Rheumatic fever activity in patients on regular penicillin prophylaxis

During the follow up of 740 rheumatic patients whose main clinical presentation to the Cardiology Clinic of the Pediatric Hospital, Cairo University was arthritis, 250 patients compliant to regular prophylaxis with benzyl penicillin G [BPG], 12 or more injections in one year, were studied for rheumatic fever [RF] recurrence. Clinical RF activity was detected in 28 patients [11.2%], 16 males and 12 females whose ages ranged 4-12 years. RF activity in the form of arthritis was detected in 14/28 cases [50%], carditis by auscultating new murmurs was detected in 9/28 cases [32.14%] and 5/28 cases [17.85] had chorea. Serum penicillin level was measured for all patients who showed clinical RF activity at the end of 3rd and 4th weeks after giving penicillin, by the agar-diffusion microbiological assay. Serum penicillin levels were below minimal therapeutic level [0.03 ug/ml] in 4/28 patients [14.28%] at the end of the 3rd week, 3 with carditis and one with arthritis. Two more cases with carditis in addition to the previous 4 cases showed low serum penicillin levels by the end of the 4th week, 6/28 cases [21.42%], both had carditis. None of the chorea patients had low serum penicillin levels at the end of 3rd or 4th week. Acute phase reactants and ASLO titers were not correlated with the presence of RF activity or low serum penicillin levels. It is concluded that RF recurrence occurs among patients on strict BPG prophylaxis, but with no evidence of streptococcal infection, other factors such as concomitant viruses or bacteria, or host factors may be responsible and needs further investigations

Variants of tetralogy of Fallot and associated anomalies, a study of 125 patients

Associated cardiac anomalies and variants of tetralogy of Fallot are common findings. They may be identified by echocardigraphy or during cardiac catheterization and angiography. In 125 patients [ps] studied, associated anomalies were present in 70. Right sided aortic arch was the most common anomaly [34 pts], left to right atrial communication in 64 pts [58 pts had a patent foramen ovale, 5 pts a secondum defect and I had a primum defect]. Miscellaneous anomalies like patent ductus arteriosus, persistent left superior vena cava, anomalies of big arteries and abnormal coronary arteries were present in 16 pts. Variation of the tetralogy were present in the form of associated valvular pulmonary stenosis and or pulmonary supravalvular narrowing or obstruction. Selective pulmonary arteriography or right ventricular outflao tract injection was performed in 98 patients [group A], and only apical right ventriculogram in 27 patients [group B] with this anomaly. Forty seven patients [48%] of the first group [group A] had other obstructions more than infundibular narrowing, of these 42 pts had Valvular stenosls, 38 pts had a hypoplastic pulmonary artery, l9pts had right or left branch stenosis and 2 had an absent pulmonary artery branch. Valvular pulmonary stenosis was only seen on left lateral right ventricular angiogram in group-B, while other pulmonary supravalvular narrowings were not well visualized. In conclusion, associated anomalies are common with tetralogy of Fallot and they can be discovered by echocardiography. Their presence and extent should be confirmed by cardiac catheterization. Multiple levels of right ventricular outflow obstruction can not be asssessed except by the outlow right ventriculogram or by pulmonary arteriography which was safe and important for the correct diagnosis of pulmonary arterial anatomy. The correct diagnosis of tetralogy of Fallot with its variants and associated anomalies is of help in planning surgical approach