A 9-yr-old girl, known case of rheumatic heart disease presented with complaints of progressive breathlessness for 2 years with recent worsening (NYHA grade II to III), fever and migratory joint pain (bilateral knee) for 10 days. There was history of orthopnea, palpitations and chest pain. There was no history of sore throat, skin rash, abnormal body movements, emotional lability and hemoptysis. She was diagnosed in 2011 with acute rheumatic fever with severe mitral regurgitation, moderate aortic regurgitation and mild tricuspid regurgitation. Supportive treatment was started and she was put on secondary erythromycin (250 mg BD) prophylaxis as she was allergic to benzathine penicillin. During follow-up, good compliance to erythromycin was noted.

On examination, child was febrile with a pulse of 110/min, respiratory rate 48/min, BP- 130/50 and raised JVP. There was no pedal edema, clubbing, lymphadenopathy, cyanosis, rash, subcutaneous nodules and features suggestive of infective endocarditis. Cardiovascular examination revealed downward and outward hyperdynamic apex beat and a grade IV pansystolic murmur in the mitral area radiating to the axilla and grade III early diastolic descrescendo murmur in the aortic area. Respiratory system revealed bilateral basal crepitations while hepatomegaly was noted on abdominal examination.On musculoskeletal examination there was no evidence of arthritis. Central nervous system was normal.

A diagnosis of recurrent acute rheumatic fever with congestive heart failure was made. Oral prednisolone was started and tapered after 4 weeks while aspirin was added. She responded and her ESR levels gradually decreased. Since recurrence occurred despite good compliance and adequate dose of erythromycin, serum erythromycin levels was planned but was not available. MIC levels could not be ascertained as the throat culture was negative. Patient was started on secondary prophylaxis of erythromycin albeit at a higher dose (40mg/kg i.e. 250 mg tds).

Children with RHD have a high risk of recurrence of acute rheumatic fever subsequent to Group A Streptococcus (GAS) pharyngitis. Primary prevention is achieved by intramuscular repository preparation of penicillin and its derivatives and/or oral penicillin until penicillin allergy is documented wherein oral macrolides, cephalosporins and clindamycin are recommended [4]. GAS resistant to penicillin have not been reported though there are reports of rising MIC levels [5]. While administering primary prophylaxis repeated course of antibiotics are not needed in asymptomatic patients who continue to harbor GAS after appropriate therapy, however a second course of antibiotics should be started in patients with previous history of rheumatic fever in themselves or in their family members. Failure to eradicate GAS from the throat usually occurs while using oral penicillin than intramuscular preparation and in children who are chronic carriers with prolonged oral colonization of the bacteria [6].

In our case the diagnosis of recurrence was based on modified Jones criteria but in absence of a positive throat culture and susceptibility reports the resistance pattern could not be adequately addressed. However the report highlights the importance of continuous monitoring of susceptibility pattern in order to observe the development of resistance over a period of time. Pediatricians must be aware of GAS resistance while treating patients with initial episode or recurrence of ARF so as to prevent the development of severe RHD which is usually a result of recurrent ARF.

Contributors: All the authors have contributed, designed and approved the study.

Funding: None; Competing interests: None stated.

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