From the Guidelines
The diagnosis of acute rheumatic fever should be based on the revised Jones Criteria, which requires evidence of a preceding group A streptococcal infection and either 2 major criteria or 1 major and 2 minor criteria, as outlined in the 2015 American Heart Association scientific statement 1. The revised Jones Criteria provide a framework for diagnosing acute rheumatic fever, taking into account the patient's risk population.
- For low-risk populations, the major criteria include:
- Carditis (clinical or subclinical)
- Arthritis (polyarthritis only)
- Chorea
- Erythema marginatum
- Subcutaneous nodules
- For moderate- and high-risk populations, the major criteria are similar, but also include monoarthritis or polyarthralgia. The minor criteria, which vary slightly between low-risk and moderate- to high-risk populations, consist of:
- Polyarthralgia (or monoarthralgia in moderate- to high-risk populations)
- Fever (≥38.5°C in low-risk, ≥38°C in moderate- to high-risk)
- Elevated acute phase reactants (ESR ≥60 mm/h and/or CRP ≥3.0 mg/dL in low-risk, ESR ≥30 mm/h and/or CRP ≥3.0 mg/dL in moderate- to high-risk)
- Prolonged PR interval on ECG It is essential to consider the patient's risk population when applying these criteria, as the diagnosis and management may differ significantly between low-risk and high-risk groups, as noted in the study 1. Echocardiography is a valuable tool in detecting subclinical carditis, which is a major criterion in the diagnosis of acute rheumatic fever, and should be used to support the diagnosis, especially in high-risk populations 1. A careful clinical assessment is necessary, as the signs and symptoms of acute rheumatic fever can overlap with other conditions, and the absence of evidence for a preceding streptococcal infection should prompt consideration of alternative diagnoses, as discussed in the 2015 American Heart Association scientific statement 1.
From the Research
Diagnostic Criteria for Acute Rheumatic Fever
The diagnosis of acute rheumatic fever is based on the presence of documented preceding Group A Streptococcal infection, in addition to the presence of two major manifestations or one major and two minor manifestations of the Jones criteria 2. The Jones criteria have been modified throughout the years, most recently in 1992, to aid clinicians in the diagnosis of initial attacks of acute rheumatic fever and to minimize overdiagnosis of the disease 3, 4.
Major Manifestations
The major manifestations of acute rheumatic fever include:
Minor Manifestations
The minor manifestations of acute rheumatic fever include:
- Fever
- Arthralgia
- Laboratory findings of elevated erythrocyte sedimentation rate, C-reactive protein, and prolonged PR interval on ECG 3, 4, 5
- A body temperature of 38°C and above 5
- An erythrocyte sedimentation rate of 30 mm/h and above 5
Diagnostic Criteria for Low-Risk and Moderate-High Risk Populations
Different diagnostic criteria have been established for the diagnosis of acute rheumatic fever for low-risk and moderate-high risk populations 5. For moderate-high risk populations, subclinical carditis found on echocardiogram in addition to clinical carditis is used as a major criterion, and aseptic monoarthritis and polyarthralgia are used as major criteria in addition to migratory arthritis 5.
Importance of Clinical Judgment
The Jones criteria are guidelines to assist the physician and should not be substituted for clinical judgment 3, 4, 5. Strictly following the Jones criteria may result in underdiagnosis of the disease, and physicians should make an accurate diagnosis of acute rheumatic fever with their own logic and assessment in addition to the proposed criteria 5.