From the Guidelines
Subcutaneous nodules, a major Jones criterion for diagnosing rheumatic fever, can indeed appear on the neck, although this is less common than at other sites. These firm, painless nodules typically develop over bony prominences or tendons, most commonly on the extensor surfaces of joints like elbows, knees, and wrists, but they can also appear on the scalp, spine, and neck 1. The nodules usually range from a few millimeters to 2 centimeters in size and may persist for several days to weeks before resolving spontaneously. They represent a manifestation of the immune-mediated inflammatory response triggered by group A streptococcal infection, specifically the formation of granulomatous lesions containing fibrinoid material.
Key Points to Consider
- The Jones criteria, used for guidance in the diagnosis of acute rheumatic fever (ARF), were revised in 2015 by the American Heart Association (AHA) to include the use of echocardiography/Doppler methodologies 1.
- The revised criteria emphasize the importance of considering the clinical context and the presence of other major or minor criteria, in addition to evidence of preceding streptococcal infection 1.
- While the presence of subcutaneous nodules on the neck is less common, it still contributes to fulfilling the Jones criteria when evaluating a patient for possible rheumatic fever.
Clinical Implications
The diagnosis of rheumatic fever relies on a combination of clinical findings, laboratory results, and imaging studies. The presence of subcutaneous nodules on the neck, although less common, should be considered as part of the overall clinical evaluation. A thorough physical examination, laboratory tests to confirm preceding streptococcal infection, and imaging studies such as echocardiography may be necessary to establish a definitive diagnosis 1.
From the Research
Subcutaneous Nodules in Jones Criteria
- Subcutaneous nodules are one of the major criteria in acute rheumatic fever (ARF) according to the Jones criteria 2, 3, 4.
- These nodules can appear in various parts of the body, but the studies provided do not specifically mention the neck as a common location 2.
- The Jones criteria require the presence of two major criteria, or one major and two minor criteria, along with evidence of antecedent group A streptococcal infection to diagnose ARF 3, 4.
Characteristics of Subcutaneous Nodules
- Subcutaneous nodules in ARF can be small in number, with an average of 18 nodules per patient, and can persist for a long time despite treatment 2.
- The nodules can disappear within 4-12 weeks after initiation of treatment, but in some cases, they can persist for more than 12 weeks 2.
- The artificial subcutaneous nodule test can be used to differentiate patients with rheumatic fever from those with inactive rheumatic heart disease 5.
Diagnosis of Rheumatic Fever
- The diagnosis of ARF is based on the Jones criteria, which include major and minor manifestations, as well as evidence of antecedent group A streptococcal infection 3, 4.
- Echocardiography can be used to support the diagnosis of ARF, particularly in cases where clinical signs of carditis are not present 3, 4.
- The use of streptococcal antibody titers, such as anti-streptolysin-O (ASO) and anti-DNase B, can aid in the diagnosis of ARF, but the results can vary 6.