Clinical Scenario:
A 9-year-old girl presents with high-grade fever and pain in the left knee for 8 days. She had a sore throat 3 weeks earlier that was untreated. On examination, temperature is 101°F, pulse is disproportionately elevated, and a new soft pansystolic murmur is heard at the apex. There is no rash, chorea, or subcutaneous nodules. Investigations: ASO titre — elevated; ESR — 60 mm/hr; CRP — raised; ECG — prolonged PR interval for age; Echocardiography — mild mitral regurgitation with rheumatic morphology. She belongs to a community with a known high prevalence of rheumatic heart disease.
As per the revised Jones criteria (AHA, 2015), what is the diagnosis?
Options:
A. Definite acute rheumatic fever
B. Indeterminate acute rheumatic fever
C. Possible acute rheumatic fever
D. Probable rheumatic heart disease
E. Subclinical carditis only
Correct answer & Explanation:
Key: A
Explanation:
In moderate/high-risk populations, monoarthralgia alone (not just polyarthritis) can be considered a major criterion, but here it is not needed — carditis already serves as the major criterion, and the arthralgia is not separately counted since only one major manifestation is required when supported by minors.
Criteria met:
- Major (1): Carditis — new mitral regurgitation murmur + echocardiographic confirmation
- Minor (2): Fever ≥38.5°C, prolonged PR interval
- Evidence of preceding group A streptococcal infection: Elevated ASO titre
→ 1 major + 2 minor + evidence of GAS infection = Definite acute rheumatic fever (per 2015 revised Jones criteria for moderate/high-risk populations)
Why others are wrong:
- B, C — Not actual Jones criteria diagnostic categories; distractors.
- D — “Probable rheumatic heart disease” is not a Jones criteria label; RHD is a chronic sequela diagnosed on structural/echocardiographic criteria during asymptomatic screening, not during an acute presentation like this.
- E — She has clinical carditis (audible murmur on auscultation), not merely subclinical (echo-only) carditis.
Reference: Gewitz MH, et al. Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography. Circulation. 2015;131:1806–1818.
