Traditional Jones Criteria: Limitation in the Diagnosis of Rheumatic Fever in Patients with Mitral Valve Repair

@#The present study aims to determine the limitations of traditional Jones criteria during the first episode of acute rheumatic fever (ARF) at the initial referral hospital, in a cohort of patients below 18 years old who had undergone mitral valve repair in National Heart Institute (IJN) from 2011 to 2016. Carditis followed by fever and joint involvement were the most frequent manifestations at first diagnosis. Of the 50 patients, only seven (14%) fulfilled the traditional Jones criteria for the diagnosis of the first episode of ARF. When compulsory evidence of a previous group A Beta hemolytic streptococcus (GABHS) was disregarded, this figure rose to 54%. Therefore, strict adherence to Jones criteria with absolute documentation of GABHS will lead to underdiagnoses of ARF. The application of echocardiographic diagnostic criteria of rheumatic heart disease (RHD) needs to be emphasized to allow early diagnosis and administration of secondary prophylaxis to prevent progression to severe valvular disease.

Rheumatic fever: update on the Jones criteria according to the American Heart Association review - 2015 / Febre reumática: atualização dos critérios de Jones à luz da revisão da American Heart Association - 2015

ABSTRACT Rheumatic fever is still currently a prevalent disease, especially in developing countries. Triggered by a Group A β-hemolytic Streptococcus infection, the disease may affect genetically predisposed patients. Rheumatic carditis is the most important of its clinical manifestations, which can generate incapacitating sequelae of great impact for the individual and for society. Currently, its diagnosis is made based on the Jones criteria, established in 1992 by the American Heart Association. In 2015, the AHA carried out a significant review of these criteria, with new diagnostic parameters and recommendations. In the present study, the authors perform a critical analysis of this new review, emphasizing the most relevant points for clinical practice.

RESUMO A febre reumática ainda é uma doença prevalente nos tempos atuais, sobretudo nos países em desenvolvimento. Deflagrada por uma infecção pelo Streptococcus β-hemolítico do grupo A, pode afetar pacientes geneticamente predispostos. A cardite reumática é a mais importante das manifestações clínicas, pode gerar sequelas incapacitantes e de grande impacto para o indivíduo e para a sociedade. Atualmente, seu diagnóstico é feito baseado nos Critérios de Jones, estabelecidos em 1992 pela American Heart Association (AHA). Em 2015, a AHA procedeu a uma significativa revisão desses critérios, com novos parâmetros e recomendações diagnósticas. No presente estudo, os autores fazem uma análise crítica dessa nova revisão e enfatizam os pontos de maior relevância para a prática clínica.

Diagnóstico inicial de febre reumática: avaliação da aplicabilidade dos critérios de Jones / Case series study with an initial diagnosis of rheumatic fever, hospitalized in a university hospital: evaluation of applicability of Jones Criteria

Introdução: A febre reumática (FR) é uma doença inflamatória que ocorre após infecção pelo estreptococo beta-hemolítico do grupo A, em indivíduos geneticamente predispostos, principalmente entre 5 e 15 anos, sem predomínio de sexo. O diagnóstico é clínico, através dos Critérios de Jones (CJ). Estatísticas indicam que o Brasil apresenta elevada incidência da doença. Objetivo: Avaliar o perfil de apresentação clínico-laboratorial e os desfechos em uma série de casos internados com diagnóstico inicial de FR. Metodologia: Estudo tipo série de casos com perfil observacional, descritivo e retrospectivo, realizado no Hospital Universitário Alcides Carneiro, em Campina Grande-PB. Resultados: Foram analisados 26 prontuários de pacientes, com idade média de 11,8 anos e procedentes de 11 municípios da Paraíba. A distribuição por sexo foi 61,5% feminino e 38,5% masculino. O diagnóstico foi confirmado em 50% dos pacientes. Daqueles que confirmaram o diagnóstico através dos CJ, associados ou não ao ecocardiograma, 40% apresentaram um critério maior e dois ou mais critérios menores. Houve simultaneidade dos seguintes critérios maiores: artrite e cardite em 40%; coreia e cardite em 10%; artrite, coreia e cardite em 10%. Coreia como sintoma isolado foi verificado em 10% desses pacientes. Conclusão: As dificuldades diagnósticas descritas pela literatura, devido à inespecificidade dos CJ, inexistência de sinal patognomônico ou teste laboratorial específico, além da grande variabilidade de manifestações clínicas foram também observadas neste estudo. As autoras sugerem uma revisão dos critérios clínicos e laboratoriais de forma a aumentar a sensibilidade diagnóstica na febre reumática.

Hemichorea as a presentation of acute rheumatic fever: a case report.

Chorea is a major manifestation of acute RF and is the only evidence of RF in approximately 20% of cases. We report on a 15-year-old boy who presented with transient right side involuntary jerky movements, apical systolic murmur, sinus bradycardia, arthralgia, elevated antistreptolysin O titer and ESR, who was diagnosed with acute rheumatic fever and improved with haloperidol, prednisolone, digoxin, aspirin and furosemide and was given benzathine penicillin prophylaxis for future RF. Patient is faring well in follow up visits. We present our case because of its rarity.

Manifestações articulares atípicas em pacientes com febre reumática / Articular manifestations in patients with atypical rheumatic fever

Objetivos: Descrever as características clínicas e a ocorrência de artrite atípica em crianças com diagnóstico de febre reumática (FR) acompanhadas em ambulatórios terciários em Salvador, Bahia. Metodologia: Estudo descritivo, de uma série de casos, do quadro clínico inicial ou recorrência de 41 crianças com diagnóstico de FR. Resultados: Dos pacientes estudados (n=41), 61% eram do sexo masculino; com média de idade de 9,2 anos e idade no momento do diagnóstico entre 5 e 16 anos. Artrite esteve presente em 75,6% dos pacientes; cardite em 75,6%; coreia em 31,7%; eritema marginado em 14,6% e nódulos subcutâneos em 4,9%. Um padrão atípico foi observado em 22 dos 31 casos com artrite (70,9%): envolvimento de pequenas articulações e/ou esqueleto axial em 12 casos (38,7%); duração maior que três semanas em nove (29%); resposta inadequada ao AINH em dois (6,5%); oligoartrite (≤ quatro articulações) em 22/31 (71%), sendo monoartrite em 6/31 (uma em pés, uma em tornozelo e quatro em joelho). A febre esteve presente em 78% dos casos e 82,9% dos pacientes utilizavam a profilaxia secundária de forma regular. Conclusão: Artrite atípica esteve presente na maioria dos pacientes que cursaram com acometimento articular, constituindo um fator de confundimento diagnóstico e atraso terapêutico adequado. .

Objectives: To describe the clinical characteristics and the occurrence of atypical arthritis in children diagnosed with rheumatic fever (RF) and followed in tertiary care clinics in Salvador, Bahia, Brazil. Methodology: A descriptive study of a case series, of the initial clinical presentation, and of recurrence in 41 children diagnosed with RF. Results: Of the patients studied (n=41), 61% were male, mean age of 9.2 years, and mean age at diagnosis between 5 and 16 years. Arthritis was present in 75.6% of patients; carditis in 75.6%; chorea in 31.7%; erythema marginatum in 14.6%; and subcutaneous nodules in 4.9%. An atypical pattern was observed in 22 of 31 cases of arthritis (70.9%): involvement of small joints and/or axial skeleton in 12 cases (38.7%); >3 weeks of duration in 9 (29%); inadequate response to NSAIDs in 2 (6.5%); oligoarthritis (≤4 joints) in 22/31 (71%), with monoarthritis in 6/31 (1 in the foot, 1 in the ankle, and 4 in the knee). Fever was present in 78% of the cases, and 82.9% of patients were regularly on secondary prophylaxis. Conclusion: Atypical arthritis was present in most patients presenting with joint involvement, being a confounding factor against a proper diagnosis and of therapeutic delay. .

Prevalence of Rheumatic Fever and Rheumatic Heart Disease in School Children of Bharateswari Homes of Bangladesh.

Background: Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to affect millions of people around the world, including Bangladesh. Children and adolescents are especially susceptible to this disease. Classical risk factors, i.e. poverty, overcrowding, ignorance and insufficient health care services are responsible for the high incidence and prevalence of these diseases. To assess the prevalence of RF and RHD among children, a school survey was conducted in Bharateswari Homes, in the district of Tangail, Bangladesh. Methods: A total of 947 students were examined. Revised Jones’ criteria (1992), and clinical examination were used for the diagnosis of RF and RHD. Results: Four cases of RF/RHD were found giving the prevalence of 4.22/1000. This is lower than the prevalence reported in eighties, but is consistent with those found in nineties. Conclusion: Among the school children, there is a declining trend in the prevalence of RF/RHD.

The Diagnosis of Rheumatic Fever and Rheumatic Heart Disease / Монголын Анагаах Ухаан

The Jones criteria is a clinical guideline for the diagnosis of rheumatic fever(RF) and carditis. The clinical features were divided into major and minor categories. Major manifestations include carditis, joint symptoms, subcutaneous nodules, erythema marginatum and chorea. The minor manifestations comprised clinical fi ndings(fever, artralgia, cardialgia,abdominal pain, nose bleeding ) and laboratory markers(Leukocytosis, elevated erythrocyte sedimentation rate and C-reactive protein, prolonged PR on ECG). It was proposed that the presence of two major, or one major and two minor manifestations offered reasonable clinical evidence of rheumatic activity.Carditis is the single most important prognostic factor in RF; only valvulitis leads to permanent damage and its presence determines the prophylactic strategy. The clinical diagnosis of carditis in an index attack of RF is based on the presence of signifi cant murmurs (suggestive of mitral and aortic regurgitation), pericardial rub, or unexplained cardiomegaly with congestive heart failure.Myocarditis(alone) in the absence of valvulitis is unlikely to be of rheumatic origin and by itself should not be used as a basis for such a diagnosis. Two dimentional echo-Doppler and colour fl ow Doppler echocardiography are most sensitive for detecting structural abnormality, abnormal blood fl ow and valvular regurgitation. This method can detect all audible valvular regurgitations to be dThe use of 2D echo-Doppler and colour fl ow Doppler echocardiography may prevent the overdaignosis of a functional murmur as a valvular heart disease. Similarly, the overinterpretation of physiological or trivial valvular regurgitation may result in misdiagnosis of iatrogenic valvular disease. Accurate interpretation of the echocardiographic signals is therefore important.