With normal electrocardiogram and echocardiogram, migratory polyarthritis involving the sacroiliac joint, knee and shoulder, and elevated anti‑streptolysin O titres after a recent streptococcal infection, is this post‑streptococcal reactive arthritis (Pondiff’s disease) or acute rheumatic fever without carditis, and what is the appropriate management?

Post-Streptococcal Reactive Arthritis (PSRA) vs. Acute Rheumatic Fever Without Carditis

With normal ECG and echocardiogram, this presentation most likely represents post-streptococcal reactive arthritis (PSRA) rather than acute rheumatic fever, and the patient should receive symptomatic treatment with NSAIDs or corticosteroids without mandatory long-term penicillin prophylaxis. 1

Diagnostic Reasoning

Why This Is Likely PSRA, Not ARF

The normal echocardiogram is the critical distinguishing feature. The 2015 AHA Jones Criteria revision mandates that echocardiography with Doppler should be performed in all cases of confirmed and suspected ARF, and echocardiographic findings not consistent with carditis should exclude that diagnosis. 1 Since your patient has normal cardiac imaging, subclinical carditis—which would count as a major criterion—is effectively ruled out. 1

The clinical presentation fits PSRA more than ARF:

• Migratory polyarthritis involving sacroiliac joint, knee, and shoulder suggests a pattern that can occur in both conditions, but sacroiliac involvement is uncommon in classic ARF (which typically affects knees, ankles, elbows, and wrists). 1

• PSRA characteristically presents with non-migratory or less migratory arthritis that is more prolonged and less responsive to salicylates than ARF arthritis. 2, 3

• PSRA typically occurs within 10 days of streptococcal infection, whereas ARF usually has a 2-3 week latency period. 3

Does This Patient Meet Jones Criteria for ARF?

Applying the revised Jones criteria systematically:

For low-risk populations (ARF incidence ≤2 per 100,000 school-aged children or RHD prevalence ≤1 per 1,000 population): 1, 4

Major criteria present:

• Polyarthritis: YES (migratory polyarthritis involving multiple large joints) 1, 4
• Carditis (clinical or subclinical): NO (normal ECG and echo) 1, 4
• Chorea, erythema marginatum, subcutaneous nodules: Not mentioned, presumed absent

Minor criteria:

• Elevated ASO: YES 4
• Fever: Not specified
• Elevated ESR/CRP: Not specified
• Prolonged PR interval: NO (normal ECG) 4

This patient has only 1 major criterion (polyarthritis) plus evidence of streptococcal infection. To diagnose ARF, you need either 2 major manifestations OR 1 major plus 2 minor manifestations. 1, 4 Without documented fever, elevated inflammatory markers, or carditis, this patient does not meet Jones criteria for ARF.

Critical Distinction: Cardiac Risk

The most important prognostic difference between PSRA and ARF is cardiac involvement:

• In prospective studies from low-risk populations (Netherlands, adults), PSRA was not associated with long-term cardiac sequelae. 1 A Dutch study of 23 patients with PSRA showed no echocardiographic or clinical evidence of carditis during acute disease or follow-up. 2

• However, some pediatric patients initially diagnosed with PSRA later developed ARF or RHD, suggesting the initial diagnosis may have been incorrect. 1 This highlights the importance of careful initial evaluation and follow-up.

• One case series reported a patient with PSRA who developed mitral and aortic stenosis 2 years after the initial episode, raising concern about cardiac risk even in PSRA. 5

Management Approach

Acute Treatment

Treat symptomatically with NSAIDs or corticosteroids. 3 Unlike ARF arthritis (which responds dramatically to salicylates within 24-48 hours), PSRA arthritis is characteristically less responsive and more prolonged. 2, 3

Antibiotic Prophylaxis Decision

The controversy centers on whether PSRA requires long-term penicillin prophylaxis:

• Against routine prophylaxis: The Dutch prospective study in low-risk white adults demonstrated no long-term cardiac sequelae, suggesting prolonged prophylactic antibiotics may not be required for adult PSRA patients. 2, 6

• For individualized prophylaxis: Some pediatric case series showed progression to ARF/RHD in patients initially labeled as PSRA, and the AHA guidelines note "controversy about secondary prophylaxis for these patients." 1, 5

Practical recommendation based on the evidence:

1. Complete a full 10-day course of penicillin or amoxicillin to eradicate the streptococcal infection. 7

2. Do NOT initiate long-term monthly penicillin prophylaxis immediately if the patient is an adult in a low-risk population with definitively normal echocardiography. 2, 6

3. Consider short-term prophylaxis (6-12 months) in pediatric patients or high-risk populations given the case reports of progression to RHD. 5

Mandatory Follow-Up

Serial echocardiography is essential to detect subclinical carditis:

• Repeat echocardiography at 1 month and 12 months after initial presentation. 1, 4 The AHA states it is reasonable to perform serial echocardiography/Doppler studies in any patient with diagnosed or suspected ARF even if documented carditis is not present on diagnosis. 1

• If any valvular abnormality develops on follow-up echo, reclassify as ARF and initiate long-term secondary prophylaxis. 4

• If recurrent arthritis occurs, re-evaluate for ARF with repeat streptococcal serology and echocardiography. 2, 3

Common Pitfalls to Avoid

Do not assume normal auscultation excludes carditis. Subclinical carditis detected only by Doppler echocardiography is now recognized as a major criterion in the revised Jones criteria. 1, 4 Always obtain formal echocardiography with Doppler in suspected post-streptococcal arthritis.

Do not use a single normal echocardiogram to permanently exclude ARF. Valvular changes can evolve over weeks, and serial imaging is recommended. 1

Do not count joint manifestations as both major and minor criteria. If polyarthritis is used as a major criterion, polyarthralgia cannot simultaneously be counted as a minor criterion in the same patient. 1, 4

Measure blood pressure at the time of echocardiography. Systemic blood pressure influences Doppler jet characteristics (length, velocity, envelope completeness), and accounting for loading conditions is essential for accurate interpretation. 1, 4

Ensure inflammatory markers are truly elevated. In ARF, ESR and CRP are almost never normal except in isolated chorea. 1 Normal inflammatory markers should prompt serious reconsideration of the diagnosis. 1