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Acute rheumatic fever without early carditis: an atypical clinical presentation

Abstract

The original Jones criteria, first introduced in 1944, have been modified four times and updated-revised criteria were published in 1992. A variety of clinical manifestations, which may be the presenting signs and symptoms of acute rheumatic fever, are not included in the updated-revised Jones criteria. A retrospective study was conducted on all children previously diagnosed to have acute rheumatic fever between September 1998 and September 2002. Review was focused on clinical presentation; out of 60 medical records reviewed, 4 patients with unusual clinical presentation were recognised and are reported here to highlight the potential diagnostic problems of acute rheumatic fever. They presented with atypical articular involvement, silent carditis and low-grade fever in the presence some time of a positive family history for rheumatic fever. Conclusion:a high index of suspicion and an awareness of the absence of early carditis are necessary to make the diagnosis of acute rheumatic fever.

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Abbreviations

ARF :

acute rheumatic fever

PSReA :

post-streptococcal reactive arthritis

RF :

rheumatic fever

References

  1. Abbag F, Benjamin B, Kardash MM, AL-Barki A (1998) Acute rheumatic fever in Southern Saudi Arabia. East Afr Med J 7: 279–281

    Google Scholar 

  2. Abernethy M, Bass N, Sharp N, Greaves S, Lennon D, Snew S, Whalley G, Grant C, Neutze J, Klarkson P (1994) Doppler echocardiography and early diagnosis of carditis in acute rheumatic fever. Aust NZ Med J 24: 530–535

    CAS  Google Scholar 

  3. Ayoub EM, Ahmad S (1997) Update on complications of group A streptococcal infections. Curr Prob Pediatr 27: 90–101

    CAS  Google Scholar 

  4. Ayoub EM, Majeed HA (2000) Post-streptococcal reactive arthritis. Curr Opin Rheumatol 12: 306–310

    Article  CAS  PubMed  Google Scholar 

  5. Bavdekar SB, Soloman R, Kamat JR (1999) Rheumatic fever in children. J Indian Med Assoc 97: 489–492

    CAS  PubMed  Google Scholar 

  6. Carapetis JR, BJ Currie (2001) Rheumatic fever in a high incidence population: the importance of monoarthritis and low-grade fever. Arch Dis Child 85: 223–227

    Article  CAS  PubMed  Google Scholar 

  7. Dajani AS, Ayoub E, Bierman FZ, Bisno AL (1992) Guidelines for the diagnosis of rheumatic fever: Jones criteria, updated 1992. JAMA 268: 2069–2073

    PubMed  Google Scholar 

  8. Dajani AS, Allen HD, Taubert KA (1993) Echocardiography for diagnosis and management of rheumatic fever. JAMA 269: 284

    Google Scholar 

  9. David L (1998) Diagnosis and treatment of rheumatic fever. Arch Pediatr 5: 681–686

    Article  CAS  PubMed  Google Scholar 

  10. De Silva NA, Pereura BA (1997) Acute rheumatic fever. Still a challenge. Rheum Dis Clin North Am 23: 545–568

    PubMed  Google Scholar 

  11. Denny FW (1987) T Duckett Jones and rheumatic fever in 1986. Circulation 76: 963–970

    CAS  PubMed  Google Scholar 

  12. Folger GM, Hajar R, Robida A, Hajar HA (1992) Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: color flow Doppler identification. Br Heart J 67: 434–438

    PubMed  Google Scholar 

  13. Jones TD (1994) Diagnosis of rheumatic fever. JAMA 126: 481–484

    Google Scholar 

  14. Kaur S, Kumar D, Grover A, Khanduja KL, Kaplan EL, Gray ED, Ganguly NK (1998) Ethnic differences in expression of susceptibility marker (s) in rheumatic fever/rheumatic heart disease patients. Int J Cardiol 64: 9-14

    Article  CAS  PubMed  Google Scholar 

  15. Khanna AK, Buskirk DR, Williams RC, Gibofsky A, Crow MK, Nenon A, Fotino M, Reid HM, Poor-King T, Robinstein P (1989) Presence of a non-HLA B cell antigen in rheumatic fever patients and their families defined by a monoclonal antibody. J Clin Invest 83: 1710–1716

    CAS  PubMed  Google Scholar 

  16. Lahat E, Aziz E, Eshel G, Mundel G (1986) Recurrent abdominal and cervical pains. An unusual clinical presentation of acute rheumatic fever. Helv Paediatr Acta 41: 549–552

    CAS  PubMed  Google Scholar 

  17. Mangione S, Nieman L, Gracely E, Kaye D (1993) The teaching and practice of cardiac auscultation during internal medicine and cardiology training. Ann Intern Med 119: 47–54

    CAS  PubMed  Google Scholar 

  18. Markowitz M (1988) Evaluation and critique of changes in the Jones criteria for the diagnosis of rheumatic fever. N Z Med J 101: 392–394

    CAS  PubMed  Google Scholar 

  19. Narula J, Chopra P, Talwar KK, Vasan RS (1993) Endomyocardial biopsies in acute rheumatic fever. Circulation 88: 2198–2205

    CAS  PubMed  Google Scholar 

  20. Nordet P (1993) WHO/ISFC Global Programme for the prevention and control of RF/RHD. J Int Soc Fed Cardiol 3: 4-5

    Google Scholar 

  21. Okuni M (1971) Problems in clinical application of revised Jones diagnostic criteria for rheumatic fever. Jpn Heart J 12: 436–441

    CAS  PubMed  Google Scholar 

  22. Rutstein DD, Bauer W, Dorfman A, Gross RE, Lichty JA, Taussing HB, Whittemore R (1956) Report of the committee on standards and criteria for programs of care of the Council of Rheumatic Fever and Congenital Heart Disease of the American Heart Association. Jones criteria (modified) for guidance in the diagnosis of rheumatic fever. Circulation 13: 617–620

    Google Scholar 

  23. Saxena A (2000) Diagnosis of acute rheumatic fever: current status of Jones Criteria and role of echocardiography. Indian J Pediatr 67: 283–286

    CAS  PubMed  Google Scholar 

  24. Shulman ST, Kaplan EL, Bisno AL, Millard HD, Amren DP, Houser H, Sanders WE, Durack DT, WatanaKunakorn C (1984) Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease of the American Heart Association. Jones criteria (revised) for guidance in the diagnosis of rheumatic fever. Circulation 70: 204A–208A

    Google Scholar 

  25. Spagnuolo M, Taranta A (1986) Rheumatic fever in siblings: similarity in its clinical manifestations. N Engl J Med 278: 1843–1848

    Google Scholar 

  26. St Clair EW, Oddone EZ, Waugh RA, Corey GR, Feussner JR (1992) Assessing house staff diagnostic skills using a cardiology patient simulator. Ann Intern Med 117: 751–756

    PubMed  Google Scholar 

  27. Stollerman GH, Markowitz M, Taranta A, Wannamaker LW, Whittemore R (1965) Report of the Adhoc Committee on Rheumatic Fever and Congenital Heart Disease of the American Heart Association: Jones criteria (revised) for guidance in the diagnosis of rheumatic fever. Circulation 32: 664–668

    PubMed  Google Scholar 

  28. Taubert KA, Rawley AH, Shulman ST (1994) Seven-year national survey of Kawasaki disease and acute rheumatic fever. Pediatr Infect Dis J 13: 704–708

    CAS  PubMed  Google Scholar 

  29. Veasy LG, Tani L, Hill H (1994) Persistence of acute rheumatic fever in the intermountain area of the United States. J Pediatr 124: 9-16

    CAS  PubMed  Google Scholar 

  30. Wilson NJ, Neutze JM (1994) Echocardiographic diagnosis of mitral insufficiency. J Pediatr 125: 673

    CAS  PubMed  Google Scholar 

  31. Wilson NJ, Neutze JM (1995) Echocardiographic diagnosis of sub clinical carditis in acute rheumatic fever. Int J Cardiol 50: 1–6

    Article  CAS  PubMed  Google Scholar 

  32. Zangwill KM, Wald ER, Londino A Jr (1991) Acute rheumatic fever in Western Pennsylvania: a persistence problem into the 1990 s. J Pediatr 118: 561–563

    CAS  PubMed  Google Scholar 

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Correspondence to Imad Khriesat.

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Khriesat, I., Najada, A.H. Acute rheumatic fever without early carditis: an atypical clinical presentation. Eur J Pediatr 162, 868–871 (2003). https://doi.org/10.1007/s00431-003-1320-x

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  • DOI: https://doi.org/10.1007/s00431-003-1320-x

Keywords

  • Clinical
  • Jordan
  • Rheumatic fever