Rheumatic fever is diagnosed based on major or minor criteria from the modified Jones criteria. Major criteria include pancarditis affecting the pericardium, myocardium and endocardium; symmetrical migratory polyarthritis affecting joints; Sydenham's chorea involving involuntary movements; erythema marginatum causing a rash; and subcutaneous nodules. Minor criteria are fever, polyarthralgia, elevated acute phase reactants and prolonged PR interval on ECG. Evidence of a preceding Group A streptococcal infection is also required through increased antibody titres, positive throat culture or antigen test. The diagnosis requires meeting criteria within 6 weeks of a streptococcal infection.

1. RHEUMATIC FEVER
2002-2003 WHO CRITERIA BASED ON JONES MODIFIED CRITERIA
1992 UPDATE
Diagnosis- (2) major or
(1) major & (2) minor criteria + evidence of recent streptococcal infection.
Major Criteria
1. Pancarditis: 50-60%
 Occurs within 6 weeks of acute rheumatic fever
 pericarditis – pericardial rub
 myocarditis – tachycardia, soft S1, S3 / CCF, arrhythmia
 endocarditis – CAREY COOMB’s murmur (MDM)- valvular lesions. The patient may have a new or
changing murmur, mitral regurgitation being the most common followed by aortic insufficiency.
2. Symmetrical Migratory polyarthritis: 30-50%; early feature
 Fleeting – moves from one joint to another
 Flitting – moves to other joint without residual damage to the joint
 typically affects knees, ankles, elbows and wrists.
 Painful joint movements responding to anti-inflammatory drugs.
3. Sydenham´s chorea (“St. Vitus´ dance"):
 Sudden, jerky, quasi purposive, non-repetitive, non-rhythmical involuntary movements
 Commonly involve face, tongue & limbs
 Self-limiting lasting for 2-6 wks; common in females
 may be the only diagnostic sign; late manifestation – upto 6 months.
 May also include emotional disturbances and inappropriate behaviour.
4. Erythema marginatum: 10-60%; early feature
 non-pruritic macular rash
 affects the trunk and proximal extremities in a bathing suit pattern, sparing the face
 well-defined serpiginous borders with central clearing
5. Subcutaneous nodules: 3-5%
 within 3-6 wks of rheumatic fever; evident of underlying carditis
 non tender, firm
 over bones or tendons ( extensor aspect of the limbs and back).
Minor Criteria:
Clinical: Fever, polyarthralgia
Laboratory: Acute phase reactants: elevated ESR and C-reactive protein (CRP),
Prolonged P-R interval on electrocardiogram (ECG)
Evidence of preceding streptococcal infection:
Any one of the following is considered adequate evidence of infection:
• Increased anti streptolysin O titre (ASO >350 todd units in children & >220 todd units in adults) or other
streptococcal antibodies
• Positive throat culture for Group A beta-haemolytic streptococci
• Positive rapid direct Group A strep carbohydrate antigen test
References: HARRISONS PRINCIPLES OF INTERNAL MEDICINE 17 TH EDITION.

2. Dr. Vijay 2nd
year PG