• Tests for recent streptococcal infection
  
  
• Tests for systemic inflammation
  
  
• Tests for recent carditis
  
  
• Tests for recent streptococcal Infection
  
  
  • ASLO - It is raised in 80% cases.
    
    
  • Anti-hyaluronidase (AH) and Antistreptokinase (ASK)- ASLO + AH are raised in 90% cases, ALSO+AH+ASK will include 95% cases.
    
    
  Antibodies return to normal within one month and therefore may be negative in insidious onset carditis and chorea.
  
  
• Tests for Systemic inflammation
  
  Raised ESR & CRP - Neither is specific but both are very sensitive. Both reflect magnitude of inflammatory process (Rheumatic activity). CRP is better than ESR because it is always negative in healthy subjects where as ESR has grey zones.
  
  
• Tests for recent carditis
  
  
  • X ray chest may show increased heart size/pericardial effusion
    
    
  • ECG - Increased PR interval is seen in 28-40% cases
    
    
  • ECHO - Shows pericardial effusion/valvular involvement
    
    

Jones Criteria were set by T. Duckett Jones in 1944 and modified in 1965 to include laboratory evidences. They were reevaluated in 1984. These are guidelines and not a set of rules.

2 major manifestations or 1 major + 2 minor manifestations suggest presence of RF

*WHO study group (1988): In developing countries, arthralgia + raised ASLO could be taken as Major manifestation instead of arthritis.

Table I: Modified Jones' Criteria for diagnosis of RF :

*If RF cannot be excluded label the patient as "Probable RF".

*In recurrent RF: One major and several minor + raised ASLO titers should be documented. Complications of RF/ RHD and intercurrent illness should be excluded.

Situations where Jones criteria need not be satisfied to make a diagnosis of RF/ RHD are:

• Pure chorea
  
  
• Insidious onset or late onset carditis
  
  

• Infectious arthritis / Osteomyelitis : Bacterial pyogenic, tubercular, syphilitic, etc.
  
  
• Rheumatoid arthritis
  
  
• Lyme's disease
  
  
• Reactive arthritis- Sterile synovial reaction to infection elsewhere in the body- following URTI, Shigella / Salmonella infection, Yersinia infection, etc.
  
  
• Allergic - Henoch Schonlein Purpura, Serum sickness or reaction to penicillin.
  
  
• Viral: Hepatitis B, Rubella, Mumps, Infectious mononucleosis
  
  
• Hematologic disorders- Leukemia, other malignancies, sickle cell disease.
  
  
• Chorea may be confused with
  
  
  • Tics and habit spasm
    
    
  •  Huntington's chorea
    
    
  • Cerebral palsy following encephalitis
    
    
  •  Wilson's disease.
    
    
• Cardiac conditions simulating RF/RHD
  
  
  • innocent murmur
    
    
  • Infective Endocarditis
    
    
  • Mitral valve prolapse
    
    
  • CHD such as small VSD, ASD with deformed mitral valve and VSD with bicuspid Aortic valve
    
    
• Viral myocarditis: Coxsackie B, Arbovirus