From the Guidelines
The Jones criteria for diagnosing acute rheumatic fever require evidence of preceding group A streptococcal infection and either 2 major manifestations or 1 major plus 2 minor manifestations, as outlined in the 2015 revised criteria 1. The criteria consist of major and minor manifestations, which vary depending on the population's risk level. Major criteria include:
- Carditis, which can be clinical or subclinical, with subclinical carditis indicated by echocardiographic valvulitis 1
- Polyarthritis, with monoarthritis considered a major criterion only in moderate- to high-risk populations 1
- Chorea
- Erythema marginatum
- Subcutaneous nodules Minor criteria encompass:
- Polyarthralgia or monoarthralgia, depending on the population's risk level
- Fever, with a higher temperature threshold for low-risk populations (≥38.5°C) compared to moderate- and high-risk populations (≥38°C) 1
- Elevated inflammatory markers, such as ESR ≥60 mm in the first hour and/or CRP ≥3.0 mg/dL for low-risk populations, and ESR ≥30 mm/h and/or CRP ≥3.0 mg/dL for moderate- and high-risk populations 1
- Prolonged PR interval on ECG, after accounting for age variability 1 The 2015 revised criteria also emphasize the importance of echocardiographic evidence of carditis and differentiate between low-risk and high-risk populations, allowing for more sensitive diagnosis in high-risk populations 1. Key points to consider in the diagnosis of acute rheumatic fever include:
- Evidence of preceding group A streptococcal infection, which can be demonstrated through positive throat culture, rapid strep test, or elevated ASO titers
- The use of echocardiography to detect subclinical carditis
- The differentiation between low-risk and high-risk populations, with more sensitive criteria applied to high-risk populations
- The importance of prompt treatment with antibiotics to prevent long-term cardiac damage, and long-term antibiotic prophylaxis to prevent recurrence and progression of rheumatic heart disease 1.
From the Research
Jones Criteria for Rheumatic Fever
The Jones criteria are guidelines used to diagnose rheumatic fever, an autoimmune disease associated with group A β-hemolytic streptococcal infection 2. The criteria were first developed in 1944 and have been revised several times, with the most recent revision being in 2015 2, 3.
Major and Minor Manifestations
The Jones criteria include major and minor manifestations of rheumatic fever. The major manifestations are:
- Carditis
- Polyarthritis
- Chorea
- Erythema marginatum
- Subcutaneous nodules 4, 5 The minor manifestations include:
- Fever
- Arthralgia
- Laboratory findings of elevated erythrocyte sedimentation rate, C-reactive protein, and prolonged PR interval on ECG 4, 5
Diagnostic Criteria
To diagnose acute rheumatic fever, two major, or one major and two minor manifestations must be accompanied by supporting evidence of antecedent group A streptococcal infection 4, 5. The 2015 Jones criteria established different diagnostic criteria for low-risk and moderate-high risk populations, with subclinical carditis found on echocardiogram being a major criterion in addition to clinical carditis 3.
Role of Echocardiography
Echocardiography plays an important role in the diagnosis of rheumatic fever, particularly in detecting subclinical carditis and valvular regurgitation 2, 4, 3. The American Heart Association recommends that all patients with suspected rheumatic fever undergo Doppler echocardiographic examination after the Jones criteria have been verified, even if no clinical signs of carditis are present 2.
Exceptions to the Jones Criteria
There are exceptions to the Jones criteria, including patients with chorea, indolent carditis, and previous history of rheumatic fever or rheumatic heart disease 4, 5. In these cases, the diagnosis of rheumatic fever may be made even if the patient does not meet the full criteria. Additionally, patients who do not fully meet the diagnostic criteria of acute rheumatic fever should be treated as acute rheumatic fever if another diagnosis is not considered and should be followed up with benzathine penicillin prophylaxis for 12 months 3.