Treatment of Moderate to Severe Sydenham Chorea with Functional Impairment (mRS 2–5)
Clinical Scenario
This protocol applies to patients with Sydenham chorea rated moderate to severe on the modified Rankin Scale (score 2–5). Motor symptoms — with or without behavioural or psychiatric features — are present with direct impact on activities of daily living, school participation, and family life.
Why Active Intervention Is Indicated
Patients with moderate to severe Sydenham chorea should be offered immunotherapy. Functional disability and accompanying behavioural or psychiatric disturbance in this group make a structured, multi-component approach appropriate from first presentation.
Treatment Approach — Overview
Management at first presentation combines antibiotic therapy, first-line immunotherapy, and symptomatic pharmacotherapy for the movement disorder. The specific agents, clinical decision points, and complete sequencing are contained in the full protocol.
Treatment Goals
Functional recovery with resolution of chorea and behavioural or psychiatric symptoms, reassessed within 2–4 weeks of treatment initiation. Immunotherapy is expected to shorten the duration of chorea.
References
- Patients with moderate and severe SC should be offered immunotherapy.
- Motor with/without behavioral or psychiatric symptoms with impact to activities of daily living, school and family life but not fulfilling criteria as in Severe Disease below.
- Symptomatic pharmacotherapy for movement disorder should be offered to all children with moderate to severe SC, in addition to antibiotics and immunotherapy.
- A lack of functional recovery (chorea or behavioral/psychiatric symptoms remain intrusive or disabling) after 2–4 weeks of treatment initiation is appropriate for considering failure to respond to treatment, and for potential treatment escalation. This period can be shorter for patients with severe SC.
- Immunotherapy will likely shorten the duration of chorea at the first episode of SC.
DOI: 10.1542/peds.2025-072466
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