Acute rheumatic fever and post-streptococcal reactive arthritis

Barash J. Rheumatic Fever and post-group a streptococcal arthritis in children. Curr Infect Dis Rep. 2013 Jun;15(3):263-8.

There are several diseases associated with group A beta hemolytic streptococcal infection; the two most common are acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PsRA). Epidemiological and clinical data for both diseases are described, as well as current recommendations for treatment and prevention. There is an ongoing debate as to whether these two are different diseases or are parts of the spectrum of the same disease. There are some reports of carditis developing after PsRA, suggesting that PsRA may be part of the spectrum of ARF. However, since there are substantial clinical, immunological, and genetic differences between PsRA and ARF, we believe PsRA to be a distinct entity.

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Uziel Y, et al. Post-streptococcal reactive arthritis in children: a distinct entity from acute rheumatic fever. Pediatr Rheumatol Online J. 2011 Oct 20;9(1):32.

There is a debate whether post-streptococcal reactive arthritis (PSRA) is a separate entity or a condition on the spectrum of acute rheumatic fever (ARF). We believe that PSRA is a distinct entity and in this paper we review the substantial differences between PSRA and ARF. We show how the demographic, clinical, genetic and treatment characteristics of PSRA differ from ARF. We review diagnostic criteria and regression formulas that attempt to classify patients with PSRA as opposed to ARF. The important implication of these findings may relate to the issue of prophylactic antibiotics after PSRA. However, future trials will be necessary to conclusively answer that question.

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van der Helm-van Mil AH. Acute rheumatic fever and poststreptococcal reactive arthritis reconsidered. Curr Opin Rheumatol. 2010 Jul;22(4):437-42.

ARF and PSRA present differently. PSRA patients are generally older, have a longer interval between group A streptococcus infection and symptom onset, and respond less dramatically to salicylates than ARF patients. The course of ARF may be complicated by carditis and valvular heart disease. Echocardiographic studies in Caucasian adults with PSRA have revealed no increase in valvular heart disease. The course of PSRA is characterized by arthritis that, in contrast to ARF, is additive, nonmigratory and is frequently chronic. Factors of the host, the Streptococcus and the immune response involved in the development of PSRA are scarcely explored, hampering comparisons with ARF.

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Barash J, et al. Differentiation of post-streptococcal reactive arthritis from acute rheumatic fever. J Pediatr. 2008 Nov;153(5):696-9.

On the basis of the results of this study, ARF and PSRA appear to be 2 distinct entities. Although ARF has a more acute presentation, with fever, acute phase response, a greater number of joints, and frequency of cardiac involvement, the response to treatment is much quicker and the course of arthritis is shorter than in PSRA. If PSRA was a milder form of the spectrum of ARF, we would not expect a slower response to treatment or a longer course of the arthritis.

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Tutar E, et al. Poststreptococcal reactive arthritis in children: is it really a different entity from rheumatic fever? Rheumatol Int. 2002 Jun;22(2):80-3.

Poststreptococcal reactive arthritis (PSRA) is an acute, nonsuppurative arthritis following documented streptococcal infections. Although most authors accepted it as a different entity, the differences from acute rheumatic fever (ARF) are not clear. To document and compare the clinical and laboratory characteristics of PSRA and ARF, 24 patients with PSRA and 20 with ARF were enrolled in the study. The latency period from upper respiratory tract infection was shorter in patients with PSRA ( P<0.01). However, 25% of the patients with ARF had also short (<10 days) latency periods. Although symmetric and nonmigratory arthritis were more frequent in patients with PSRA, there was no significant difference for the distribution of mono-, oligo-, and polyarticular disease between PSRA and ARF patients. The frequency of small joint and hip involvement was also similar between the patient groups. Unresponsiveness of articular symptoms to salicylate therapy within 72 h was more frequent in patients with PSRA (P<0.001). However, in a substantial part of the patients with ARF (nine patients, 45%), joint symptoms also had no response during the first 72 h. Since there is a considerable overlap of symptoms, signs, and laboratory features of PSRA and ARF, a line between these two entities could not be easily drawn. We conclude that these two conditions are actually different presentations of the same disease.

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