ACEM Fellowship
Rheumatic fever
Epidemiology
- Mostly following GAS pharyngitis but can follow impetigo in high risk groups
- Mainly children 5-14 yo
- Polyarthritis most common in adolescents and young adults
- High-risk groups
- Aboriginal and Torres Strait Islanders
- Pacific Islanders
- Maori
- High-risk communities/poor housing/overcrowding/poverty/immigrants from developing countries
JONES criteria – High risk groups
Two major ; One major and 2 minor; or 3 minor if recurrent
Need evidence of preceding GAS infection
Major manifestations
- • Carditis (including subclinical evidence on echo)
- • Polyarthritis or aseptic monoarthritis or polyarthralgia
- • Chorea
- • Erythema marginatum
- • Subcut nodules
Jones criteria – Low risk groups
2 major; 1 major and 2 minor; or 3 minor if recurrent episode
Need evidence of preceding GAS infection
Major criteria
- • Carditis (excluding subclinical evidence on echo)
- • Polyarthritis
- • Subcutaneous nodules
- • Chorea
- • Erythema marginatum
Minor criteria
- CRP/ESR elevated
- Monoarthralgia (high-risk) or polyarthralgia/aseptic monoarthritis (low-risk)
- Fever
- Prolonged PR
Presentation
- Polyarthritis usually first symptom
- Typically migratory affecting several joints in quick succession and starting in large joints of lower limb
- Objective signs of arthritis are not prominent
- Sydenham’s chorea affects face/upper limbs, emotional lability and rarely transient psychosis
- Subcutaneous Aschoff nodules on extensor surfaces of wrists/elbows/knees
- Carditis – Pericarditis, CCF, new murmurs, heart block
- Erythema marginatum – 5% of ARF with blanching ring-like pink macules with serpiginous edge and central clear portion
- Not itchy
- Come and go for months
- Spares the face
Erythema marginatum
Labs
- ASOT and ANti-DNAseB
- Peak at 6 weeks
- ASOT only after pharyngitis and NOT impetigo
- High-risk populations have high background titres or ASOT
- Throat swab is only positive in 10% of high risk populations
Management
- Aspirin for arthralgia (highly sensitive)
- 25mg/kg QID (as for Kawasaki) for 1-2 weeks
- Treat heart failure/block
- Phenoxymethylpenicillin 10mg/kg up to 500mg BD for 10 days
- Commence Benzathine penicillin prophylaxis
- Ongoing follow-up
Last Updated on November 20, 2021 by Andrew Crofton
Andrew Crofton
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