ACUTE RHEUMATIC FEVER (ARF)
Definition
Acute Rheumatic Fever is an acute, immune-mediated, non-suppurative inflammatory
disease that occurs 2–3 weeks after untreated or inadequately treated Streptococcus
pyogenes (Group A β-hemolytic streptococcal) pharyngitis, mainly affecting the heart,
joints, brain, skin, and subcutaneous tissues.
Etiology
• Causative organism: Streptococcus pyogenes (Group A Streptococcus)
• Preceding infection: Streptococcal sore throat (pharyngitis)
• Common age: 5–18 years
Pathogenesis (Immunological)
Type of Hypersensitivity
Type II (Antibody-mediated) Hypersensitivity
Mechanism – Molecular Mimicry
1. Streptococcal throat infection.
2. Body produces antibodies against M-protein.
3. These antibodies cross-react with host tissues (heart, joints, brain).
4. Inflammation and tissue damage occur.
5. In heart → Pancarditis and Aschoff bodies (pathognomonic).
6. Recurrent attacks → Rheumatic Heart Disease (mitral valve most common).
Clinical Features – Jones Criteria
Diagnosis is based on Evidence of recent streptococcal infection + Jones Criteria
Major Criteria
• Carditis – tachycardia, murmurs, cardiomegaly, heart failure
• Migratory Polyarthritis – large joints (knees, ankles)
• Sydenham Chorea – involuntary movements, emotional lability
• Erythema Marginatum – non-itchy ring-shaped rash
• Subcutaneous Nodules – painless over extensor surfaces
Minor Criteria
• Fever
• Arthralgia
• Elevated ESR / CRP
• Prolonged PR interval (ECG)
Laboratory Diagnosis
Evidence of Recent Streptococcal Infection (Most Important)
• ASO Titer ↑ (Antistreptolysin O) – key test
• Anti-DNase B ↑
• Throat swab culture (early phase)
• Rapid antigen test (if recent)
Inflammatory Markers
• ESR ↑
• CRP ↑
• Leukocytosis
Cardiac Evaluation
• ECG: Prolonged PR interval
• Echocardiography: Valve regurgitation, carditis
• Chest X-ray: Cardiomegaly (late)
ASO Test (Exam Highlight)
• Detects antibodies to Streptolysin O toxin
• Indicates recent streptococcal throat infection
• Significant rise usually >200 Todd units (lab dependent)
• Not reliable after skin infections → use Anti-DNase B
Complications
• Rheumatic Heart Disease (RHD)
• Mitral stenosis / regurgitation
• Heart failure
• Arrhythmias
• Recurrent attacks worsen valve damage
Management
1. Eradication of Streptococcus
• Penicillin / Amoxicillin
• If allergy → Erythromycin / Azithromycin
2. Anti-Inflammatory Treatment
• Aspirin / NSAIDs – arthritis
• Corticosteroids – severe carditis
3. Bed Rest
• During active carditis
4. Secondary Prophylaxis (Very Important)
• Benzathine Penicillin G IM every 3–4 weeks
• Long-term prevention of recurrence and RHD
Prevention
• Early treatment of streptococcal sore throat
• Good hygiene and access to antibiotics
• Regular prophylactic penicillin in previous ARF patients
Key Exam Keywords
Group A Streptococcus – Molecular Mimicry – M Protein – Jones Criteria – ASO Titer –
Pancarditis – Aschoff Bodies – Mitral Valve – Benzathine Penicillin
One-Line Exam Conclusion
Acute Rheumatic Fever is an immune-mediated post-streptococcal inflammatory disease
diagnosed by Jones criteria and elevated ASO titers, with early antibiotic therapy and long-
term penicillin prophylaxis essential to prevent Rheumatic Heart Disease.