Abstract

To assess the incidence of acute rheumatic fever among Arab children in the Eastern Province of Saudi Arabia, we reviewed the medical records of children admitted to Dhahran Health Center with acute rheumatic fever between 1 January 1980 and 31 December 1984. Thirty Arab children with definite initial attacks of acute rheumatic fever were identified. The mean annual incidence rate of acute rheumatic fever was 22 per 100,000 Arab children between 5 and 14 years old. The clinical manifestations included arthritis in 80% of the 30 patients, carditis in 60%, and chorea in 6.6%. The results of this study indicate that rheumatic fever is a significant health problem in Saudi Arabia.

MeSH KEYWORDS: Rheumatic fever–occurrence

In the west, the incidence of acute rheumatic fever has declined steadily for the last 30 years. Incidence rates ranging between 0.2 and 0.64 per 100,000 population have been reported in series from the United States.^1-5 However, there are little data on the incidence rates of rheumatic fever in the Middle East.^6,7

The purpose of this study is to report the incidence rate of rheumatic fever and the frequency of its manifestations among Arab children in the Eastern Province of Saudi Arabia.

Patients and Methods

The Arabian American Oil Company (ARAMCO) Medical Organization serves a population of 182,564, of which 27,064 are Arab children in the age range from 5 to 14 years (1983 statistics). ARAMCO employees and their dependents live in the Eastern Province of Saudi Arabia. The area can be considered subtropical–maximum summer temperatures approach 45°C, and on occasional midwinter days, freezing temperatures may occur.

We reviewed the records of Arab children admitted to Dhahran Health Center with rheumatic fever between 1 January 1980 and 31 December 1984. In all cases, our diagnosis of acute rheumatic fever was based on the modified Jones criteria⁸; that is, each child had to have at least one major criterion, two minor criteria, and supporting evidence of a recent streptococcal infection. Isolated Sydenham's chorea has been included as a definite cause of acute rheumatic fever. It is the practice of pediatricians in our institution to admit all patients with suspected diagnosis of acute rheumatic fever.

Results

Thirty definite cases of initial attacks of acute rheumatic fever and two recurrences were admitted during the 5-year period, 17 boys and 13 girls, ranging in age from 5 to 14 years. The mean annual incidence rate of initial attacks of acute rheumatic fever was 22 per 100,000 Arab children in the age range of 5 to 14 years. Fifty-seven percent of patients were admitted between September and December (Figure 1).

The clinical manifestations are summarized in Table 1. Polyarthritis was present in 24 patients (80%). Seven patients (23%) had arthralgia, and each one of these seven patients developed carditis. Eighteen patients (60%) were diagnosed to have carditis, and five patients (17%) had congestive heart failure. Chorea was diagnosed in two patients (7%). None of the children had either erythema marginatum or subcutaneous nodules. History of prior sore throat or upper respiratory tract infection was obtained in 17 patients (57%), and the streptozyme test was positive in > 1:200 dilution in 25 patients (83%), 1:100 dilution in four patients (14%), and one patient with Sydenham's chorea had a negative test.

Table 1. Clinical and laboratory findings in 30 patients with acute rheumatic fever.

All patients were treated with aspirin at a daily dosage of 100 mg/kg, and approximately 15% of these patients developed clinically significant hepatotoxicity.

Discussion

Rheumatic fever continues to be a significant health problem, especially in developing countries and the Middle East. Data from our study show a high age-adjusted incidence rate of acute rheumatic fever (22/100,000) among Arab children in the Eastern Province of Saudi Arabia. The rapid increase in the number of schools, urbanization, and overcrowding might explain the apparently high incidence of acute rheumatic fever in this country and other countries of Middle East.

One third of cases of acute rheumatic fever occurred during the months of November and December, and this aggregation during early winter months might be explained by an increase in upper respiratory infections during these months. The clinical manifestations of acute rheumatic fever in the Eastern Province of Saudi Arabia were similar to the findings reported recently from developed countries.^1,9

Carditis was present in 18 patients (60%) and in 12 of them it was mild. Such mild cases of acute rheumatic fever are in contrast to many reports from developing countries about the severity of acute rheumatic fever.^10,11 This variation is most probably secondary to inadequacy of reporting of mild cases in these countries and to inclusion of recurrent cases in their series. Majeed et al¹² and Sanyal et al¹³ recently reported the mild nature of acute rheumatic fever in Kuwait and India, respectively. In this study and other recent studies, neither erythema marginatum nor subcutaneous nodules were observed.^9,14

Salicylates in high doses were used to treat rheumatic fever in our patients. Clinically significant hepatotoxicity occurred in approximately 15% of these patients. It is important to monitor liver function tests in these patients, and serum salicylate levels should be maintained at between l.l and l.8 mmol/L.^15,16

We conclude that the incidence of confirmed cases of rheumatic fever in the Eastern Province is relatively high, and more intensive effort should be made to prevent the spread of streptococcal infection by obtaining frequent cultures from children with pharyngitis and treating those with positive streptococcal cultures. The throat culture has presented a significant drawback that interferes with early treatment, namely the 48-hour delay in obtaining results. Recently, several rapid methods of detecting group A streptococci directly from the throat have been developed. The tests can be done in 2 to 10 minutes, and if the results are positive, treatment may be started promptly.^17,18

Acknowledgment

We thank M. Speckhard, MD, and H. Arrighi, MSpH, Department of Preventive Medicine, for their help in interpretation of statistical data.

References

1. Land MA, Bisno AL. Acute rheumatic fever: a vanishing disease in suburbia. JAMA 1983;249(7):895-8.

2. Holmberg SD, Faich GA. Streptococcal pharyngitis and acute rheumatic fever in Rhode Island. JAMA 1983;250(17):2307-12.

3. Schwartz RH, Hepner SI, Ziai M. Incidence of acute rheumatic fever: a suburban community hospital experience during the 1970s. Clin Pediatr 1983;22(12):798-801.

4. Markowitz M. The decline of rheumatic fever: role of medical intervention. J Pediatr 1985;106(4):545-50.

5. Sievers J, Hall P. Incidence of acute rheumatic fever. Br Heart J 1971;33:833-6.

6. Majeed HA. Acute rheumatic fever in Kuwait: some clinical, epidemiological and preventive aspects. J Kuwaiti Med Assoc 1983;17:3-8.

7. Gharib R. Acute rheumatic fever in Shiraz, Iran: its prevalence and characteristics in two socioecomonic groups. Am J Dis Child 1969;118:694-9.

8. Committee report. Jones' criteria (revised) for guidance in the diagnosis of rheumatic fever. Circulation 1965;32:664-8.

9. Tamer DM. Acute rheumatic fever in a South Florida county hospital 1967-1971. Circulation 1974;50(4):765-7.

10. Tahernia AC, Moatamed F, Sharif H. Some clinical observations of rheumatic fever in childhood: patterns of the disease as seen in Southern Iran. Clin Pediatr 1971;10:530-6.

11. Robinson RD Jr, Sultana S, Abbasi AS, et al. Acute rheumatic fever in Karachi, Pakistan. Am J Cardiol 1966;18:548-51.

12. Majeed HA, Khan N, Dabbagh M, et al. Acute rheumatic fever during childhood in Kuwait: the mild nature of the initial attacks. Ann Trop Paediatr 1981;1:13-20.

13. Sanyal SK, Thapar MK, Ahmed SH, et al. The initial attack of acute rheumatic fever during childhood in North India: a prospective study of the clinical profile. Circulation 1974;49(1):7-12.

14. Dahl D, Bessinger FB Jr, Kaplan EL. Rheumatic fever in Minnesota: current assessment of reported cases. Minn Med 1978;61(4):249-54.

15. Hamdan J, Ahmad M, Sa'di AR. Salicylate hepatotoxicity in rheumatic fever. Ann Trop Paediatr 1983;3(2):89-91.

16. Hamdan JA, Manasra K, Ahmed M. Salicylate-induced hepatitis in rheumatic fever. Am J Dis Child 1985;139(5):453-5.

17. Araj GF, Majeed HA. Evaluation of a two-minute strep A direct swab test (SADST) on patients with pharyngitis at a primary care clinic. J Hyg 1986;97(1):133-8.

18. Chang MJ, Mohla C. Ten-minute detection of group A streptococci in pediatric throat swabs. J Clin Microbiol 1985;21(2):258-9.