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. 2020 Aug 17;14(8):e0008558.
doi: 10.1371/journal.pntd.0008558. eCollection 2020 Aug.

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

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How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Alaa Ghamrawy et al. PLoS Negl Trop Dis. .

Abstract

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Components of the national rheumatic heart disease prevention and control program founded in Egypt in 2006.
The program follows the conceptual framework for comprehensive RHD control programs. Footnote of Fig 1: ARF; acute rheumatic fever, BPG; benzathine penicillin G, HIS; Health Information Systems, REDcap; Research Electronic Data Capture, Rh.A; rheumatic arthritis, RHD; rheumatic heart disease, S. Chorea; Sydenham’s Chorea.
Fig 2
Fig 2. Total number of RHD operative procedures and expenditures in the El-Mahalla tertiary care cardiac centre (1998–2018).
Footnote of Fig 2: RHD; rheumatic Heart disease, CABG; Coronary artery bypass grafting, CHD; Congenital heart disease, EGP; Egyptian pound.
Fig 3
Fig 3. Number of screened subjects versus the number of cases diagnosed with rheumatic fever or its sequelae per year, in El-Mahalla canter (2006–2018).
Fig 4
Fig 4. Age distribution of acute rheumatic fever and rheumatic heart disease patients.
Fig 5
Fig 5. Tonsillectomy among cases with a history of recurrent attacks of tonsillitis attending the El-Mahalla RHD centre (2006–2018).

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