Title : The faces of post-streptococcal cardiac involvement in Paediatrics: A case series
Abstract:
Group A Streptococcus (GAS) is a global burden, including in Indonesia, with long-term morbidity and mortality complications. The different response to nephrogenic and rheumatogenic strain makes concurrent post-streptococcal glomerulonephritis with acute rheumatic fever a rarity. Pancarditis progression in acute rheumatic fever can deteriorate to dilated cardiomyopathy, leading to cardiogenic shock and death. While in another side, rheumatic fever (RF) can progress to rheumatic heart disease (RHD) and increase the risk of future heart failure, arrhythmias, cardiovascular disease, and endocarditis.
We report three cases of post-streptococcal cardiac complications. Patient 1, an 8-year-old female with palpitations and a recurring cough, was diagnosed with RF. Patient 2, a 10-year-old female child with haemoptysis, lungs and extremities oedema due to acute rheumatic carditis and a history of suspected vegetation. Both had severe mitral regurgitation due to prolapse, tricuspid regurgitation and EF >60%. Both recovered well with heart failure management, antibiotic, and aspirin. And Patient 3, a 9-year-old male initially diagnosed with post-streptococcal glomerulonephritis, deteriorated to dilated cardiomyopathy with EF 32% and multiple organ dysfunction syndromes. Under intensive diuresis, heart failure and infection management, the patient recovered after nine-day and was dismissed without symptoms. Unfortunately, Patient 1 had not returned for further follow-up.
Clinicians should be aware of post-streptococcal cardiac involvement despite rare cases, especially cardiomyopathy in post-streptococcal glomerulonephritis. Unlike RF, the progression to dilated cardiomyopathy remains unclear in PSGN patients. Unfortunately, we cannot check for GAS strains or biopsies due to limited facilities. Although RF is more common in tropical and developing countries, GAS outbreaks and mutation have been found in high-income countries. Early recognition and aggressive management are recommended since severe valve lesions and heart failure contribute to poor predictors for death in children. The prevention and long-term effects of cardiac-related need to be addressed, not only in GAS but also in other infectious diseases affecting the heart. Learning from the pandemic, how COVID-19 can easily be transmitted and mutated due to the progress of globalisation and its cardiovascular complications, guidelines are needed to face the upcoming challenges against infectious diseases.
Audience Take Away Notes
- Understand the management of a spectrum of post-streptococcal cardiac involvements. Mitral prolapse is more profound in early rheumatic heart disease.
- Due to different strains, cardiac involvement in post-streptococcal glomerulonephritis is rare but can be devastated. Continuous monitoring is essential and carditis must be suspected in worsening symptoms.
- Aggressive treatment and prevention in paediatrics are substantial as their long-term management and complications increase the global burden.
- The need to increase awareness and address group A streptococcus as one of the neglected diseases. Future research and guidelines are required to face the upcoming infectious disease in era of globalisation.
