الفهرس 
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Abstract
Polyarthritis is the most common manifestation of rheumatic fever. It is known that some patients with rheumatic arthritis who have no cardiac murmurs have significant valvular regurgitation detected by Doppler echocardiography denoting that carditis have occurred in a subclinical form in such patients.
This work was undertaken to study the risk of development of rheumatic heart disease (RHD) in patients who were clinically free of carditis at the initial attack and to study the factors related to the development of RHD in these patients.
The study comprised 50 patients with a history of initial attacks of isolated rheumatic arthritis, who were followed up for at least five years at the Cardiology Clinic of the Alexandria University Children’s hospital. All patients were diagnosed according to the revised Jones criteria for diagnosis of acute rheumatic fever. They were twenty seven (54%) females and twenty three (46%) males. Their ages at the time of study ranged form 10-25 years with a mean of 14.8 ± 4.75years.
Detailed history was obtained form each patient to determine the exact mode of onset of the illness, the age of onset, secondary prophylaxis program, number and type of recurrences (if any). Data about the cardiac status at the initial attacks were obtained from the hospital records. Complete clinical and echocardiographic examinations were done for each patient for detection of any cardiac affection and for comparing the echo finding with that of the initial diagnosis. Compliance was assessed by revision of the patients’ follow up cards at the clinic. The average age of patients at onset of the initial rheumatic attack was 5-16 years with a mean of 10.7±3.30. Positive family history was found in 40% of cases.
Seventy four percent of cases belonged to large families in which the average sibling number equals or exceeds five.
The duration of secondary prophylaxis ranged from 5-16 years with a mean of 9.9 ± 3.26 years. Ninety eight of patients used regular intramuscular injections of benzathine penicillin G for prophylaxis, 78% every two weeks, 12% every three weeks, 8% every four weeks. One patient received oral daily sulfadiazine because of penicillin allergy. Sixty five percent of the patients had good compliance (>90% of injections/year) and the remaining 35% had poor compliance. During the period of follow up, fifteen patients had twenty seven recurrences with an average of 1.8 recurrences per patient. Clinical manifestations of recurrences were as follow: 63% arthritis, 22.2% carditis, and 14.8% chorea. The echocardiographic examination at the end of follow-up period revealed that 72% had no valvular lesion and 28% had valvular lesions. The mitral valve was the commonest valve affected where 14% of patients had mitral regurgitation, 4% had aortic regurgitation, 2% had double mitral lesions (MR & MS), 4% had combined valvular lesions (mitral+aortic) and 4% had mitral valve prolapse with mitral regurge. It is known that the main cause of development of rheumatic heart disease (RHD) is recurrence, however, out of 14 patients who developed RHD, six patients (43%) developed RHD despite the absence of any history of recurrences. The cause of this is unknown. It is possible that these patients developed RHD at the end of follow up period because subclinical carditis had occurred but was not discovered at the initial diagnosis as echocardiographic was not routinely done for all patients or patients had subclinical activity.
As rheumatic arthritis is a common manifestation of rheumatic fever, and some times is difficult to diagnose especially in cases with atypical presentation and borderline laboratory findings, echocardiographic examination in these cases could reveal abnormal blood flow through the valve giving a support to the diagnosis. Not only that but also echocardiographic examination will add more help while deciding the duration of secondary prophylaxis and considering prophylaxis against bacterial endocarditis in these patients.