A Neurological Curtain Unmasking Rheumatic Carditis in Early Adolescents: Two Illustrative Cases From a Tertiary Care Center in Maharashtra, India

Group A β-hemolytic streptococcal pharyngitis, if inadequately treated, can trigger an autoimmune inflammatory response known as acute rheumatic fever (ARF). While ARF classically presents with migratory arthritis, carditis, and other Jones criteria, it may also manifest as Sydenham's chorea, a delayed neurological complication. In some patients, chorea can occur as the sole clinical feature, making diagnosis challenging. Importantly, these individuals may harbor subclinical carditis, valvular inflammation, and dysfunction detectable only by echocardiography, which, if missed, can progress to chronic rheumatic heart disease (RHD), a major cause of morbidity and mortality in resource-limited settings. We report early adolescent cases presenting with Sydenham chorea as the initial and only clinical sign of ARF. Both children, enrolled in primary school and belonging to lower socioeconomic families, showed no history of arthritis or obvious signs of carditis. Although ECG findings were non-specific, 2D echocardiography revealed subclinical carditis in both cases. Laboratory results showed raised erythrocyte sedimentation rate (ESR) and high anti-streptolysin O (ASO) titers, indicating inflammatory and possible cardiac involvement. Nutritional insufficiencies were also observed, adding to the children's vulnerability. Early treatment with benzathine penicillin and symptomatic management of chorea were initiated, and families were educated about the need for long-term secondary prophylaxis. However, barriers such as the cost and availability of injections at distant healthcare centers remain major concerns. Sydenham chorea can present as an isolated sign of ARF. These cases highlight the importance of early echocardiographic evaluation and the need to strengthen primary healthcare services to ensure timely diagnosis and continuous secondary prevention, particularly in resource-limited settings.