Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years.

PURPOSE: To report the result of patients treated with IV methylprednisolone divided into three groups and compare their follow-up during the last 12 years. METHODS: Seventy children with active rheumatic carditis (76 episodes) in heart failure Class III and IV (NYHA) were studied. The diagnosis was based on modified Jones' criteria. After ruling out infections and strongyloidiasis, treatment with IV methylprednisolone bolus was started three times a week until the laboratory tests became negative. Patients were divided into 3 groups, according to the time of hospital admittance: Groups 1, 2 and 3, comprising of 40, 18 and 12 children, respectively. RESULTS: Eighteen children in Group 1 (45%) were in their 1st attack: 2 series of pulsetherapy were used in 10 (25%), 3 in 9 (23%) and 4 in 21 (52%). In Group 2, 14 cases (77%) were in their 1st attack: 2 series were used in 7 (39%), 4 in 9 (50%) and 5 in 2 (11%). The echocardiogram showed a flail mitral valve in 12 (66%) of these patients (1 death occurred after mitral valvoplasty). In Group 3, 6 patients needed 5 or more series of pulsetherapy and a flail mitral valve was present in 5 (41%). One child underwent mitral valve replacement while still in the active phase, after 8 series of pulsetherapy, and another died. The number of patients who needed 5 or more series was significantly higher in Group 3. CONCLUSION: There were variations in the presentation and evolution of the cases during these 12 year. The established pulsetherapy protocol continues to be useful to treat severe cases.

[Clinical and echocardiographic study of mitral valve in children with severe rheumatic carditis. Aspects of prolapse or rupture]. / Estudo clínico e ecocardiográfico das alterações do aparelho mitral em crianças com cardite reumática grave. Aspecto de prolapso ou ruptura.

PURPOSE: To describe cases of rheumatic carditis with echocardiographic aspects of prolapse or rupture of mitral structures. METHODS: We described 16 cases of acute carditis (ages between 5-15 years). In 10 (group 1) there was aspect of mitral prolapse, in 6 (group 2) aspect of "flail". The measurements of anterior chordae and anuli were compared to the ones of 5 cases of chronic rheumatic fever with dilated left ventricle and aortic regurgitation (group 3) and to 20 normal children of same ages. The same measurements were repeated after treatment. RESULTS: The mean of the measurements in group 1 was; 26.48 +/- 11.46mm-anterior chordae; 32.13 +/- 7.35mm anuli; in the group 2 was respectively 29.63 +/- 4.57mm and 35.63 +/- 7 mm. In the group 3 anterior chordae was 34.52 +/- 6.8mm, anuli: 34.8 +/- 4.61 mm. In the normal group, respectively was: 18.19 +/- 4.26mm and 24.66 +/- 2.85mm. After corticosteroid many cases improved. In the statistical analyses, the measurements among patients of group 1 and 2 compared to normal children, the difference was significant but it was not compared to group 3. Comparing the measurements pre and post treatment the decrease was not significant. CONCLUSION: The acute carditis in these cases lead to significant elongation of anterior chordae and dilatation of anuli, but there was not a significant decrease after treatment.

Estudo clínico e ecocardiográfico das alteraçöes do aparelho mitral em crianças com cardite reumática grave. Aspecto de prolapso ou ruptura / Clinical and echocardiographic study of mitral valve in children with severe rheumatic carditis. Aspects of prolapse or rupture

Objetivo - Descrever casos de cardite reumática com aspecto ecocardiográfico de prolapso ou ruptura de cordoalha da mitral. Métodos - foram estudados 16 casos de cardite aguda (entre 5 e 15 anos), sendo que em 10 havia aspecto de prolapso mitral (grupo 2). As medidas das cordoalhas anteriores e anéis foram comparadas a 5 casos de febre reumática fora da atividade com dilataçäo de ventrículo esquerdo com insuficiência aórtica (grupo 3) e a 20 crianças normais com mesmas idades. Nos grupos 1 e 2 repemos as medidas após o tratamento. Resultados - A média das medidas no grupo 1 foi cordoalha naterior 26,48 + ou - 11,46 mm, diâmetro do anel 32,13 + ou - 7,35 mm; no grupo 2, respectivamente 29,72 + ou - 4,57 mm e 35,63 + ou - 7 mm e no grupo 3, 34,52 + ou - 6,8 mm para cordoalha anterior e 34,8 + ou - 4,61 mm para o anel. Entre as crianças normais as medidas foram, respectivamente, 18,19 + ou - 4,26 mm e 24,66 + ou - 2,85 mm. Após imunossupressäo (corticoterapia) ocorreur melhora do aspecto ecocardiogrfco em alguns casos. A analise estatística revelou que comparando as medidas das crianças dos grupos 1 e 2 com as normais, a diferença foi significativa, mas näo com as do grupo 3. Comparando as medidas antes e depois do tratamento também näo houve diminuiçäo siginificativa (grupo 1 e 2). Conclusäo - a cardite aguda provocou, nestes casos, alongamento significativo das cordoalhas e dilataçäo do anel mitral. A diminuiçäo das medidas após o tratamento näo foi significativa.

Purpose - To describe cases of rheumatic carditis with echocardiographic aspects of prolapse or rupture of mitral structures. Methods - We described 16 cases of acute carditis (ages between 5-15 years). In 10 (group 1) there was aspect of mitral prolapse, in 6 (group 2) aspect of "flail". The measurements of anterior chordae and anuli were compared to the ones of 5 cases of chronic rheumatic fever with dilated left ventricle and aortic regurgitation (group 3) and to 20 normal children of same ages. The same measurements were repeated after treatment. Results - The mean of the measurements in group I was; 26.48±11.46mm ­ anterior chordae; 32.13±7.35mm anuli; in the group 2 was respectively 29.63±4.57mm and 35.63±7mm. In the group 3 anterior chordae was 34.52 ±6.8mm, anuli: 34.8 ±4.61mm. In the normal group, respectively was: 18.19±4.26mm and 24.66±2.85mm. After corticosteroid many cases improved. In the statistical. In the statistical analyses, the measurements among patients of group 1 and 2 compared to normal children, the difference was significant but it was not compared to group 3. Comparing the measurements pre and post treatment the decrease was not significant. Conclusion ­ The acute carditis in these cases lead to significant elongation of anterior chordae and dilatation of anuli, but there was not a significant decrease after treatment

[Pulse therapy (high doses of venous methylprednisolone) in children with rheumatic carditis. Prospective study of 40 episodes]. / Pulsoterapia (altas doses de metil-prednisolona venosa) em crianças com cardite reumática. Estudo prospectivo de 40 episódios.

PURPOSE: To use corticosteroids in a shorter period to treat rheumatic carditis, keeping the patient in the hospital; and verify the time interval of normalization of rheumatic activity tests with this method. METHODS: In 36 patients (40 episodes) intravenous methyl-prednisolone (1g/day) was administered. The number of series ranged from two to four, according to severity of the disease. The ages ranged from 6 to 17 years old, all of them fulfilled the criteria of Jones for diagnosis of rheumatic fever. They were submitted to treatment to eradicate the streptococcus, worms, PPD and dental focus extraction, before use of corticosteroids. RESULTS: In all patients the signals and symptoms of heart failure improved. In six cases occurred complications during pulse therapy that were easily controlled with clinical measures. Two series of methylprednisolone were used in 10 children, three in nine and four in 21 episodes. Eight patients were sent to valve replacement. The interval of time that laboratory tests of rheumatic activity became negative was 41.2 +/- 13.3 days. CONCLUSION: Using this IV corticotherapy it was possible decrease the amount of days of this medication, keeping the patient in the hospital. In this way we eliminate the problem of interruption of the treatment. There was not significative difference between oral and IV corticotherapy in order to the laboratory tests become negative.