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PubMed This is a summary of 9 peer-reviewed journal articles Updated
Pediatrics · Acute Rheumatic Fever

Getting the Right Diagnosis: The Jones Criteria

At a Glance

Acute rheumatic fever is diagnosed using the 2015 Revised Jones Criteria. Doctors must first confirm a recent strep infection using blood tests or swabs, and then identify a specific combination of major and minor symptoms like heart inflammation, joint pain, rashes, or chorea.

Diagnosing Acute Rheumatic Fever (ARF) is a complex process because there is no single “rheumatic fever test” that gives a simple yes or no answer [1]. Instead, doctors use a strict set of medical guidelines called the 2015 Revised Jones Criteria [2].

These criteria act like a checklist. To make a diagnosis, a doctor must find a specific combination of “Major” and “Minor” symptoms, while also definitively proving that the child recently had a Group A Streptococcus (GAS) infection [3].

The Mandatory First Step: Proving Strep

Before a doctor even looks at the symptom checklist, they must confirm that your child had a recent strep infection [4]. This is mandatory because ARF is triggered specifically by the strep bacteria [1]. Doctors prove this using one or more of the following:

  • ASO or Anti-DNase B Titers: These are blood tests that measure strep antibodies. High or rising levels prove the body recently fought off strep [5][6]. It is important to know that these antibody levels can take 1 to 2 weeks to rise. If the first blood test is normal, your doctor might repeat it a week later to see if the levels have gone up [6].
  • Throat Culture or Rapid Test: A physical swab of the throat. Note that these are often negative by the time ARF symptoms start weeks later, which is why blood titers are frequently used instead [6].

Understanding Your Risk Category

One of the most significant parts of the 2015 update is that the diagnostic rules change depending on whether your child belongs to a low-risk or a moderate-to-high-risk population [7].

  • Low-Risk: Typically includes regions where ARF is very rare (fewer than 2 cases per 100,000 children per year) [7].
  • Moderate-to-High-Risk: Includes regions or specific communities where ARF is more common. In these areas, doctors use “wider” criteria because the stakes for missing a diagnosis are higher [2][4].

The Symptoms Checklist

A diagnosis of a first ARF episode usually requires two major criteria OR one major and two minor criteria (along with proof of strep) [7].

Symptom Type Low-Risk Population Moderate-to-High-Risk Population
Major Criteria • Carditis (Heart inflammation, includes subclinical signs found only on an echo/ultrasound) [8]
• Polyarthritis (Pain and swelling in multiple joints) [7]
• Chorea (Jerky, uncoordinated movements) [7]
• Erythema marginatum (A pink, ring-like rash) [7]
• Subcutaneous nodules (Painless bumps under the skin) [7]		 • Carditis (Includes subclinical signs found only on an echo/ultrasound) [8]
• Monoarthritis, Polyarthritis, or Polyarthralgia (Pain in one or more joints, with or without swelling) [2][9]
• Chorea [7]
• Erythema marginatum [7]
• Subcutaneous nodules [7]
Minor Criteria • Fever (≥38.5°C / 101.3°F) [9]
• Polyarthralgia (Pain in multiple joints without swelling) [7]
• High ESR or CRP (Markers of inflammation in the blood) [9]
• Prolonged PR interval (A specific finding on an ECG/heart trace) [7]		 • Fever (Lower threshold: ≥38.0°C / 100.4°F) [9]
• Monoarthralgia (Pain in just one joint without swelling) [9]
• High ESR or CRP (Lower threshold: ESR ≥30 mm/h) [9]
• Prolonged PR interval [7]

Diagnosis Completeness Checklist

To ensure no stones are left unturned, check that your medical team has completed these five steps before finalizing a diagnosis:

  1. [ ] Documented evidence of a recent strep infection (Titers, Culture, or Rapid Test) [4].
  2. [ ] Performed a full physical exam to check for joint swelling, rashes, or nodules [7].
  3. [ ] Ordered an ECG (heart rhythm trace) AND an Echocardiogram (heart ultrasound) [8].
  4. [ ] Conducted blood work to check for systemic inflammation levels (ESR and CRP) [9].
  5. [ ] Determined if the child meets the required combination of Major and Minor criteria based specifically on your local risk population [7].

Common questions in this guide

How do doctors diagnose acute rheumatic fever?
Doctors use a strict medical checklist called the 2015 Revised Jones Criteria. They must first confirm your child had a recent strep infection, and then find a specific combination of major and minor symptoms, such as joint pain, heart inflammation, or fever.
Why does my child need a blood test if their strep throat swab was negative?
Throat swabs are often negative by the time rheumatic fever symptoms start weeks later. Blood tests, like ASO or Anti-DNase B titers, measure strep antibodies to prove the body recently fought off a strep infection, which is a mandatory step for diagnosis.
Does where we live affect how rheumatic fever is diagnosed?
Yes. The diagnostic rules change depending on whether you live in a low-risk or moderate-to-high-risk area for the disease. In higher-risk communities, doctors use broader criteria because the consequences of missing a rheumatic fever diagnosis are severe.
What are the major symptoms of rheumatic fever?
Major symptoms on the Jones Criteria checklist include carditis (heart inflammation), arthritis (joint pain and swelling), chorea (jerky, uncoordinated movements), a pink ring-like rash, and painless bumps under the skin.

Questions for Your Doctor

5 questions

  • •Based on where we live and our background, is my child considered part of a 'low-risk' or 'moderate-to-high-risk' population for the Jones criteria?
  • •What were the results of my child's ASO and Anti-DNase B titers, and do we need to repeat them if they are currently normal?
  • •If the throat culture was negative, what other evidence are we using to conclusively confirm a recent strep infection?
  • •Which specific combination of major and minor criteria does my child meet for this diagnosis?
  • •Could any of these joint or skin symptoms be explained by a different illness, like juvenile arthritis or Lyme disease?

Questions for You

4 questions

  • •Did your child's joint pain 'migrate' (move from one joint to another over a few days), or stay in just one or two joints?
  • •Did your child have a fever, and do you know roughly how high the temperature was?
  • •Have you noticed any faint, pink, ring-like rashes on your child's trunk or limbs?
  • •Have you felt any small, painless bumps under the skin near your child's joints?

References

References (9)
  1. 1

    Concomitant rapidly progressive glomerulonephritis and acute rheumatic fever after streptococcus infection: a case report.

    Pornrattanarungsi S, Eursiriwan S, Amornchaicharoensuk Y, et al.

    Paediatrics and international child health 2022; (42(2)):100-104 doi:10.1080/20469047.2022.2046966.

    PMID: 35298890
  2. 2

    Acute Rheumatic Fever.

    Holloway AR

    Pediatric annals 2022; (51(12)):e457-e460 doi:10.3928/19382359-20221006-03.

    PMID: 36476197
  3. 3

    Carditis in Acute Rheumatic Fever in a High-Income and Moderate-Risk Country.

    Fabi M, Calicchia M, Miniaci A, et al.

    The Journal of pediatrics 2019; (215()):187-191 doi:10.1016/j.jpeds.2019.07.072.

    PMID: 31587860
  4. 4

    Clinical characteristics of pediatric patients with first-attack acute rheumatic fever following the updated guideline.

    Güler M, Laloğlu F, Olgun H, Ceviz N

    Turk pediatri arsivi 2019; (54(4)):220-224 doi:10.14744/TurkPediatriArs.2019.69376.

    PMID: 31949413
  5. 5

    Streptococcal Serology Reference Intervals in an Australian Pediatric Cohort.

    Tsoi SK, Choo S, Lee LY, et al.

    Journal of the Pediatric Infectious Diseases Society 2025; (14(7)) doi:10.1093/jpids/piaf054.

    PMID: 40476715
  6. 6

    Potential for Molecular Testing for Group A Streptococcus to Improve Diagnosis and Management in a High-Risk Population: A Prospective Study.

    Ralph AP, Holt DC, Islam S, et al.

    Open forum infectious diseases 2019; (6(4)):ofz097 doi:10.1093/ofid/ofz097.

    PMID: 31011589
  7. 7

    Acute rheumatic fever diagnosis and management: Review of the global implications of the new revised diagnostic criteria with a focus on Saudi Arabia.

    Alqanatish J, Alfadhel A, Albelali A, Alqahtani D

    Journal of the Saudi Heart Association 2019; (31(4)):273-281 doi:10.1016/j.jsha.2019.07.002.

    PMID: 31516307
  8. 8

    Acute rheumatic fever: 10-year single-center experience: clinical and laboratory findings, with subclinical carditis and treatment complications.

    Bulbul L, Akyol MB, Civan HA, et al.

    Cardiology in the young 2021; (31(9)):1489-1494 doi:10.1017/S1047951121003528.

    PMID: 34462031
  9. 9

    Update on diagnosis of acute rheumatic fever: 2015 Jones criteria.

    Eroğlu AG

    Turk pediatri arsivi 2016; (51(1)):1-7 doi:10.5152/TurkPediatriArs.2016.2397.

    PMID: 27103858

This page explains the diagnostic process for acute rheumatic fever for educational purposes only. Always consult your pediatrician or specialist for formal diagnosis and medical advice.

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