Rheumatic fever is still one of the major public health problems in developing countries. Recurrences have been reported during continuous regular prophylaxis. Here, we describe a 13-year-old girl who had four apparent recurrences of
carditis while on a regimen of intramuscular
benzathine penicillin G (BPG) every three weeks. The interesting and special features of this case were the presence of frequent recurrences of
carditis with no evidence of
arthritis despite regular BPG
injections every three weeks, the requirement of long-term
corticosteroid therapy due to these recurrences, and the shortness of time periods between attacks after withdrawal of
steroid therapy. In this case, the administration of supraphysiologic doses of
glucocorticoids caused iatrogenic
Cushing syndrome with decreased bone mineral density and bilateral avascular tibial
necrosis mimicking the symptoms of
arthritis. Thus, this is a rare case. In similar cases with recurrences of either
arthritis or
carditis, instead of long-term
corticosteroid therapy, we suggest a regimen of BPG prophylaxis every two weeks rather than every three weeks or monthly BPG
injections because of the superiority of the every two weeks schedule in the adequate control of
rheumatic fever recurrences, as shown in some previous studies.