台灣地區之風濕熱與風濕性心臟病

Rheumatic Fever and Rheumatic Heart Disease in Taiwan

風濕熱乃繼於A群鏈球菌上呼吸道感染發生於兒童、青少年及壯年人的非發膿性全身炎症性疾病，主要侵犯心臟、關節、腦、血管及皮下組織。風濕熱在20世紀初期以前的台灣，可能沒有或很少。台大醫院小兒科日據時代至現在的病歷回顧顯示，風濕熱病例初次出現於1946年，1964年至1980最多，1982以後滅少，但1988突然又增加，隨之減少至今。國人風濕熱臨床病徵，與歐美相似，唯心炎出現率較高，67%至93%，關節炎較低，27%至53%。風濕性心臟病瓣膜病變，以僧帽瓣膜症最多，佔77%至88%，僧帽瓣及主動脈瓣，9%至17%，單獨主動脈瓣0%至2%，三個瓣膜0%至10%。著者等1979至1992前瞻性對照研究230例風濕性心臟病人顯示，美三洲或四週注射benzathine penicillin G, 1,200X103單位，幾乎完全有效預防風濕熱之再發，存活率高達98%，且其46%至61%的瓣膜症自癒，心臟雜音消失。著者等建議：風濕熱再發危險因素高者，應每三週注射盤尼西林，危險因素較低者，每四週注射一次，以後，即依年齡及心臟病況，改口服penicillin V 或磺胺素，甚至考慮停止。盤尼西林預防是風濕熱治療史上最大的突破，可惜，國人過度恐懼盤尼西林，風濕熱預防因而未能落實，有待研究改善。

Rheumatic fever is a diffuse inflammatory disease involving the heart, joints, brain, blood vessels, and subcutancous tissue. It occurs among children, adolescents, and young adults following acute streptococcal upper respitratory infection. Rheumatic fever was probably rare or non-existent in Taiwan before the 20th century. A review of the pediatric records of the National Taiwan University Hospital showed that the earliest case occurred in 1946. The number of cases increased thereafter, teaching a peak during the period from 1964 to 1980. The number of cases started to decrease in 1982, then suddenly increased again in 1988, followed by a steady fall until 1997. In the 1950s, rheumatic heart disease was common in Taiwan, comprising 10% to 30% of adult cardiovascular diseases at the National Taiwan University and Taipei Veteran's General Hospital. The prevalence of rheumatic heart disease among school children was the highest (1.42 ‰) in 1970 and (1.26 ‰) in 1971, then fell to 0.39% in 1987. The prevalence suddenly rose to 0.7 ‰ in 1988, indicating a resurgence of rheumatic fever, followed by a steady decrease until 1997. The manifestations of rheumatic fever in Taiwan are similar to those in the West, except that the frequency of carditis is higher (67% to 93%), and the frequency of polyarthritis lower (27% to 53%) in Taiwan. The most common valvular lesions are mitral (77% to 88%), followed by mitral and aortic (9% to 17%), isolated aortic (0% to 2%),and triple (0% to 10%). A prospective and controlled study of 230 patients with heart disease during 1979-1992 revealed that intramuscular injections of benzathine penicillin G 1,200X103 U every 3 to 4 weeks almost completely prevented recurrences of rheumatic fever. Of patients receiving this regimen, 98% survived, and 46% to 61% of their valve lesions and murmurs were resolved. Penicillin prophylaxis is a breakthough in the control of rheumatic fever. Excessive penicillin phobia in Taiwan, a handicap to the prevention program, remains to be alleviated.