A 29-year-old woman who immigrated to the United States from India comes to the office to establish care. She has a mild sore throat that she believes may have come from her toddler, who recently had a fever. The patient has no other concerns. She has a history of gestational diabetes during her 2 pregnancies. In childhood, the patient had a febrile illness associated with loss of motor control. She takes no medications and does not use tobacco or alcohol.
Temperature is 36.7 C (98.1 F) , blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 14/min. Examination shows mild erythema of the nasal mucosa and posterior pharynx. Jugular venous pulsation is normal and there is no cervical lymphadenopathy. The lungs are clear. There is a low-pitched diastolic murmur with presystolic accentuation at the apex. Neurologic examination is normal.
She is referred for transthoracic echocardiography that shows normal left ventricular function with moderate left atrial enlargement and doming of the mitral valve leaflets in diastole. The estimated mitral valve area is 1.7 cm². There is mild mitral regurgitation.
Which of the following is the most appropriate recommendation regarding antibiotic therapy in this patient?

Question

Quizplus · Accepted Answer

11ec193a_9770_4f12_853d_b17216b0f571_MD0002_00 This patient's childhood history of a febrile illness with movement disorder (chorea) is consistent with previous rheumatic fever complicated by persistent valvular disease (mitral stenosis). Rheumatic fever occurs as a complication of group A beta-hemolytic Streptococcus (GAS) pharyngitis; the initial acute disease and recurrences can be characterized by fever, arthritis, chorea, and heart failure. This patient's current presentation is not consistent with rheumatic fever recurrence; however, the sore throat raises suspicion for GAS pharyngitis. With repeated exposure to GAS, patients with prior rheumatic fever are at high risk for recurrent rheumatic fever and consequent progression of rheumatic heart disease. Therefore, they should receive continuous antibiotic prophylaxis to prevent GAS pharyngitis. Long-acting penicillin G benzathine given intramuscularly every 3-4 weeks is the preferred approach for secondary prevention of rheumatic fever recurrence, and the duration of antibiotic prophylaxis depends on the severity of underlying rheumatic heart disease (presence or absence of carditis and valvular disease). The first dose of intramuscular penicillin would also treat any current GAS colonization/infection. Regardless of whether this patient was previously on antibiotics for rheumatic fever, she should receive an intramuscular dose of penicillin now and should be on continuous antibiotic prophylaxis until age 40 (given her valvular disease). (Choice A) Antibiotic prophylaxis to lower the risk of infective endocarditis is indicated prior to dental procedures in only patients with the highest-risk cardiac conditions. It is not indicated for rheumatic disease of a native heart valve. highest-risk cardiac conditions (Choice B) Antistreptococcal antibody titers can be helpful in the initial diagnosis of rheumatic fever, but do not play a role in guiding antibiotic prophylaxis for secondary prevention. (Choice C) This patient is at risk for further heart damage with recurrent GAS infection, and long-term antibiotic prophylaxis is indicated. Recommending no antibiotic therapy is not appropriate. (Choice E) Oral penicillin V potassium is an acceptable treatment option for acute GAS pharyngitis (primary prevention of rheumatic fever). It is also an alternate treatment for secondary prevention of rheumatic fever recurrence; however, due to increased failure rates with orally administered antibiotics, intramuscular penicillin G is preferred. Educational objective: Patients with rheumatic fever should receive continuous antibiotic prophylaxis to prevent recurrent GAS pharyngitis and limit the risk of progression of rheumatic heart disease. Intramuscular penicillin G benzathine every 3-4 weeks is preferred, and the duration of therapy is determined by the severity of underlying rheumatic heart disease (presence or absence of carditis and valvular disease). __________ References: Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. (http://www.ncbi.nlm.nih.gov/pubmed/19246689)

A 29-Year-Old Woman Who Immigrated to the United States from India