Jones Criteria for Acute Rheumatic Fever Diagnosis

2015 Revised Jones Criteria for ARF diagnosis

The original Jones Criteria for acute rheumatic fever was created back in 1944 by Dr Jones to aide with clinical diagnosis of ARF after GAS infection.

The criteria were updated in 1992 and revised in 2015 by the American Heart Association (AHA), to include the use of findings from doppler echocardiography (i.e. evidence of pathologic mitral regurgitation or aortic regurgitation, or morphologic valvulitis findings) to fulfil carditis item from the major criteria, in the absence of clinical/auscultatory findings.

Because other illnesses may have a similar presentation to ARF, laboratory evidence of an antecedent group A streptococcal (GAS) infection is the mandatory set of criteria to be met for ARF diagnosis to be considered (at least 1 of the three below):

• Increased or rising anti-streptolysin O titer or other streptococcal antibodies (anti-DNASE B) (Class I, Level of Evidence B). A rise in titer is better evidence than a single titer result.
• A positive throat culture for group A β-hemolytic streptococci (Class I, Level of Evidence B).
• A positive rapid group A streptococcal carbohydrate antigen test in a child whose clinical presentation suggests a high pretest probability of streptococcal pharyngitis (Class I, Level of Evidence B).

Then, depending on whether the patient is in the low or moderate and high-risk population, the Major and Minor criteria are as follows:

* The revised version also distinguishes between low or moderate and high-risk populations with the definition for low-risk populations as those with ARF incidence ≤2 per 100,000 school-aged children or all-age rheumatic heart disease prevalence of ≤1 per 1000 population per year.

** This is the prevalence of Major criteria for initial ARF: carditis (50-70%), followed by arthritis (35-66%), chorea (10-30%), subcutaneous nodules (0-10%), erythema marginatum (<6%).

ARF positive diagnosis (initial episode) if:

• Evidence of preceding group A streptococcal (GAS) infection is present;

AND

• 2 major criteria OR 1 major and 2 minor criteria are present;

ARF positive diagnosis (subsequent episode) if:

• Evidence of preceding GAS infection is present;
• Previous history of ARF or established rheumatic heart disease;

AND

• 2 major criteria OR 1 major and 2 minor criteria OR 3 minor criteria* are present.

* When minor manifestations alone are present, the exclusion of other more likely causes of the clinical presentation is recommended before a diagnosis of an ARF recurrence is made (Class I, Level of Evidence C).

ARF is a condition that can be easily over-diagnosed, hence the appropriate use of the criteria can reduce the risk of unwanted consequences of over-diagnosis such as long-term sequelae of prophylactic antibiotic use.

References

Original reference

Bach DS. Revised Jones Criteria for Acute Rheumatic Fever | Ten Points to Remember; American College of Cardiology 2015.

Gewitz et al. and on behalf of the American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young: Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography. A Scientific Statement From the American Heart Association 2015.

Jones, TD. The diagnosis of rheumatic fever. JAMA. 1944;126(8):481-484.

Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992;268(15):2069-73.