Technical notes
| Diagnosis or manifestation type | High-risk groups(a) | All other groups |
|---|---|---|
Definite initial episode of acute rheumatic fever (ARF) | 2 major or one major and 2 minor manifestations plus evidence of a preceding group A streptococcus (Strep A) infection(b) | 2 major or one major and 2 minor manifestations plus evidence of a preceding Strep A infection(b) |
Definite recurrent episode of ARF in a patient with known past ARF or rheumatic heart disease (RHD) | 2 major or one major and 2 minor or 3 minor manifestations plus evidence of a preceding Strep A infection(b) In the 2012 guidelines- 2 major or one major and one minor or 3 minor manifestations plus evidence of a preceding Strep A infection(b) | 2 major or one major and 2 minor or 3 minor manifestations plus evidence of a preceding Strep A infection(b) In the 2012 guidelines, 2 major or one major and one minor or 3 minor manifestations plus evidence of a preceding Strep A infection(b) |
Probable ARF | A clinical presentation that falls short by either one major or one minor manifestation, or the absence of streptococcal serology results, but one in which ARF is considered the most likely diagnosis. Such diagnoses should be further categorised according to the level of confidence with which the diagnosis is made:
| A clinical presentation that falls short by either one major or one minor manifestation, or the absence of streptococcal serology results, but one in which ARF is considered the most likely diagnosis. Such diagnoses should be further categorised according to the level of confidence with which the diagnosis is made:
|
Major manifestations | Carditis (including subclinical evidence of rheumatic valvulitis on echocardiogram) Polyarthritis(c) or aseptic mono-arthritis or polyarthralgia Chorea(d) Erythema marginatum(e) Subcutaneous nodules | Carditis (including subclinical evidence of rheumatic valvulitis on echocardiogram) In the 2012 guidelines, Carditis (excluding subclinical evidence of rheumatic valvulitis on echocardiogram) Polyarthritis(c) Chorea(d) Erythema marginatum(e) Subcutaneous nodules |
Minor manifestations | Monoarthralgia Fever(f) ESR≥30mm/h or CRP ≥30 mg/L Prolonged P-R interval on ECG(g) | Fever(f) Polyarthralgia or aseptic mono-arthritis ESR ≥60 mm/h (ESR ≥30 mm/h in the 2012 guidelines) or CRP ≥30 mg/L Prolonged P-R interval on ECG(g) |
CRP = C-reactive protein
ECG = electrocardiogram
ESR = erythrocyte sedimentation rate
Strep A = group A streptococcus
- High-risk groups are those living in communities with high rates of ARF (incidence>30/100,000 per year in 5–14 year olds) or RHD (all-age prevalence >2/1000). First Nations people living in rural or remote settings are known to be at high risk. Data are not available for other populations, but First Nations people living in urban settings, Māori’s and Pacific Islanders, and potentially immigrants from developing countries, may also be at high risk.
- Elevated or rising antistreptolysin O or other streptococcal antibody, or a positive throat culture or rapid antigen test for Strep A.
- A definite history of arthritis is sufficient to satisfy this manifestation. Note that if polyarthritis is present as a major manifestation, polyarthralgia or aseptic mono-arthritis cannot be considered an additional minor manifestation in the same person.
- Chorea does not require other manifestations or evidence of preceding Strep A infection, provided other causes of Chorea are excluded.
- Care should be taken not to label other rashes, particularly non-specific viral exanthemas, as erythema marginatum.
- Oral, tympanic or rectal temperature ≥38.5°C (≥38°C in the 2012 guidelines) on admission, or a reliably reported fever documented during the current illness.
- If carditis is present as a major manifestation, a prolonged P-R interval cannot be considered an additional minor manifestation.
Source: RHDAustralia 2020.
RHDAustralia (ARF/RHD writing group) (2020) The 2020 Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease, 3.2 edn (2022), RHDAustralia, Menzies School of Health Research, Darwin.