Post Streptococcal Reactive
Arthritis or Acute Rheumatic Fever?
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Dr. Lehman is the author
of many textbook chapters and articles on the care of children and young adults
with SLE. He practices in
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Many
physicians are confused about the relationship between POST-STREPTOCOCCAL
REACTIVE ARTHRITIS and ACUTE RHEUMATIC FEVER. Definite ACUTE RHEUMATIC
FEVER is thought by many physicians to require two of Jones major criteria with
evidence of a recent strep infection.
Jones Criteria major
1. arthritis
2. carditis
3. chorea
4. erythema
marginatum
5. nodules
Minor Criteria
arthralgia
fever
elevated acute phase reactants
ESR
CRP
prolonged PR interval
Evidence of recent strep infection
positive throat culture or elevated or
rising streptococcal antibody titer.
Everyone agrees children who fulfill these criteria
are at risk for carditis with a future streptococcal
infection and should receive antibiotic prophylaxis. {The belief that
children who did not have carditis with their first
episode would not have carditis with future episodes
was not correct.}
Pediatricians are often confronted by children who
have evidence of a recent streptococcal infection, an elevated sedimentation
rate and arthritis, but do not have a second major criterion. These children
have rheumatic fever with one major and two minor criteria. Others do not
believe these children have rheumatic fever. POST-STREPTOCOCCAL REACTIVE
ARTHRITIS is a term developed to describe
these children. For a long time physicians continued to debate whether these
children should receive prophylaxis. However, in January of 1993 the American
Heart Association published a reformulated version of Jones Criteria which
specifically includes children with migratory polyarthritis following a strep infection. Since these children fit the reformulated
Jones Criteria (arthritis is a major criteria; fever and an elevated esr are two minor) there is no
basis for not giving them penicillin prophylaxis.
Why do children with definite rheumatic fever
receive prophylaxis? These children receive prophylaxis to prevent
streptococcal infections which may result in carditis
and permanent heart damage. Children who have POST-STREPTOCOCCAL REACTIVE
ARTHRITIS are also at increased risk for carditis
with subsequent strep infections. Many pediatricians
conclude that children with POST-STREPTOCOCCAL REACTIVE ARTHRITIS should
receive prophylaxis. If they have one major and two minor criteria they have
acute rheumatic fever and they should be treated.
In contrast, I often get calls about children with
high ASO titers who look well. This means the patient
has a significant immunologic reaction to streptococcal infection. However, the
ASO titer often remains elevated for eight to ten weeks after the infection is
cleared and in some cases for months. A high ASO indicates past infection. It
does not necessarily indicate current infection or require treatment. However,
a rising ASO titer is good evidence of a recent infection, but of itself does
not require treatment.
IF you have a confusing
case or need more information let me know.
For more information
you may wish to consult my book.
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at
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“Dr. Tom Lehman’s experience and compassion are evident on every page of this
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and healthcare professional alike – through the
world of childhood arthritis. This book
is an absolute gem written with a single goal in mind: improve the lives of kids with arthritis.” -- Jack Klippel, M.D. President and
CEO of the Arthritis Foundation
“Dr. Lehman has given parents and families of children with
arthritis the first book that speaks to the parent and child as equals. His book explains the illnesses, the
medications, the lab tests, and the disease course in simple, understandable
lay language and givens them valuable insight into how a pediatric
rheumatologist thinks. Bravo!”-- Charles Spencer, M.D.,
Professor of Clinical Pediatrics,
It’s not just
growing pains.
A guide to childhood muscle, bone, and joint pain,
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Click here to see the table of
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It
has always been a frustration trying to answer the many questions I have
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take the time and give them the detail I would like to. I have to take care of my patients. This book is a distillation of my experience
answering questions for parents and health professionals over 25 years of
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questions families, pediatricians, and other health care providers have asked
me over the years.
Dr. Lehman is the author of many
textbook chapters and articles on the care of children and young adults with
rheumatic diseases including SLE, JRA, dermatomyositis, scleroderma,
Click for BOOKS dealing with
children with rheumatic disease
This site provided by Thomas J. A. Lehman MD
Chief, Division of Pediatric Rheumatology
The Hospital for Special
Surgery
535 E 70 St,
212-606-1151, fax 212-606-1938, e-mail goldscout@aol.com