Acute rheumatic fever in adults over the age of 45 years: an analysis of 23 patients together with a review of the literature.

The natural history of acute rheumatic fever (ARF) in adults has been studied from an analysis of 23 patients together with a review of a further 466 published cases. In contrast to the picture in juvenile ARF, in our patients (average age 55 yr), only arthritis (83%) and carditis (35%) were major criteria for the diagnosis. All patients had at least 3 minor criteria. To summarize, 39% of the patients, average age 56 yr were seen in their initial attack of ARF. In those patients with a previous history of rheumatic fever, the mean interval between the index attack and the first illness was 20.5 yr. Contact with young children appeared to be an important predisposing factor. None had an ESR of less than 50 mm in the first hour, even in the presence of cardiac failure. Findings in the acute illness included anemia (70%), hyperglobulinemia (70%), urinary sediment (66%), and hypercalcemia in 7 out of 12 cases. The response to treatment was good and only 1 patient of 13 followed-up developed a new valvular lesion. A survey of the literature shows that attacks of ARF may occur at any age; death in the acute episode is rare and occurs only in patients with severe preexisting valvular disease with congestive failure. The problem of diagnosing active carditis in the presence of rheumatic heart disease (RHD) is discussed. While juvenile ARF may be overdiagnosed, the diagnosis may be missed in the adult rheumatic patient whose cardiac state inexplicably deteriorates. In such patients evidence for a preceding streptococcal infection should be sought. Patients with a high risk of developing ARF include those with carditis in previous attacks, with preexistent RHD, and with several children in the family. These factors should be considered when advising on the duration of antibiotic prophylaxis.