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 New York City.  Click here for more information about Dr. Lehman or the Hospital for Special Surgery.



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



elevated acute phase reactants



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.


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    Dr. Tom Lehmans experience and compassion are evident on every page of this book, and they help guide the readerchild, parent, 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, University of Chicago, La Rabida



It’s not just growing pains.
A guide to childhood muscle, bone, and joint pain,
rheumatic diseases and the latest treatments


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It has always been a frustration trying to answer the many questions I have received from people over the web.  I can’t 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 practice.  If you want to know about the diseases, the tests, the medications, or how to be sure you are getting the best care– If you are the family member of a child with joint pains, this book will give you the answers.  If you are a general physician, a pediatrician, or a nurse who cares for children with these diseases it will answer many of the questions families ask you, and you can recommend it to them.  It will also answer many of your questions about what shots to give, what precautions to take, and the other 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, Kawasaki disease and related conditions.  He practices in New York City.  Click here for more information about Dr. Lehman or the Hospital for Special Surgery.


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This site provided by Thomas J. A. Lehman MD
Chief, Division of Pediatric Rheumatology
The Hospital for Special Surgery
535 E 70 St,
New York, NY 10021
212-606-1151, fax 212-606-1938, e-mail