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