GAS Isn't Always Strep Throat : ID Consult

The Jones criteria for rheumatic fever, first established in 1944 and revised most recently in 1992 (JAMA 1992;268:2069-73), require evidence of antecedent GAS infection along with either two or more major criteria (carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules), or one major criterion plus at least two minor criteria (fever, arthralgia, previous rheumatic fever or rheumatic heart disease, elevated acute phase reactants, prolonged PR interval).

This definition leaves us with a conundrum: what to do with the child who has two or more of the minor criteria but none of the major ones, particularly if the child has a single joint arthritis. These may be post-GAS syndromes. Or could the child have some other arthritis that coincidentally occurred following GAS?

Further, do these children need more than 10 days of penicillin (up to a year)? Without prophylaxis, some who initially had an autoimmune joint flare-up without classic carditis or polyarthritis may convert to full-blown rheumatic fever the next time they're exposed to GAS.

It seems reasonable to put such children on prophylaxis for 12 months, especially during the winter GAS season. If the joint symptoms recur on adequate GAS prophylaxis, you can be more confident that it's not due to GAS and therefore should be referred to a rheumatologist. If the child develops some evidence of valvular abnormality over the year of prophylaxis, then it's an atypical case of rheumatic fever.