Paediatrics - Queensland Health - Queensland Government

Immune complications
Australian guidelines for the diagnosis of Acute rheumatic fever in high risk groups [1]
For an initial episode of ARF to be confirmed there must be 2 major manifestations or 1 major and 2
minor manifestations, plus evidence of a recent group A streptococcal infection.
Since Sydenham’s chorea can occur after all other signs and symptoms have resolved, it can be used
alone to confirm the diagnosis
A recurrent episode of ARF (known past ARF or chronic RHD) requires 2 major or 1 major and 2 minor
or 3 minor manifestations plus evidence of a recent GAS infection
Major manifestations
• Polyarthritis or aseptic monoarthritis or
polyarthralgia. Usually migratory i.e. finishes
in one joint, begins in another
• Chorea - strange jerky movements of the
trunk and / or limbs which the patient cannot
control
• Carditis - (including subclinical evidence of
rheumatic valve disease on echocardiogram)
• Erythema marginatum - pink skin rash with
definite rounded borders, occurring mainly
on the trunk, never on the face, and blanches
under pressure
• Subcutaneous nodules - small painless pea
sized nodules over bony prominences (e.g.
elbows)
• Carditis identified on echocardiogram may
be included as a major manifestation [1]
Minor manifestations
• History of fever or presenting fever >38ºC
• Laboratory / other clinical findings:
-- elevated acute phase reactants - ESR
≥ 30 mm/hr or CRP ≥ 30 mg / L
-- prolonged PR interval on ECG
Supporting evidence of group A streptococcal infection
• Group A streptococcus isolated on throat culture
• Elevated or rising streptococcal antibody titre. See link for age related levels www.heartfoundation.
org.au/Professional Information/Clinical Practice/ARF RHD/Pages/default.aspx
These serological titres are often high at baseline in Aboriginal and Torres Strait Islander community
children because of repeated infections with GAS. So acceptable evidence for recent GAS infection are
either:
-- titres of > 2 x reference e.g. ASOT > 400 IU / mL or Anti-DNase B > 600 U / mL or
-- a rising titre when repeated after 10 - 14 days
4. Management
• Consult MO who will likely advise:
-- evacuation / hospitalisation - confirmation and management of ARF should
occur in hospital (a wrong diagnosis either positive or negative will have
serious consequences)
-- blood for FBC, ESR, C-reactive protein (CRP), ASOT, anti-DNase B and
streptococcal serology
-- swab throat and any skin sores
• Take blood cultures if temperature ≥ 38°C
• Record ECG
• Consider chest x-ray and echocardiogram
• Provide pain relief as required. Use paracetamol for pain and fever. Do not give
aspirin or non-steroidal anti-inflammatory drugs (NSAID) until the diagnosis is
confirmed - these may cause joint symptoms to disappear and complicate the
diagnosis
Primary Clinical Care Manual 2011 Controlled copy V 1.0 577