Rheumatic fever commonly followsS. pyogenes infection of the throat or skin. Some children present with fever and pains in the large joints, which may move from one joint to another. The infection can damage the heart valves (especially the mitral and aortic valves), leading to respiratory distress and heart failure. Children with mild disease may have only a heart murmur.

Severe disease can present with fever, fast or difficult breathing and lethargy. The child may have chest pain or fainting. Affected children are usually > 5 years of age. Those that present with heart failure have a rapid heart rate, respiratory distress and an enlarged liver.

Diagnosis
Diagnosis of rheumatic fever is important because penicillin prophylaxis can prevent further episodes and avoid worsening damage to the heart valves.
Acute rheumatic fever is diagnosed clinically by WHO criteria based on the revised Jones criteria (Table 20). The diagnosis is based on two major or one major and two minor manifestations plus evidence of a previous group A streptococcal infection.

Investigations
Diagnosis of rheumatic fever requires evidence of a prior streptococcal infection.

• Streptococcal serum antibody tests (antistreptolysin-O test and antideoxyribonclease B test)
• acute-phase reactants (erythrocyte sedimentation rate and C-reactive protein)
• full blood count
• chest X-ray
• echocardiography with Doppler examination if available.

Management

Admit to hospital

► Give aspirin at 20 mg/kg every 6 h until joint pains improve (1–2 weeks), and then reduce dose to 15 mg/kg for an additional 3–6 weeks.

Follow-up care

All children will require antibiotic prophylaxis.

► Give monthly benzathine benzylpenicillin at 600 000 U IM every 3–4 weeks or oral penicillin V at 250 mg twice a day.

• Ensure vaccinations are up to date.
• Review every 3–6 months.