Treatment of Sydenham Chorea — Mild Severity (Modified Rankin Scale 0–1)

This protocol addresses Sydenham chorea presenting at mild severity, defined by a modified Rankin Scale (mRS) score of 0–1, where motor symptoms — with or without behavioral or psychiatric features — do not interfere with activities of daily living, school, or family life.

Clinical scenario

Patients in this category have motor involvement that remains functionally non-limiting. Behavioral or psychiatric symptoms may be present but do not impair routine function. Patients with mild Sydenham chorea may not require immunotherapy.

Treatment approach

Even at mild severity, antibiotic therapy is indicated at first presentation — irrespective of whether cardiac disease is present. The antibiotic choice depends on allergy history; options span several antibiotic classes.

The full antibiotic selection algorithm — including choices for penicillin allergy, alternatives, and the complete structured regimen — is available in the protocol.

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References

DOI: 10.1542/peds.2025-072466

Motor with/without behavioral or psychiatric symptoms without impact to activities of daily living, school and family life.
Patients with mild SC may not require immunotherapy.
In all children with SC, regardless of the presence of cardiac disease, antibiotic therapy is required to prevent recurrence of ARF and development or progression of rheumatic heart disease, as per existing recommendations for rheumatic fever.
At the time of SC diagnosis, if there is no penicillin allergy, either a single dose of intramuscular benzathine benzylpenicillin G, or a 10-d course of oral penicillin V or oral amoxicillin should be given, even in the absence of a positive throat culture or cardiac disease.
For patients with non-immediate allergy to penicillin, a 10-d course of oral cephalexin (or other 1st generation cephalosporin) should be used at the time of diagnosis. For patients with immediate allergy to penicillin, an oral macrolide is recommended at the time of diagnosis.

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