Evidence of recent Streptococcus pyogenes infection (throat swab or elevated anti-streptolysin O titres/anti-DNase B)
2 major criteria OR 1 major + 2 minor criteria

JONES PEACE

Major criteria (JONES):

Minor criteria (PEACE):

Diagnosis

Blood tests: FBC, ESR, CRP
Infectious evidence: Streptococcal ASOT and anti-DNase B titres, throat swab MCS
Imaging:
- ECG: Look for PR prolongation, signs of carditis
- Echocardiogram: Essential even in the absence of symptoms, particularly to identify subclinical carditis
- CXR: Assess for cardiomegaly in suspected severe carditis

Treatment

Short term:

Antibiotics: IM benzathine benzylpenicillin (same dose as for streptococcal throat infections)
- For penicillin-allergic patients: Cephalexin or azithromycin (duration per guidelines)
Symptomatic relief:
- Arthritis: Ibuprofen (10 mg/kg TDS) or paracetamol (15 mg/kg QID)
- Severe arthritis/arthralgia: Aspirin (continue until symptom-free for 1–2 weeks, usually for 6 weeks)
Bed rest: Until CRP normalises

Long term:

Secondary prophylaxis: IM benzathine benzylpenicillin monthly
- Duration:
  - 10 years post-episode or until age 21 (whichever is later)
  - Until age 35 for moderate rheumatic heart disease (RHD)
  - Until age 40 or lifelong for severe RHD or post-cardiac valve surgery

Note:

Perform an echocardiogram even in asymptomatic cases to detect subclinical carditis
In patients with a previous history of RF, diagnosis may be based on 3 minor criteria alone

Causes of elevated RF other than RA

Normal variant
Infections: Hepatitis, tuberculosis, Epstein-Barr virus (EBV)
Autoimmune/connective tissue diseases: SLE, Sjögren’s syndrome, systemic sclerosis
Liver cirrhosis
Sarcoidosis

Rheumatic Fever (RF)

Diagnostic Criteria

Evidence of Recent Streptococcus pyogenes Infection
- Positive throat swab culture for group A strep, or
- Elevated anti-streptolysin O (ASOT) / anti-DNase B titres.
Major and Minor Criteria (JONES PEACE)
- 2 major OR 1 major + 2 minor criteria are required for diagnosis (with evidence of strep infection).

Major Criteria (JONES)

J: Joints → Migratory polyarthritis (hot, swollen joints)
O: Heart → Carditis (endocarditis, myocarditis, pericarditis, new or changed murmurs)
N: Nodules (subcutaneous, painless)
E: Erythema marginatum (non-itchy, pink, ring-like rash)
S: Sydenham chorea (involuntary movements, emotional lability)

Minor Criteria (PEACE)

Diagnosis

Blood Tests

Imaging

Important Note

In patients with previous rheumatic fever, ≥3 minor criteria can suffice for re-diagnosis.

Treatment

Short Term

Antibiotics
- IM Benzathine Benzylpenicillin (same dose as for strep throat) single dose
- If penicillin-allergic: Cephalexin or Azithromycin (duration per guidelines)
Symptomatic Relief
- Arthritis: Ibuprofen (~10 mg/kg TDS) or paracetamol (15 mg/kg QID)
- Severe arthritis/arthralgia: Aspirin (continue until 1–2 weeks after symptom resolution, usually 6 weeks total)
- Bed Rest: Until CRP normalises

Long Term (Secondary Prophylaxis)

IM Benzathine Penicillin monthly
Duration:
- Minimum 10 years post-episode or until age 21 (whichever is longer) if no RHD
- Until age 35 for moderate RHD
- Until age 40 or lifelong for severe RHD or post-valve surgery

Note

Echocardiogram recommended in all cases (including asymptomatic) to detect subclinical carditis.
Consider repeating antibiotic prophylaxis in recurrent episodes.

Causes of Elevated RF (Rheumatoid Factor) Other than RA

(Not directly linked to Rheumatic Fever – “RF” can also mean Rheumatoid Factor)

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