carditis is diagnosed clinically (palpitations, shortness of breath, heart failure, or a new heart murmur) or by echocardiography/doppler studies revealing mitral or aortic valvulitis. both of clinical and subclinical carditis are now considered a major criterion. subcutaneous nodules: painless, firm collections of collagen fibers over bones or tendons. they commonly appear on the back of the wrist, the outside elbow, and the front of the knees. erythema marginatum: a long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. this rash typically spares the face and is made worse with heat. sydenham's chorea (st. vitus' dance): a characteristic series of involuntary rapid movements of the face and arms. this can occur very late in the disease for at least three months from onset of infection. minor criteria arthralgia: polyarthralgia in low-risk populations and monoarthralgia in others. however, joint manifestations cannot be considered in both major and minor categories in the same patient. fever: ≥ 38.5 °c (101.3 °f) in low-incidence populations and ≥ 38 °c (100.4 °f) in high-risk populations. raised erythrocyte sedimentation rate (≥60 mm in the first hour in lox-risk populations and ≥30 mm/h in others) or c reactive protein (>3.0 mg/dl). ecg showing a prolonged pr interval after accounting for age variability (cannot be included if carditis is present as a major symptom) prevention rheumatic fever can be prevented by effectively and promptly treating strep throat with antibiotics. in those who have previously had rheumatic fever, antibiotics in a preventative manner are occasionally recommended. as of 2017 the evidence to support long term antibiotics in those with underlying disease is poor. the american heart association suggests that dental health be maintained, and that people with a history of bacterial endocarditis, a heart transplant, artificial heart valves, or "some types of congenital heart defects" may wish to consider long-term antibiotic prophylaxis. treatment the management of rheumatic fever is directed toward the reduction of inflammation with anti-inflammatory medications such as aspirin or corticosteroids. individuals with positive cultures for strep throat should also be treated with antibiotics. aspirin is the drug of choice and should be given at high doses. one should watch for side effects like gastritis and salicylate poisoning. in children and teenagers, the use of aspirin and aspirin-containing products can be associated with reye's syndrome, a serious and potentially deadly condition. the risks, benefits, and alternative treatments must always be considered when administering aspirin and aspirin-containing products in children and teenagers. ibuprofen for pain and discomfort and corticosteroids for moderate to severe inflammatory reactions manifested by rheumatic fever should be considered in children and teenagers. vaccine no vaccines are currently available to protect against s. pyogenes infection, although research is underway to develop one. difficulties in developing a vaccine include the wide variety of strains of s. pyogenes present in the environment and the large amount of time and people that will be needed for appropriate trials for safety and efficacy of the vaccine. infection people with positive cultures for streptococcus pyogenes should be treated with penicillin as long as allergy is not present. the use of antibiotics will not alter cardiac involvement in the development of rheumatic fever. some suggest the use of benzathine benzylpenicillin. monthly injections of long-acting penicillin must be given for a period of five years in patients having one attack of rheumatic fever. if there is evidence of carditis, the length of therapy may be up to 40 years. another important cornerstone in treating rheumatic fever includes the continual use of low-dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence. inflammation while corticosteroids are often used, evidence to support this is poor. salicylates are useful for pain. steroids are reserved for cases where there is evidence of an involvement of the heart. the use of steroids may prevent further scarring of tissue and may prevent the development of sequelae such as mitral stenosis. heart failure some patients develop significant carditis which manifests as congestive heart failure. this requires the usual treatment for heart failure: ace inhibitors, diuretics, beta blockers, and digoxin. unlike typical heart failure, rheumatic heart failure responds well to corticosteroids. epidemiology deaths from rheumatic heart disease per million persons in 2012 0–7 8–14 15–20 21–25 26–32 33–38 39–45 46–52 53–63 64–250 disability-adjusted life year for rheumatic heart disease per 100,000 inhabitants in 2004. no data less than 20 20–40 40–60 60–80 80–100 100–120 120–140 140–160 160–180 180–200 200–330 more than 330 about 33 million people are affected by rheumatic heart disease with an additional 47 million having asymptomatic damage to their heart valves. as of 2010 globally it resulted in 345,000 deaths, down from 463,000 in 1990. in western countries, rheumatic fever has become fairly rare since the 1960s, probably due to the widespread use of antibiotics to treat streptococcus infections. while it has been far less common in the united states since the beginning of the 20th century, there have been a few outbreaks since the 1980s. the disease is most common among indigenous australians (particularly in central and northern australia), māori, and pacific islanders, and is also common in sub-saharan africa, latin america, the indian subcontinent, and north africa. rheumatic fever primarily affects children between ages 5 and 17 years and occurs approximately 20 days after strep throat. in up to a third of cases, the underlying strep infection may not have caused any symptoms. the rate of development of rheumatic fever in individuals with untreated strep infection is estimated to be 3%. the incidence of recurrence with a subsequent untreated infection is substantially greater (about 50%). the rate of development is far lower in individuals who have received antibiotic treatment. persons who have had a case of rheumatic fever have a tendency to develop flare-ups with repeated strep infections. the recurrence of rheumatic fever is relatively common in the absence of maintenance of low dose antibiotics, especially during the first three to five years after the first episode. recurrent bouts of rheumatic fever can lead to valvular heart disease. heart complications may be long-term and severe, particularly if valves are involved. in countries in southeast-asia, sub-saharan africa, and oceania, the percentage of people with rheumatic heart disease detected by listening to the heart was 2.9 per 1000 children and by echocardiography it was 12.9 per 1000 children. echocardiographic screening among children and timely initiation of secondary antibiotic prophylaxis in children with evidence of early stages of rheumatic heart disease may be effective to reduce the burden of rheumatic heart disease in endemic regions.