Acute rheumatic fever is an immune reaction that follows an untreated group A strep throat infection, usually in children 5 to 15 years old. It can inflame the joints, heart, brain and skin, and lasting valve damage (rheumatic heart disease) is the main danger.
Key symptoms
- Sore throat 2 to 4 weeks before
- Fever
- Painful, swollen joints, moving from one joint to another
- Shortness of breath or chest pain
- Jerky, purposeless movements (Sydenham chorea)
What you find on exam
- Migratory arthritis of large joints such as knees and ankles
- New murmur, often mitral regurgitation; pericardial rub
- Erythema marginatum: pink rings on the trunk
- Painless firm nodules over bones and tendons
- Chorea
Tests
- Evidence of recent strep: ASO or anti-DNase B titers, throat culture
- ESR and CRP
- ECG: prolonged PR interval
- Echocardiogram for carditis even without a murmur
Treatment basics
- Benzathine penicillin G IM to clear the strep
- Aspirin or naproxen for arthritis
- Heart failure care for severe carditis
- Long-term prophylaxis with benzathine penicillin G every 4 weeks
- Prevention: prompt antibiotics for strep throat
Red flags
- Shortness of breath, edema or other signs of heart failure
- New loud murmur or chest pain
- Severe chorea that interferes with eating or walking
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.