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Modiefied jones criteria

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rheumatic fever AND diagnosis

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2023 revised Jones criteria acute rheumatic fever AHA major minor criteria evidence preceding streptococcal infection

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https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/diag…

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site:cdc.gov/group-a-strep/hcp/clinical-guidance/diagnosing-acute-rheumatic-fever "Low-risk" "polyarthritis"

Modified (Revised) Jones Criteria

Used to diagnose acute rheumatic fever (ARF) following a recent Group A Streptococcus (GAS) infection.

Diagnosis of a first episode of ARF

Requires:
  • Evidence of preceding GAS infection, plus
  • Either 2 major criteria, or 1 major + 2 minor criteria
Evidence of recent GAS infection includes positive throat culture or rapid antigen test, elevated/rising ASO or anti-DNase B titre, or recent scarlet fever. CDC diagnostic guidance
CategoryLow-risk population*Moderate/high-risk population
Major criteriaCarditis, clinical or subclinical (Doppler echocardiography); polyarthritis; Sydenham chorea; erythema marginatum; subcutaneous nodulesCarditis, clinical or subclinical; monoarthritis, polyarthritis, or polyarthralgia; Sydenham chorea; erythema marginatum; subcutaneous nodules
Minor criteriaPolyarthralgia; fever ≥38.5°C; ESR ≥60 mm/h and/or CRP ≥3.0 mg/dL; prolonged PR interval on ECGMonoarthralgia; fever ≥38.0°C; ESR ≥30 mm/h and/or CRP ≥3.0 mg/dL; prolonged PR interval on ECG
*A low-risk population has ARF incidence <2 per 100,000 school-aged children per year, or rheumatic heart disease prevalence ≤1 per 1,000 at any age. Others are moderate/high risk.

Important points

  • Carditis includes subclinical carditis detected only by Doppler echocardiography. Echocardiography is recommended in all suspected or confirmed ARF, even without a murmur.
  • Do not count arthritis and arthralgia together as separate major and minor criteria. Likewise, do not count carditis and PR prolongation together.
  • Chorea or indolent/chronic carditis can support a presumptive diagnosis even when evidence of preceding GAS infection is absent, because they may appear late.
  • For a recurrent ARF episode, with documented preceding GAS infection, diagnosis may be made with: 2 major, 1 major + 2 minor, or sometimes 3 minor criteria after excluding other causes.
The major change from the older Jones criteria is the risk-stratified joint criteria and acceptance of Doppler-detected subclinical carditis. The 2015 AHA revision is summarized in CDC guidance.

Supportive criteria

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rheumatic fever AND diagnosis

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CDC acute rheumatic fever diagnostic preceding group A strep infection ASO anti DNase B ECG PR interval

Supportive evidence in Modified Jones Criteria

Supportive findings are not major criteria. They strengthen the diagnosis of acute rheumatic fever when combined with the required major/minor manifestations.
  1. Evidence of preceding Group A streptococcal infection
    • Positive throat culture for Group A Streptococcus
    • Positive rapid streptococcal antigen test
    • Raised or rising antistreptolysin O (ASO) titre
    • Raised or rising anti-DNase B titre
    • Recent scarlet fever
  2. Laboratory evidence of inflammation
    • Raised ESR
    • Raised CRP
    • Leukocytosis may be present but is nonspecific
  3. ECG
    • Prolonged PR interval after accounting for age variation
    • Do not count PR prolongation as a minor criterion if carditis has already been counted as a major criterion.
  4. Other supportive investigations
    • Chest X-ray: cardiomegaly or pulmonary congestion if significant carditis/heart failure
    • Echocardiography with Doppler: identifies clinical or subclinical valvulitis/carditis, especially mitral or aortic regurgitation.
Key rule: For typical ARF, preceding GAS infection must be demonstrated in addition to either 2 major or 1 major + 2 minor Jones criteria. It may be absent in late presentations with Sydenham chorea or indolent carditis. CDC guidance
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