It is a non–suppurative sequela of a group A ß haemolytic streptococcal (GABHS) pharyngeal infection.

Diagnostic criteria

Jones Criteria

Major Criteria

• Carditis

• Migratory polyarthritis

• Sydenham’s chorea

• Erythema Marginatum

Minor Criteria

Clinical

• Fever

• Arthralgia

• Laboratory

• Elevated Acute Phase Reactants eg CRP

• Prolonged PR interval

  
  

Plus Supporting evidence of recent group A streptococcal infection e.g. positive throat culture or antigen detection and/or elevated streptococcal antibody tests* *Anti –Streptolysin O, Anti –Deoxyribonuclease B

Definitive Diagnosis

Two major criteria or One major criterion with two minor criteria, with evidence of antecedent streptococcal infection

Pharmacological

Treatment of acute attack for eradication of streptococci in throat: Regardless of the presence or absence of pharyngitis at the time of diagnosis.

A: Benzathine benzylpenicillin 1.2 MU IM stat. Children: under 5 years 0.3 MU, 5–10 years 0.6 MU, over 10 years 1.2 MU IM stat.

OR

A: Phenoxymethylpenicillin (penicillin V) 500 mg PO every 8–12 hours for 10 days. Children: over 10 years 500 mg, 5–10 years 250 mg, under 5 years 125 mg every 8–12 hours for 10 days.

Patients allergic to penicillin

A: Erythromycin 500 mg or 40 mg/kg PO every 6 hours for 10 days.

⚠ Dose check note: STG 2026 prints erythromycin as "500mg or 40mg/kg 6hourly". 40 mg/kg every 6 hours would be 160 mg/kg/day; WHO gives children erythromycin 40–50 mg/kg/day divided into doses every 6 hours (about 12.5 mg/kg per dose, maximum 500 mg per dose) and adults 500 mg every 6 hours. Cross-check this dose against the WHO recommendation before prescribing.

Treatment of Acute Arthritis and Carditis:

Aspirin orally 25mg/kg, 4 times a day as required. Aspirin should be continued until fever, all signs of joint inflammation and the ESR have returned to normal and then tapered gradually over 2 weeks. If symptoms recur, full doses should be restarted. Dose should be reduced if tinnitus or other toxic symptoms develop

In severe carditis with development of increasing heart failure or failure of response to aspirin,

Add

Prednisolone 1–2mg/kg once a day for 3–4 weeks.

Then review and gradual reduction and discontinuation of prednisolone may be started after 3–4 weeks when there has been a substantial reduction in clinical disease.

Treat heart failure in the usual way: loop diuretic (furosemide), an ACE inhibitor (captopril or enalapril) and, when out of the congestive state, a beta-blocker (carvedilol); limit salt and fluid.

Treatment of Sydenham’s Chorea:

Haloperidol 1.5–3mg (O) 8hourly a day as required (Adult). Paediatrics 50µg/kg in 2 divided doses.

Referral: Ideally all patients should be referred to high level of care a specialized hospital care; where surgery is contemplated

Antibiotic prophylaxis after rheumatic fever:

Prophylaxis should be given to all patients with a history of acute rheumatic fever and to those with rheumatic heart valve lesions. The optimum duration of prophylaxis is controversial, but should be continued up to at least 21 years of age.

Note: Specific situations requiring prophylaxis for longer periods (up to 30 years as a guide):

Definitive carditis in previous attacks high risk of exposure to streptococcal infection at home or work (crowded conditions, high exposure to children)

Medicine of choice

Benzathine Penicillin IM Adult 2.4MU monthly or every three weeks. Paediatrics <12yrs 1.2MU every 4 weeks or 3 weeks for up to 21–30yrs

OR

Penicillin V (PO) 250mg 12 hourly Adult. Paediatric <12yr 125–250mg 12 hourly a day up to 21–30yrs

OR

Erythromycin 250mg 12hourly a day Adult. Paediatric <12yr 125–250mg 2 times a day up to 21–30yrs, Every 3week regimen is more effective

Non pharmacological

Treatment Acute stage:

• Bed rest and supportive care until all evidence of active carditis has resolved

• Patient education.

• Intensive health education for prevention of sore throats