Rheumatic heart disease due to rheumatic fever

Rheumatic fever is an autoimmune disease that develops following a bout of untreated group A β-hemolytic streptococcal infection in persons that exhibit genetic susceptibility. It affects multiple organs, leading to its characteristic clinical manifestations that develop either in isolation or in multitudes. These include subcutaneous nodules, erythema marginatum, chorea, arthritis and carditis in ascending order of frequency.

Rheumatic fever leads to rheumatic heart disease (RHD). RHD has affected not less than 33 million people around the planet.
The larger number of cases are in resource-limited settings like Africa-Uganda.

Rheumatic heart disease due to rheumatic fever.
Rheumatic heart disease due to rheumatic fever.
source: Wikipedia

There are about half a million new cases of rheumatic fever, with approximate mortality of up to 230,000 world-wide. It is typically a disease of the socioeconomically underprivileged class of people. We all know where we can find such people around the globe. So, it is not surprising that Africa is one of the regions where the disease is endemic.

Read this article: Improving maternal and newborn health: what are the recommended interventions?

Rheumatic heart disease, a complication of the fever is one of the most common causes of acquired valvular heart diseases in the African region. However, we aren’t here to discuss the nitty-gritty of this devastating disease, but rather, shed some light into the updates in the modified Jones criteria.

‘Jones criteria’ are the diagnostic criteria for rheumatic fever. Jones first coined them in 1944, after-which American Heart Association in 1992. From 1992 to 2015, we were using the modified Jones Criteria to diagnose rheumatic fever. The criteria are a combination of both clinical and laboratory findings that we group into major and minor criteria.

Using the modified Jones criteria in 1992, the diagnosis of the disease could be confirmed if there were two majors or one major and two minors, in addition to the evidence of recent infection with group A β-hemolytic streptococcal illness. However, clinicians have come across cases of rheumatic fever with either chorea or carditis as the sole clinical findings.

The expert panel modified the 1944 Jones criteria in 1992. The American Heart Association updated it and published the 2015 revised version.

In addition to the parameters contained within the previous version, the revised 2015 version makes identification of a low, medium, and high-risk populations. Also, there was a consensus that echocardiographic examination becomes the frontline diagnostic tool for the confirmation, diagnosis, and monitoring of valvular heart lesions due to rheumatic fever. It is especially critical for all patients with subclinical carditis.

Having outlined a preamble about rheumatic fever, below is a table showing modified 2015 Jones criteria for its diagnosis.

Major criteria
Low risk populationHigh risk population
Carditis (clinical or subclinical)
Arthritis – only polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Carditis (clinical or subclinical)
Arthritis – monoarthritis or polyarthritis
Polyarthralgia
Chorea
Erythema marginatum
Subcutaneous nodules
Minor criteria
Low risk population
High risk population
Polyarthralgia
Hyperpyrexia (≥ 38.5ºC)
ESR ≥ 60 mm/h and/or CRP ≥ 3.0 mg/dl
Prolonged PR interval (after taking into account the differences related to age; if there is no carditis as a major criterion)
Monoarthralgia
Hyperpyrexia (≥ 38.0ºC)
ESR ≥ 30 mm/h and/or CRP ≥ 3.0 mg/dl
Prolonged PR interval (after taking into account the differences related to age; if there is no carditis as a major criterion)
       Source: AHA

For more information about this condition, read the review paper by Mariana. et al., here and another review paper by Muhamed. et al., here.
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By IAmDrSsekandi

I am a medical officer interested in maternal and child health. I am a content creator, author and founder of https://ssekandima.com. I do private practice with a public touch. I am a certified digital marketer. I earned certificates in Understanding Clinical Research and Writing in Sciences from the University of Cape Town and Stanford University respectively.

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