50 Years Ago in The Journal of Pediatrics:

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McCue, CM. J Pediatr 1957;50:255-61

Although the incidence of rheumatic fever had been declining in the United States for more than 30 years, in the 1950s it remained a feared illness. Aspirin was available to treat systemic and articular manifestations of the disease, but its efficacy in carditis was uncertain. Many affected children were left with disability, and some died of their illness.

The report by Dr. McCue describes her experience with glucocorticoids to treat 94 children with acute rheumatic fever at the Medical College of Virginia during the years 1950 to 1957. Not all the children had carditis, but of those who did, some had pericarditis or severe congestive heart failure. Rheumatic fever was diagnosed using contemporary Modified Jones Criteria and treated using a protocol that evolved during the course of the study. Most patients received between 200 to 300 mg of cortisone or 60 mg prednisone orally for 21 days, followed by a 60-day taper. Outcome was judged according to grade of heart murmur, radiographic size of the cardiac silhouette, and survival. This was an uncontrolled study. However, of 36 patients with carditis who began treatment during the first 28 days of illness, 74% were judged to be either free of heart disease or greatly improved, a significantly better outcome when compared with a group of patients treated 10 years earlier. Furthermore, dramatic responses were observed in individual cases, some of which attending physicians judged to be life-saving.

Dr. McCue’s report was one of several studies from the same era, which included larger controlled, multicenter trials. Taken together, these studies failed to establish the superiority of glucocorticoids over aspirin for treatment of acute rheumatic carditis. Since their publication, the incidence of rheumatic fever has continued to decline in most industrialized countries. In contrast, it remains endemic in much of Africa, Asia, and South America,¹ where it far exceeds Kawasaki disease as the most common cause of acquired heart disease in childhood. Because of this, it is rather disturbing that, despite advances in cardiac imaging and development of newer immunosuppressive medications, no therapy has ever been convincingly shown to reduce the risk of heart valve lesions in acute rheumatic carditis.²

Efforts are underway to develop a vaccine against group-A streptococcus, the microorganism that elicits the immunologic response that causes rheumatic fever. However, until an efficacious, non-rheumatigenic vaccine becomes available, the need for an effective and affordable treatment for rheumatic carditis will remain as urgent as it was in 1957.

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Reference 

1. Rheumatic fever and rheumatic heart disease. Report of a WHO expert consultation Geneva 29 October 1-November 2001. WHO technical report series 923; Geneva, Switzerland, 2004. Available at: http://www.who.int/cardiovascular_diseases/resources/en/cvd_trs923.pdf. Accessed April 30, 2007.
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2. Cilliers AM, Manyemba J, Saloojee H. Anti-inflammatory treatment for carditis in acute rheumatic fever. Cochrane Database Syst Rev. 2003;2:CD003176
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