When the skin speaks but the heart remains silent: acute rheumatic fever with three major Jones manifestations without carditis

Abstract

Acute rheumatic fever is classically associated with carditis, particularly when erythema marginatum and subcutaneous nodules are present. We report a 13-year-old boy who fulfilled three major Jones manifestations—migratory polyarthritis, erythema marginatum, and subcutaneous nodules—supported by evidence of recent streptococcal infection, yet had no clinical, electrocardiographic, or echocardiographic evidence of carditis on serial assessment over three months. Serial photographs documented the evolving morphology of erythema marginatum in dark skin. A transient ocular inflammatory episode occurred during convalescence. This case highlights an uncommon phenotype of acute rheumatic fever and underscores the importance of recognising major extracardiac manifestations even when the heart remains unaffected.