Modified Jones Criteria

S160293 LP 3
Modified Jones Criteria

During my rotation in the wards, I came across a patient that had symptoms and
signs of rheumatic fever. I was unable to make a diagnosis as the patient did not
fulfill the Jones criteria which we were taught i.e the patient had carditis,
polyarthlagia and evidence of group A streptococcus infection (1 major and only 1
minor with evidence of strep infection). Upon discussion with the registrar, he
diagnosed the child as rheumatic fever. This learning portfolio aims to identify
how the diagnosis was made using the modified Jones criteria (specifically looking
at joint involvement) and the evidence for and against its use.
Acute rheumatic fever is the most common acquired cardiac disease in children
and young adults in developing countries. Rheumatic fever is one of the non-
suppurative sequelae of Group a Beta hemolytic streptococci other than scarlet
fever and acute glomerulonephritis. Interestingly unlike the other two sequalae,
rheumatic fever only develops secondary to only streptoccal phargits (usually 3-4
weeks after). There has been no clear evidence documenting the development of
rheumatic fever following impetigo or any other streptococcal infection. This is
probably due to the large reserve of lymphoid tissue present there that are vital in
the pathogenesis of the disease i.e the initiation of the atypical response to those
antigens which can cross-react with target organs (molecular mimicry) causing
inflammation leading to the signs and symptoms of rheumatic fever.
The Jones criteria is used to diagnose ARF and was defined in 1944. The criteria
was then revised in 1965, 1984, 1992 and 2015 by the American Heart
Association. While the disease has been almost eradicated in North America and
Europe, it continues to be a major problem for countries like ours. To improve the
sensitivity and specificity, certain modifications have been laid out for high-risk
countries. While looking at joint involvement, the clinical presentation can be
different from the typical migratory polyarthritis. Patients can also present with
just monoarthritis and a low grade fever. Moreover, the greater access to anti-
inflammatory agents like asprin can prevent the development of signs of
inflammation leading to just arthlagia. In light of such scenarios the criteria was
modified in high risk countries in 2015 and has well supported literature. A
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retrospective chart review done in Northern Australia by Currie et al on 555 cases

of known rheumatic fever found that “monoarthritis occurred in 17% of
confirmed non-chorea cases and 35% of unconfirmed cases, including up to 27 in
whom the diagnosis was missed because monoarthritis is not a major
manifestation” [CITATION JCa \l 1033 ]. The results of the study are valid as it had a
defined population to study. Furthermore, the data can be used in Fiji due to the
high prevalence of acute rheumatic fever (15.2/ 100000) which was similar to the
location in this study. The results of the study have also been used in Fiji’s
guidelines i.e. Joint involvement (monoarthritis, polyarthritis and polyarthalgia
are all major symptoms.
The criteria for carditis had also been amended in 2015. Some of the changes
include:
 Addition of subclinical carditis as a major criteria.
 Performing an echo in all confirmed cases of ARF.
 Performing an echo is suspected cases of ARF.
 Clinical carditis can be disproven by echo.
The addition of subclinical carditis had been recent as it was suspected that it
could cause an overdiagnosis, subjecting children to unnecessary penicillin for at
least 10 years. It can also lower the specificity. However, recently there have been
new evidence that support the use of echocardiography. A systemic review by
Marrisa et al published in 2004 looked at 24 articles found that the prevalence of
subclinical carditis in ARF was 18.1% (95%CI 11.1 to 25.2) [ CITATION Mar04 \l 1033 ].
This meta-analysis looked at ample articles to make a conclusion. Furthermore,
the articles were in support of subclinical carditis being present in ARF in almost
20% i.e. a doctor could potentially miss carditis in 1 out 5 cases if an echo was not
performed. In my opinion, the benefit of performing an echo justifies the cost and
resources for the use of echocardiogram and I agree with recommendation to
perform an echo in all suspected cases of ARF.
In this learning portfolio I learned that polyarthalgia or monoarthritis can be used

as a major criteria to diagnose ARF and that echocardiogram is very useful in ARF.
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References
Currie, J. C. (2001). Rheumatic fever in a high incidence population: the importance of monoarthritis and
low grade fever. PubMed.
Marissa Tubridy-Clark 1, J. R. (2004). Subclinical carditis in rheumatic fever: a systematic review.

PubMed.

Modified Jones Criteria

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S160293 LP 3

Modified Jones Criteria

retrospective chart review done in Northern Australia by Currie et al on 555 cases

In this learning portfolio I learned that polyarthalgia or monoarthritis can be used

Marissa Tubridy-Clark 1, J. R. (2004). Subclinical carditis in rheumatic fever: a systematic review.

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