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 Table of Contents 
Year : 1996  |  Volume : 3  |  Issue : 1  |  Page : 35-38  

Preliminary study on acute rheumatic fever at high and low altitudes of Asir region

Department of Child Health, College of Medicine, King Saud University - Abha Branch, Abha, Saudi Arabia

Date of Web Publication31-Jul-2012

Correspondence Address:
Fuad L Abbag
Department of Child Health, College of Medicine, King Saud University - Abha Branch, P. O. Box 641, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 23008546

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Objective : The objective was to study the profile of acute rheumatic fever (ARF) at high and low altitudes (hot and temperate areas respectively) with particular attention to the influence of these differences on the frequency or severity of carditis.
Methodology : Thirty eight children with initial attack of ARF, diagnosed between November 1987 and July 1995, were studied.
Result : Twenty seven were living at altitude, temperate climate (group-1) while 11 were living at low altitudes of Tihama, hot climate (group-2). Twenty two were males and 16 were females. The mean age was 9.7 years. Arthritis was the commonest feature (86.8%) and carditis (68.4%) came second. Mitral regurgitation occurred in 96.2% of those with carditis, aortic regurgitation occurred in 19.2% and tricuspid regurgitation in 7.7%. Mitral stenosis and aortic stenosis were not encountered. A comparison between group-1 and group-2 showed the frequency of carditis to be 66.7% and 72.7% respectively and the frequency of severe carditis in those affected to be 27.8% and 25% respectively. Chorea, erythema marginatum and subcutaneous nodules were uncommon.
Conclusion: The study indicates that altitude and climate may not affect the frequency nor severity of carditis.

Keywords: Acute rheumatic fever, carditis, altitude, Asir.

How to cite this article:
Abbag FL. Preliminary study on acute rheumatic fever at high and low altitudes of Asir region. J Fam Community Med 1996;3:35-8

How to cite this URL:
Abbag FL. Preliminary study on acute rheumatic fever at high and low altitudes of Asir region. J Fam Community Med [serial online] 1996 [cited 2021 Dec 2];3:35-8. Available from:

   Introduction Top

Acute rheumatic fever (ARF) is a serious public health problem in the developing countries. [1],[2],[3] It has shown little if any decline in many of these countries, in contrast to the significant decline in the developed countries with the exception of several recent outbreaks in the United States. [4],[5] It has been argued that ARF has a more fulminant course in the developing countries and its profile differs from that in temperate areas. [6],[7]

The varied topography of Asir province, i.e. an altitude of 3000 m in Abha with temperate climate (temperature range: 5-28°C) [8] and that of the low altitudes of Tihama areas with hot climate (temperature range 25 - 45°C) [8] provided an opportunity to compare the epidemiological and clinical aspects of the disease in these different altitudes and climates.

   Materials and Methods Top

The medical records of children aged less than 18 years who were diagnosed between November 1987 and July 1995 at Asir Central Hospital as having first attack of ARF were reviewed. The diagnosis of ARF was based on revised Jones criteria. [9]

Demographic, medical and laboratory data were obtained in each case. Complete blood count (CBC), erythrocyte sedimentation rate (ESR) using Wintergreen method, antistreptolysin O (ASO) titer using Latex agglutination test and throat swab culture were done in all patients. All patients had chest X-ray and electrocardiogram and the presence of carditis was confirmed using two-dimensional and Doppler echocardiography. Carditis was considered mild in absence of cardiomegaly, moderate in presence of mild to moderate cardiomegaly and severe in presence of severe cardiomegaly or overt congestive heart failure.

A comparison between the profile of ARF in children living at high altitudes and children living at low altitudes was made with particular attention to the frequency and severity of carditis.

   Results Top

Thirty eight patients were studied. Twenty two were males and 16 were females with male to female ratio 1.4:1. Their ages ranged from 4 to 12 years (mean age 9.7 years). Affected children living at high altitudes were 27 (group-1) and those at low areas were 11 (group-2). The mean age was 9.6 year and male to female ratio was 2:1 for group-1 while group-2 had a mean age of 9.6 year and male to female ratio 0.6:1. The average family size was 9.7 considering all patients; 10 for group-1 and 9 for group-2. Fifteen of the cases (55.6%) occurred during late autumn and winter in group-1, while nine of the cases (81.8%) occurred during late spring and summer in group-2.

A history of upper respiratory tract infection few weeks before the onset of ARF was positive in 22 cases (57.9%). Throat swab culture was positive for group A beta-hemolytic streptococci in one patient only (2.6%).

Arthritis was the most common presenting feature; it occurred in 33 patients (86.8%). It was polyarticular in 84.8% and monoarticular in the remainder. Fever (temperature z 38°C) occurred in 25 patients (65.8%).

Carditis occurred in 26 patients (68.4%). Mitral valve regurgitation was the most common lesion and occurred in 25 patients (96.2%) of those with rheumatic carditis. Aortic valve regurgitation occurred in five patients (19.2%) and significant tricuspid valve regurgitation was present in two patients (7.7%). Mitral stenosis, aortic stenosis and pulmonary valve involvement were not documented. Pericarditis with or without effusion occurred in four patients (15.4%). Carditis was moderate/severe in seven of them (26.9%). No fatality occurred.

Chorea occurred in two patients (5.3%), erythema marginatum in two and subcutaneous nodules in one patient (2.6%).

The profile of ARF in the two groups is shown in [Table 1]. Carditis occurred in 18 patients (66.7%) of group-1 and was moderate/severe in five (27.8%) of them, while it occurred in eight patients (72.7%) of group-2 and was moderate/severe in two (25%) of them. The overall frequency of moderate/severe carditis was 18.4% (7 out of 38). Arthritis was present in 24 (88.9%) of group-1 and in nine (81.8%) of group-2.
Table 1: Profile of acute rheumafic fever at high altitude (temperate climate) (group1) and low altitude (hot climate) (group-2)

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ASO titer was elevated (a 300 iu/ml) in 76.3% of all patients and the ESR was a 30 mm/hr in 97.4% of them. Thrombocytosis and leukocytosis were present in 28.9% and 26.3% respectively. Thrombocytopenia or leukopenia was not encountered.

   Discussion Top

The age and sex distribution in this study are comparable to those from Riyadh. [10] The peak incidence of ARF at altitudes was during winter which is comparable to the findings in Riyadh [10] while the peak incidence at low altitudes was in late spring and summer. The importance of crowding as a contributory factor in the development of ARF may be implied by the large average family size of the patients in this series.

Arthritis was the most common feature (86.8%). The frequency of carditis was 68.4% which is higher than previously reported incidence (43%) in Riyadh series [10] but close to what has been reported from other countries.5,11 Mitral valve regurgitation was the most common cardiac lesion which is in agreement with the finding in other studies. [10],[11] Mitral valve stenosis was not encountered and this may reflect the mild nature of the initial attack of ARF in Saudi Arabia as previously reported. [10] The syndrome of juvenile mural stenosis which affects people under the age of 20 years [12],[13] may be rare in Saudi Arabia.

The frequency of carditis in ARF at high and low altitudes was similar (66.7% vs. 72.7%). Furthermore the frequency of moderate/severe carditis was also similar (27.8% vs. 25%). Although the sample is small to draw a solid conclusion, this preliminary study may indicate that the profile of ARF in general and the frequency and severity of carditis in particular are similar in high altitude areas with temperate climate and in low altitude areas with hot climate. These findings are in contrast with those from some tropical countries [6],[7] where the incidence of carditis has been considerably higher, and similar to those from United States (59%). [5] Okorama et al [6] reported the incidence of carditis to be 98.5% in Nigerian children. The frequency of moderate/severe carditis in this study (18.4%) is similar to that reported from Riyadh and Kuwait; [10],[11] 15.7% and 14% respectively.

The apparently high incidence of carditis in studies from some tropical countries was attributed to a biased sample as in poor countries only severe cases are brought to medical care and also to the inclusion of cases affected by recurrent attacks of ARF [14] where carditis tends to be worse than during initial attacks.

The finding of low incidence of chorea (5.3%) in this series is in contrast with the findings in studies from some tropical countries. [14] A high incidence of chorea was reported from Pakistan, 29% and from the United States, 30%. [5] Erythema marginatum and subcutaneous nodules were uncommon features in this series.

In conclusion, this study demonstrates that the profile of ARF in this area is similar to that in western countries, and there may be no difference in the frequency and severity of carditis between the high areas (temperate climate) and low areas (hot climate) of Asir region, and this may indicate that climate and altitude have no direct effect on the severity of ARF once it occurs. A further study, including a larger number of patients is needed to confirm these findings.

   References Top

1.Anabwani GM, Amoa AB, Muita AK. Epidemiology of rheumatic heart disease among primary school children in Western Kenya, Int J Cardiology 1989; 23:249-252.  Back to cited text no. 1
2.DiSciascio G, Taranta A. Rheumatic fever in children, Am Heart J 1980; 99:635-658.  Back to cited text no. 2
3.Ibrahim-Khalil S, El Hag M, Elngi A, Mahgoub F, Hakiem S, Omer N, Shafie S, Mahgoub E. An epidemiological survey of rheumatic fever and rheumatic heart disease in Sahafa Town, Sudan. J Epidemiology Community Health 1992; 46:477-479.  Back to cited text no. 3
4.Veasy LG, Weidmeier SE, Orsmond GS, Ruttenberg HD, Boucek MM, Roth SJ, Tait VF, Thompson JA, Daly JA, Kaplan EL, Hill HR. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 1987; 316: 421-427.  Back to cited text no. 4
5.Wald ER, Dashefsky B, Feidt C, Chiponis D, Byers D. Acute rheumatic fever in western Pennsylvania and the tristate area. Pediatrics 1987; 80: 371-374.  Back to cited text no. 5
6.Okoroma EO, Ihenacho HNC, Anyanwu CH. Rheumatic fever in Nigerian children. Am J Dis Child 1981; 135: 236-238.  Back to cited text no. 6
7.Ismail SA, El Amin A. Rheumatic fever in Sudanese children. Arab J Med 1983; 2: 21-24.  Back to cited text no. 7
8.Adzaku F, Addae S, Annobil S, Mohammed S. Clinical features of sickle cell diseases at altitude. Journal of Wilderness Medicine 1992; 3: 260-268.  Back to cited text no. 8
9.American Heart Association. Jones criteria (revised) for guidance in the diagnosis of rheumatic fever. Circulation 1984; 69: 204A-208A.  Back to cited text no. 9
10.Al-Eissa YA, Al-Zamil FA, Al-Fadely FA, Al-Herbish AS, AI-Mofada SM, Al-Omair AO. Acute rheumatic fever in Saudi Arabia: Mild pattern of initial attack. Pediatr Cardiol 1993; 14: 89-92.  Back to cited text no. 10
11.Majeed HA, Yousof AM, Khuffash FA, Yusuf AR, Farwana S, Khan N. The natural history of acute rheumatic fever in Kuwait: A prospective six year follow-up report. J Chron Dis 1986; 39: 361-369.  Back to cited text no. 11
12.MarKowitz M. Observations on the epidemiology and preventability of rheumatic fever in developing countries. Clin Ther 1981; 4: 2'40-51.  Back to cited text no. 12
13.Roy SB. Challenge of juvenile mitral stenosis in India. Jap Circ J 1975; 39: 198.  Back to cited text no. 13
14.Jamal M, Abbas KA. Clinical profile of acute rheumatic fever in children. J Trop Ped 1989; 35: 10-13.  Back to cited text no. 14


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