Missed Opportunities for Preventing or Diagnosing Acute Rheumatic Fever: A Retrospective Cohort Study of 20 Young Australians Diagnosed With Rheumatic Heart Disease on Screening Echocardiography.

Abstract

Background and aim: A cross-sectional echocardiographic screening study in a remote Aboriginal community in Australia identified hyperendemic levels of rheumatic heart disease (RHD). 20/613 screened were newly diagnosed with RHD, and 18/20 had no known history of acute rheumatic fever (ARF). Our aim was to explore the medical histories of those newly diagnosed with RHD for potential (1) missed opportunities for primary prevention of ARF through management of Group A Streptococcal (Strep A) infection, and (2) missed opportunities for diagnosis of ARF.

Methods: We assessed community clinic and tertiary hospital medical records of those children with new diagnoses of RHD (n = 20), and collected information regarding previous episodes of possible Strep A infection or its sequelae.

Results: All 20 participants had previous documented possible or confirmed Strep A infections, predominantly in the form of impetigo or infected scabies (range 1-17 episodes per participant). At least 15/20 participants had potential Strep A infections where treatment that was documented may not have adequately covered Strep A. 11/20 participants had scabies diagnosed without documented scabies treatment. 2/20 participants had previously diagnosed ARF, however these were diagnosed within the month prior to the community-wide screening for RHD. 2/20 participants had undiagnosed, probable or possible ARF when classified retrospectively from review of their case documentation. 13/20 participants had non-specific presentations with joint complaints that may have represented an ARF episode but with inadequate workup to fulfil diagnostic criteria on retrospective assessment.