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February 19, 2017
Rheumatic Heart Disease Duckett Jones

Duckett Jones (1899-1954)

The diagnosis of rheumatic fever. JAMA, 1944, 126, 481-84



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Duckett Jones was an American physician and started his investigations on rheumatic fever in the 1930's. He  published his criteria for the diagnosis of this disease in 1944. The clinical syndrome was determined by a series of major and/or minor manifestations.

Major Manifestations:

  1. 1) Carditis: Jones included the following elements for acute carditis : cardiac enlargement, significant  
         cardiac murmurs, pericarditis( friction rub), and congestive failure. Regarding the cardiac 
          murmurs, he wrote:

                   "A loud long, apical systolic murmur, widely heard and not varying with position may be considered 
                     significant, as well as any type of diastolic murmur."


          Among electrocardiographic changes, he mentioned "prolongation of auriculoventricular conduction 
          time, and prolongation of PR interval."  

  2. 2) Arthralgia: Migrating polyarthritis was described as a classic feature of rheumatic fever

  3. 3) Chorea

  4. 4) Subcutaneous nodules

  5. 5) Recurrences of rheumatic fever


 Minor manifestations:

1)   Fever
2)   Abdominal pain
3)   Precordial pain
4)   Rashes
5)   Epistaxis
6)   Pulmonary findings
7)   Laboratory findings: elevated white blood count and increase in the erythrocyte sedimentation rate
      

In the summary of his article, Jones wrote that any combination of the major manifestations or the combination of at least one of the major manifestations with two of the minor manifestations constituted reasonably certain diagnostic criteria of rheumatic fever.

He also mentioned that "the presence of rheumatic heart disease increases the diagnostic significance of the minor manifestations, when no other cause for these manifestations exists."

Surprisingly, Jones did not include the immunological factor in his criteria in 1944. Since the initial publication, these criteria have been revised several times by a committee of the American Heart Association (The Jones criteria update*).

Migrating polyarthritis is considered major criteria whereas isolated arthralgia is among minor criteria. Erythema marginatum is a major criteria. Electrocardiographic changes and previous episodes of rheumatic fever are  minor criteria. Abdominal pain, precordial pain, epistaxis and pulmonary findings are excluded. Finally supporting evidence of streptococcal infection such as elevated or rising antistreptolysin O titre or DNAase has been added.

REFERENCES

*Dajani AS, Ayoub E, Bierman FZ. Guidelines for the diagnosis of rheumatic fever: Jones criteria. JAMA 1992;268:2069


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