Pediatrics · Topic 13 of 42

Rheumatic Fever

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Pediatrics · autoimmune

Rheumatic Fever

An autoimmune reaction 2–4 weeks after untreated strep throat. The danger is carditis, which can permanently damage the mitral valve.

01 · The dangerCarditis: permanent mitral valve damage

02 · PreventionFinish every antibiotic dose for strep

03 · After an attackBenzathine penicillin G IM every 4 weeks

Why it happens

An autoimmune reaction 2–4 weeks after untreated group A strep throat

Untreated strep throat → autoimmune attack 2–4 weeks later

Carditis is the only lasting damage — usually the mitral valve

Each recurrence damages the heart valves further

Most cases: children 5–15 years old

CDC gives a wider window of 1–5 weeks. Rheumatic fever is linked mainly to strep throat, not skin infection; impetigo may play a role in some high-risk populations.

What you'll see

Heart, joints, skin and brain — only the heart can scar

New or changed murmur, tachycardia — carditis report now

Migratory polyarthritis: knees, ankles, wrists, one after another

Joints red, swollen, very tender — heal without damage

Erythema marginatum (pink rash, clear centers, on the trunk)

Subcutaneous nodules (painless) over joints

Sydenham chorea (involuntary jerky movements, emotional lability) late finding

Labs & diagnostics

Prove a recent strep infection: a rising ASO or anti-DNase B titer

Rising ASO (antistreptolysin O) titer

Rising anti-DNase B titer

Throat culture is often negative by then

Revised Jones criteria: evidence of strep infection plus 2 major criteria, or 1 major and 2 minor. Majors: carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules. Mitral regurgitation (apical holosystolic murmur) is the earliest valve lesion; progressive damage can lead to mitral stenosis.

Red flags

New or changed heart murmur, or tachycardia report now

Shortness of breath, cough, edema, tachycardia heart failure

Fever and joint pain coming back report recurrence

Treatment

Penicillinclear the strep

penicillin

Given first to clear any remaining strep

Anti-inflammatoryarthritis and fever

aspirin naproxen

Aspirin or another NSAID

Prophylaxisprevent recurrence, for years

benzathine penicillin G

IM about every 4 weeks

Keep it going even when well

Prophylaxis length and other drugs

No carditis: 5 years or until age 21

Carditis without valve disease: 10 years or age 21

Residual valve disease: 10 years or age 40 (whichever is longer)

High-risk populations: every 3 weeks (21 days); CDC every 3–4 weeks

Oral penicillin V twice daily is an alternative, but less effective

Naproxen often replaces high-dose aspirin (salicylate levels, Reye risk)

Corticosteroids may be added for severe carditis, sometimes for chorea

Sydenham chorea usually resolves in about 6 weeks to 6 months

Nursing priorities

Auscultate the heart every shift — report a new or changed murmur

Watch for heart failure: dyspnea, cough, edema, tachycardia

Give penicillin first, then aspirin or an NSAID as ordered

Chorea: protect from injury and reduce stimulation

Teach the family to keep prophylaxis going for years

Teach your patient

Finish every antibiotic dose for strep throat

Keep the penicillin injections going, even when well

Report fever and joint pain that come back

Chorea is not misbehavior

Pearl

Untreated strep throat → rheumatic fever 2–4 weeks later; carditis is the part that lasts. Finish the antibiotics, then keep the penicillin shots every 4 weeks.

Sources · StatPearls: Acute Rheumatic Fever (NCBI Bookshelf) · CDC — Clinical Guidance for Acute Rheumatic Fever (Group A Strep) · Follow your facility's protocol for antibiotic prophylaxis.

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