infection
positive throat culture or
rapid antigen detection test; and/ or elevated or
increasing streptococcal antibody test
(e.g., anti-streptolysin O, anti-deoxyribonuclease B, anti-hyaluronidase).

Carditis of ARF :
What Paediatrician should know ?

* Pancarditis (endocarditis most serious, always present)
* 40 and 60% of patients with ARF
* Characterised by
-persistent tachycardia
-organic cardiac murmurs not previously present
(mitral regurgitation)
- pericardial friction rub
- cardiomegaly
- prolonged PR interval and evidence of heart failure
may be present nonspecific
Mitral regurgitation
What Paediatrician should know ?

Apical, softer and blowing holosystolic murmur

Pure rheumatic MR due
to shortening of valve
cusps and of papillary
muscles, chordae
tendineae that become
matted and adherent to
the valve.
Chronic RHD:
What Paediatrician should know ?

Rheumatic fever cause
- chronic process of
valvular fibrosis
- commissures are fused
- the cusps are severely
thickened
- calcification with
shortened,
thickened chordae
tendineae
Subcutaneous nodules
What Paediatrician should know ?

Rarely seen and when
present
Usually associated with
severe carditis.
Painless, firm, movable,
measuring around 0.5 to
2 cm.
Located over extensor
surfaces of the joints,
particularly knees, wrists
and elbows
Erythema Marginatum
What Pediatrician should know ?

erythematous lesions
with pale centers and
rounded or serpiginous
margins
Laboratory Investigations:
What Pediatrician should know ?

No specific laboratory investigations
1. Acute phase reactant
(CRP, SAA, SAP, Complements, Coagulation
Proteins)
2. Serologis and bacteriologis (ASO, Anti-
DNAse B titres, Culture)
3. Electrocardiography, radiology,
echocardiograpphy
Differential diagnosis of rheumatic fever
What Pediatrician should know ?

* Rheumatic fever and rheumatoid arthritis are
completely different diseases although both
are immmunologically mediated diseases.

* But remmember R.F. is more serious and
more important as it can be prevented.




MANAGEMENT
Step 0 : Primordial prevention
Step I : Primary prevention
(eradication of streptococci)
Step II : Anti inflammatory treatment
(aspirin,steroids)
Step III : Supportive management &
management of complications
Step IV :Secondary prevention
(prevention of recurrent attacks)
Step 0: Primordial Prevention
* Primordial prevention of the disease
- Immunization (?)
- Socio economic
- Nutrition
- Public education (school going age, parents,
teachers, all personel involve with children, etc)
* Control spread of disease to others
- Reduce risk of cross-transmission of organisms
- Infection control policies
- Handwashing
- Overcrowding
- Availability to prompt medical care

STEP I: Primary Prevention of
Rheumatic Fever
* The most important way to prevent
rheumatic fever is by proper and
prompt treatment of GABHS throat.

* Identification & Eradication of
GABHS

Anti inflamatory
* Definite Carditis No cardiomegaly
Salicylates 100 mg/kg/day
-In one or two weeks, reduce to 75 mg/kg/day
-Continue for 6 - 8 weeks
-Shift to prednisone if cardiomegaly develops
* Severe Carditis Cardiomegaly or CHF
Prednisone 1 - 2 mg/kg/day for 2 - 4 weeks
-Begin Salicylates in final weeks of prednisone
and continue for 6 8 weeks



Step II : Identification and treatment
of ARFand RHD
Step II : Identification and treatment
of ARFand RHD

Antibiotic regimens
ANTIBIOTIC ERADICATION REGIMEN
Benzathine penicillin,
im
Bodyweight < 27 kg 600,000 IU x 1
Bodyweight < 27 kg 1.2 MIU x 1
Penicillin V, oral 100,000 IU/kg/day for 10 days
in 3 doses/day
Erythromycin 50 mg/kg/day
in 3 doses/day for 10 days
The roles for antibiotics
in Rheumatic Fever
(1) initially treat GABHS pharyngitis
(2) prevent recurrent streptococcal
pharyngitis, RF, and RHD
(3) provide prophylaxis against bacterial
endocarditis.
Bed rest
Treatment of congestive cardiac failure:
-digitalis,ace inhibitor, diuretics
Treatment of chorea:
-diazepam or haloperidol
Rest to joints & supportive splinting

Supportive & management of
complications
Step III:
Variable After 6
months
After 10
weeks
After 6
8
weeks
All
Activties
3 months or
longer
3 months 4 weeks 3 weeks Outdoor
3 months 6 weeks 3 weeks 2 weeks Indoor
3 6 months 6 weeks 3 weeks 2 weeks Bed Rest
Carditis; with
enlargement
Carditis; No
enlargement
Minimal
Carditis
Arthritis
Bed rest in Rheumatic Fever
Activity :
->Initially, on bed rest, a period of indoor activity
,permitted to return to school.

->Do not allow full activity directly.

->Patients with chorea may require a wheelchair.
Treatment of congestive cardiac failure:
Recommendations of American Heart Association
Treatment of congestive cardiac failure:
Recommendations of American Heart Association
Treatment of congestive cardiac failure:
Recommendations of American Heart Association
Treatment of congestive cardiac failure:
Recommendations of American Heart Association
Treatment of congestive cardiac failure:
Recommendations of American Heart Association
STEP IV : Secondary Prophylaxis of RF
(Prevention of Recurrent Attacks)
Agent Dose Mode

Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral
or
Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral
1.0 g once daily for patients >27 kg (60 lb)
For individuals allergic to penicillin and sulfadiazine
Erythromycin 250 mg twice daily Oral

*In high-risk situations, administration every 3 weeks is justified and
recommended
Recommendations of American Heart Association
Function of Secondary Prophylaxis
The regular administration of antibiotics

Prevents GABHS infections
(which can result in recurrent ARF)
Reduces the severity of RHD
Helps prevent death from severe RHD.
Prevention of bacterial endocarditis
What Paediatrician should know ?

* Patients who had RF without valve damage
do not need endocarditis prophylaxis.

* Do not use penicillin, ampicillin, or amoxicillin
for endocarditis prophylaxis in patients already
receiving penicillin for secondary RF
prophylaxis (relative resistance of oral
streptococci to penicillin and aminopenicillins).

* Alternate drugs recommended by the
American Heart Association for these
patients include oral clindamycin
(children: 20 mg/kg; adults: 600 mg)
and
oral azithromycin or clarithromycin
(children: 15 mg/kg; adults: 500 mg)
Prevention of bacterial endocarditis
What Paediatrician should know ?

Surgical vs Non Surgical Care:
* Surgery for patients who remain symptomatic
despite medical management.
* Critical MS : valvotomy / valve replacement
(<= 1.75 0.85 cm)
-balloon valvuloplasty
-open valvotomy/valvuloplasty can be done.
-valve replacement is necessary
Diet:
* Without restrictions except in patients
with CHF, who should follow a fluid-
restricted and sodium-restricted diet.

* Potassium supplementation
(mineralocorticoid effect of corticosteroid
and the diuretics)
Patient Education:
->Timely evaluation and treatment of
pharyngitis in children.

->Secondary prophylaxis.

->Additional prophylactic antibiotics prior to
dental and surgical procedures.

Complications:
* CHF from valve insufficiency (acute RF) or
stenosis (chronic RF).
* Atrial arrhythmias
* Pulmonary edema
* Recurrent pulmonary emboli
* Infective endocarditis
* Thrombus formation
* Systemic emboli.

Rheumatic Fever - Prognosis
Is good if recurrence is prevented by continuous
antibiotic prophylaxis- particularly if no carditis in the
initial attack.

Can recur if not on prophylactic medicines.

Good prognosis for older age group & if no carditis
during the initial attack.

Bad prognosis for younger children & those with
carditis with valvar lesions.
Is It Possible to Prevent Rheumatic Fever ?
In the future
Primary prevention will have to wait
till a safe and effective GABHS
vaccine becomes available.

PRIORITY ISSUES TO BE COVERED
SOCIO ECONOMIC STATUS OF THE PEOPLE
EARLY DIAGNOSIS OF THE STREPTOCOCAL THROAT
CASE DETECTION OF ARF
PRIMARY PREVENTION (3 to 15 YEARS OF AGE).
SECONDARY CONTINOUS PROPHYLAXIS (3 to 21/35
years).
REFERRAL SYSTEM, FOLLOW UP AND ADHERENCE


Rheumatic Fever
A post-infectious connective tissue disease
Follows GAS pharyngitis by 3 weeks (vs. nephritogenic strains of
GAS)
Injury by GAS antibodies cross-reacting with tissue
Dx JONES criteria (major and minor)
Tests Throat Cx, ASO titer, CRP, ESR, EKG, +/- ECHO
Rx PCN x10 days and high-dose ASA or steroids
2
o
Prophylaxis daily po PCN or monthly IM PCN
Jones Modified Criteria
Rheumatic Carditis
Present in 50% cases
Sleeping tachycardia is an early sign
Mitral and aortic valves most commonly involved
Rheumatic Arthritis
Most common manifestation
Pain, swelling and erythema
Resolves within 1 week

Rheumatic Fever organs
affected
1. Heart muscle & valves myocarditis & endocarditis
(pericarditis rare w/o the others)
2. Joints polyarthritis
3. Brain Sydenhams Chorea (milkmaids grip or better yet,
motor impersistance)
4. Skin erythema marginatum (serpiginous border) due to
vasculitis
5. Subcutaneous nodules non-tender, mobile and on extensor
surfaces
Rheumatic Fever: The Problem
#1 Cause of Acquired heart disease in children.
( world-wide but not in USA )
- AHA: >3200 deaths in US, related to RF/RHD in 2004.
Sequelae of inadequately treated strep. pharyngitis.
( strep throat )
Highly Uncommon - < 1% of untreated infections.
- Gp A beta-hemolytic - rheumatogenic strains M proteins.
- 1/3
rd
of cases follow inapparent strep infections.
A Non-Suppurative Systemic Inflammatory illness
occuring 1 - 2 wks following a Strep.Infection.
Pathogenesis - Autoimmune mediated.
Multiple systems affected. (Joints, Skin, CNS & Heart !)
Primarily affects: 5 15 year old age group.
Rheumatic Fever: Clinical Features
Polyarthritis w/ low grade fever, large joints, ( > 75%)
migratory - often 1 at a time, w/ no permanent dysfx.
Carditis - pericarditis, cardiomegaly, or valvulitis ( ~ 50%)
(valvulitis is the most serious manifestation.)
Chorea late occurrence, 3 - 4 months after ( ~ 10%)
infection, self-limiting, resolves in 1- 3 months.
Erythema Marginatum classic truncal rash, ( ~ 10%)
migratory - appears & disappears within hours.
(pink rash irregular red edges clear center)
Subcutaneous Nodules late occurs late (1 - 2%)
( months after infection), painless small nodules
over bony prominences - elbows, knees, spine.
Rheumatic Fever: Jones Criteria
*
(Reqs: 2 Major or 1 Major & 2 Minor)
Major Minor
Polyarthritis Arthralgia
Carditis Prolonged PR interval
Chorea Elevated CRP, ESR
Erythema marginatum Fever (1012 F)
Subcutaneous Nodules Elevated WBC

* with (+) evidence of a prior strep. infection
( incrd ASO or anti-DNAse AB)
or Hx of (+) C/S or Rapid Strep Test
Rheumatic Fever: Prevention
ANTIBIOTICS - 2 TYPES of USE:
Primary Prevention - Appropriate detection
& treatment of Strep. Pharyngitis.
Secondary Prevention - Patients with Hx
of Rheumatic Fever require continuous
prophylactic antibiotics due to:
1) increased susceptibility to recurrences
2) increased severity of recurrences, &
3) asymptomatic nature of Strep. Infections
Rheumatic Fever Primary Prevention:
ANTIBIOTICS: Therapeutic Course
IM - Benzathine Penicillin Drug of Choice !
0.6 MU IM 1Time (< 27 Kg or 60 lbs)
1.2 MU IM 1Time ( >27 Kg or 60 lbs)
PO - Phenoxymethyl Penicillin (Pen VK)
Children ( 40mg/kg/day ) 250 mg B-TID x10 days
Adolescent /Adult 500 mg B-TID x10 days
( See Strep.Pharyngitis for alternatives )

ANTI-INFLAMMATORY AGENT: ASA or CCS
SYMPTOMATIC TX: for CHF or Chorea
BEDREST: Limited physical activity
Rheumatic Fever: Secondary Prevention
Continuous Prophylaxis of Recurrent Attacks
Benzathine Penicillin
0.6 MU IM q4 weeks* ( < 27 Kg or 60 lbs)
1.2 MU IM q4 weeks* ( > 27 Kg or 60 lbs)
* q3 wks for high-risk individuals
Penicillin VK 250 mg PO BID
( < 5 years old 125 mg PO BID )
Sulfadiazine 0.5 gm PO QD (< 27 Kg or 60 lbs)
1 gm PO QD ( >27 Kg or 60 lbs)
Erythromycin 250 mg PO BID


Duration of Rheumatic Fever Prophylaxis
Based on: Time since last episode of RF, Age,
& Presence of Residual Carditis/Valve Damage

With Carditis & Residual Valve Dis:
Continue ABX for 10 yrs after last episode
& until 40 yoa. ( potentially lifelong ??? )
With Carditis but without Residual Valve Dis:
Continue ABX for 10 yrs after last episode
& well into adulthood.
Without Carditis:
Continue ABX for 5 yrs after last episode and
until 21 yoa. ( whichever is longer )
Acute Pharyngitis (AP): Background
GaBHS
*
- most common Bacterial cause of AP.
Majority of AP cases are Viral.
Age Relationship: GaBHS accounts for ONLY;
20 - 30 % of AP in children 5 - 15 yrs old
10 - 20 % in adoles./adults 15 - 35 yrs
5 - 10 % after 35 yrs
Seasonal: winter and early spring.
~ 75% of patients seen in primary care settings
receive ABX Rxs for AP. ( 6.7 million visits/yr )
Also causes Skin Infections Impetigo/Pyoderma
( * GaBHS = Gp A beta-hemolytic strep. )
aka: strep pyogenes
Nimishikavi S, Stead L Streptococcal Pharyngitis Images in Clinical Medicine.
NEJM 2005: 352:e10.
Acute Pharyngitis: Clinical Features
Suggest Bacterial Suggest Viral
( GaBHS )
Sudden Onset Sore throat Conjunctivitis
Pain on Swallowing Runny Nose
Fever ( 101-104 F) Cough
Headache Diarrhea
N/V & Abdominal Pain Hoarseness
(+) Cervical Nodes
Pharyngeal / Tonsillar
Erythema & Exudates
Strep. Pharyngitis: Diagnostic Options
Throat Culture - Gold Standard ( read at 24 & 48 hrs )
High Specificity & High Sensitivity
- True positives / Few False negatives
Rapid Antigen Detection Test (RADT) - Detects GaBHS CHO.
High Specificity & but only Good Marginal Sensitivity.
- True positives / Many False negatives
Strept Antibody test - detects ASO & anti-DNAse ABs.
- No immediate value in deciding treatment.
Recommended approach:
(+) C/S or RADT confirms presence of GaBHS = Treat !
In child or adoles.- (-) RADT needs C/S confirmation.
In adults, (-) RADT doesnt require C/S confirmation.

No Method Identifies GaBHS Carriers with Viral AP
$$$$$$ - Lots of testing ???
Modified Centor Score & Management Approach
( McIsaac - JAMA 2004 )
Criteria Points
Temperature >38 C 1
Absence of Cough 1
Swollen Tender Cervical Node 1
Tonsillar Swelling / Exudate 1
Age: 3 - 14 years 1
15 44 years 0
45 years or older -1
Total Score: ( )
Management Approach:
SCORE: 0 - 1 No Further Testing or ABX Therapy.
2 - 3 Culture All: ABXs only for (+)C/S.
>4 Treat Empirically (No C/S or RADT).
Strep. Pharyngitis:
First Line Treatment Options
Child - Penicillin VK 250 mg B-TID x 10 days
Amoxicillin 20-40 mg/kg/day divd TID x 10 days
Benzathine Pen G 600,000 units IM 1X ( <60lbs )
Erythromycin 40 mg/kg/day B-QID x 10 days
( max 1gm/day )
Adolescent and Adults
Penicillin VK 500mg B-TID x 10 days
Amoxicillin 500mg TID x 10 days
or 1000 mg BID x 6 days
Benzathine Pen 1.2 MU IM 1X (>60lbs)
Erythomycin 250mg QID / 500mg BID x 10 days


DOSE MAX/DAY
Cefixime 8 mg/kg/day div q12 24h 400 mg
Cephalexin 25 - 50 mg/kg/day div B-QID 2000 mg
Cefadroxil 30 mg/kg/day div BID 2000 mg
Clindamycin 20-30 mg/kg/day div T-QID 1800 mg
Azithromycin 12 mg/kg/day QD X5 days 500 mg
(>2y/o)
Cefdinir 14 mg/kg/day div BID X5 days 600 mg
Cefpodoxime 10 mg/kg/day div BID X5 days 400 mg
STREP. PHARYNGITIS:
Alternative Treatment Options
Pedi <12 yoa or < 40Kg
STREP. PHARYNGITIS:
Alternative Treatment Options
Adults/ Adolescents >12 yoa or > 40Kg
DOSE MAX/DAY
Cefixime 400 mg QD 400 mg
Cephalexin 250-500 mg QID 2000 mg
Cefadroxil 1-2 gms/day div Q12-24hr 2000 mg
Clindamycin 300-450 mg T-QID 1800 mg
Azithromycin 500 mg day 1, then
250 mg QD X4 days
Cefdinir 300 mg BID X5 days 600 mg
Cefpodoxime 200400 mg BID X5 days 800 mg
Antibiotics NOT Recommended
for Strep. Pharyngitis:
Sulfonamides
Trimethoprim / Sulfamethoxazole
Fluoroquinolones
Tetracyclines / Doxycycline /
Minocycline

References
Endocarditis:
- Wilson W et al. AHA Guideline Prevention of Infective Endocarditis.
(A guideline from the AHA Rheumatic Fever, Endocarditis, &
Kawasaki Disease Committee, Council on Cardiovascular Disease
in the Young, & Council on Clinical Cardiology, Council on
Cardiovascular Surgery & Anesthesia, & the Quality of Care &
Outcomes Research Interdisciplinary Working Group.)
Circulation 2007;116:1736-54.
- Dajani AS et al. Prevention of Bacterial Endocarditis Recommendations
by the American Heart Association. JAMA 1997; 277: 1794-1801.
- Brook MM. Pediatric bacterial endocardiotis: treatment and prophylaxis.
Pediatric Clinics of North America 1999; 46: 275-87.



References
Rheumatic Fever:
- Dajani AS et al. Guideline for the Diagnosis of Rheumatic Fever: Jones
Criteria, Updated 1992. The Committee on Rheumatic Fever,
Endocarditis, & Kawasaki Disease of the Council on Cardiovascular
Disease in the Young. Amer Heart Ass. Circulation 1993;87:302-7.
- Ferrieri P. AHA Scientific Statement - Proceedings of the Jones Criteria
Workshop. Circulation 2002;106:2521 3.
- Saxena A. Treatment of Rheumatic Carditis Symposium on Pediatric Cardiology. Indian J
of Peds 2002;69:513-6.




Streptococcal Pharyngitis:
- Bisno AL et al. Practice Guidelines for the Diagnosis and Management
of Group A Streptococcal Pharyngitis. (IDSA Guidelines)
Clinical Infectious Diseases 2002; 35:113-25.
- The American Heart Association. Treatment of Acute Streptococcal
Pharyngitis and Prevention of Rheumatic Fever A Statement for
Health Professionals. Pediatrics 1995;96:758-764.
- McIsaac WJ et al. Empirical Validation of Guidelines for the management
of Pharyngitis in children and adults. JAMA 2004;291:1587-95.
- Shulman ST et al. So whats wrong with penicillin for strep throat?
Pediatrics 2004; 113: 1816-19.

References