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Acute rheumatic fever
Rheumatic fever is an immune reaction appearing 2–4 weeks after group A streptococcal pharyngitis and diagnosed by the Jones criteria; the significant damage is to the heart valves, so after diagnosis secondary prophylaxis with benzathine penicillin is given for years.
Why it matters in the exam
The question describes a school-age child with fever and migratory arthritis of large joints that responded dramatically to aspirin, or a girl with involuntary movements and difficulty writing (Sydenham chorea), and asks for the diagnosis, which criteria are met and the preventive treatment. A first diagnosis needs evidence of a preceding GAS infection together with two major criteria, or one major and two minor criteria.
Per the 2015 AHA revision the criteria depend on population risk. In a low-risk population (such as Israel) the major criteria are carditis (clinical or echocardiographic only), polyarthritis, chorea, erythema marginatum and subcutaneous nodules; the minor criteria are polyarthralgia, fever of 38.5°C or more, ESR of 60 mm/h or more or CRP of 3 mg/dL or more, and a prolonged PR interval. Chorea alone is enough for the diagnosis, even without evidence of GAS, because it appears months after the infection.
Carditis mainly affects the mitral valve — mitral regurgitation in the acute phase and mitral stenosis in chronic disease years later. Treatment includes GAS eradication, aspirin or NSAIDs for the arthritis, and heart failure treatment when needed. Secondary prophylaxis is benzathine penicillin G every 4 weeks: 5 years or until age 21 without carditis, 10 years or until age 21 with carditis but no residual damage, and 10 years or until age 40 (sometimes lifelong) when valve damage remains.
Key points
- Appears 2–4 weeks after GAS pharyngitis.
- Diagnosis: evidence of GAS with 2 major, or 1 major and 2 minor criteria.
- Sydenham chorea is enough on its own.
- Carditis affects the mitral valve.
- Secondary prophylaxis with benzathine penicillin every 4 weeks, according to cardiac involvement.
Summary table
| Criterion (low risk) | Type | Detail | Note |
|---|---|---|---|
| Carditis | Major | Mitral regurgitation, even if seen only on echocardiography | The important permanent damage |
| Arthritis | Major | Migratory polyarthritis of large joints | Dramatic response to aspirin within 48 hours |
| Chorea (Sydenham) | Major | Involuntary movements, emotional lability | Enough on its own; can appear months after the infection |
| Erythema marginatum and nodules | Major | Transient ring-shaped rash; painless nodules over bony prominences | Relatively rare |
| Minor criteria | Minor | Polyarthralgia, fever of 38.5°C or more, ESR 60 or more or CRP 3 mg/dL or more, prolonged PR | The same finding is not counted twice |
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Sources
- AHA Scientific Statement: Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography, 2015 — Low-risk and moderate/high-risk criteria
- AHA Scientific Statement: Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis, 2009 (current) — Secondary prophylaxis and its duration
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Rheumatic Fever
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.