Clinical presentation of rheumatic fever: History Rheumatic fever manifests as various signs and symptoms that may occur alone or in various combinations. Sore throat Although estimates vary, only 35%-60% of patients with rheumatic fever recall having any upper respiratory symptoms in the preceding several weeks. Many symptomatic individuals do not seek medical attention, go undiagnosed, or do not take the prescribed antibiotic for acute rheumatic fever (ARF) prevention. If a course of penicillin or another appropriate antibiotic is taken at this time, the risk of ARF is reduced by approximately 80%.  Polyarthritis Overall, arthritis occurs in approximately 75% of first attacks of ARF. The likelihood increases with the age of the patient, and arthritis is a major manifestation of ARF in 92% of adults.  The arthritis of ARF is usually symmetrical and involves large joints, such as the knees, ankles, elbows, and wrists. Tenosynovitis is common in adults and may be severe enough to suggest a diagnosis of disseminated gonococcal disease.  The evolution of arthritis in individual joints tends to overlap; therefore, multiple joints may be inflamed simultaneously, causing more of an additive than a migratory pattern. Monoarticular arthritis can occur in ARF if NSAIDs are used early in the course. Although not recognized in the Jones criteria, this is included as a major manifestation in the New Zealand diagnostic criteria for ARF.  In most instances, the entire bout of polyarthritis subsides within 4 weeks without any permanent damage. If not, a different diagnosis should be entertained. Carditis Of first attacks of ARF, carditis occurs in 30%-60% of cases. It is more common in younger children but does occur in adults.  Severe inflammation can cause congestive heart failure (CHF). Patients with carditis may present with shortness of breath, dyspnea upon exertion, cough, paroxysmal nocturnal dyspnea, chest pain, and/or orthopnea. Carditis may also be asymptomatic and may be diagnosed solely by auscultation or, perhaps, echocardiography Sydenham chorea This occurs in up to 25% of ARF cases in children but is very rare in adults. It is more common in girls. Sydenham chorea in ARF is likely due to molecular mimicry, with autoantibodies reacting with brain ganglioside.  Sydenham chorea may occur with other symptoms or as an isolated finding. It typically presents 1-6 months after the precipitating streptococcal infection and usually has both neurologic and psychological features.  In the isolated form, laboratory evidence of a preceding streptococcal infection may be lacking. Like the polyarthritis, Sydenham chorea usually resolves without permanent damage but occasionally lasts 2-3 years and be a major problem for the patient and her family. Erythema marginatum In first attacks of ARF in children, erythema marginatum occurs in approximately 10%. Like chorea, it is very rare in adults. Patients or parents may report a nonpruritic, painless, serpiginous, erythematous eruption on the trunk. It is usually noted only in fair–skinned patients.  The lesions may persist intermittently for weeks to months. Subcutaneous nodules Subcutaneous nodules are rarely noticed by the patient (see Physical). Other symptoms Other symptoms may include fever, abdominal pain, arthralgia, malaise, and epistaxis.