Sydenham's Chorea

Synonym: St Vitus' dance

Sydenham's chorea is a neurological manifestation of rheumatic fever. Chorea (from the Greek word meaning "dance") occurs in 26% of patients with rheumatic fever. It remains the most common cause of acute chorea worldwide and, despite now being a rarity in the developed world, there have been recent outbreaks of rheumatic fever with chorea in North America and Australia.¹

An autoimmune process is triggered after infection with group A β-haemolytic streptococci (GABHS). Molecular mimicry between streptococcal and CNS antigens is thought to underly the pathogenesis of this disease. Cross-reactive anti-basal ganglia antibodies (ABGAs) are formed in genetically predisposed patients and these are thought to cause the neurological insult.

Thomas Sydenham described chorea in 1686 in a work entitled Schedula monitoria de novae febris ingressu but the association with rheumatic fever was not appreciated until 180 years later by Roger in 1866. The Jones criteria for the diagnosis of rheumatic fever originated in 1944² but, only on their revision in 1992,³ was Sydenham's chorea accepted as a diagnostic feature of rheumatic fever.

Much of the literature concerning Sydenham's chorea is very old. The disease itself appears to have changed over time: it is substantially less common than it was but also symptoms tend to be less severe and relapses less frequent.⁴ This may be partially due to penicillin, but improved social conditions and a natural reduction in the virulence of the streptococci have also played a role.

• Typical age of onset is 8-9 years. It is rare under 5 years old.
• There is a female preponderance reported in most studies.
• A predisposition runs in families.
• The incidence of Sydenham's chorea reflects that of rheumatic fever. It is rarely seen in developed countries nowadays. In developing countries, the rate is much higher but with much variation and often poor recording.
• Both primary and recurrent episodes are equally common.

Risk factors

Overcrowding and poor hygiene are important.

It often presents with other features typical of rheumatic fever, at least on the first occasion; however, it can present in isolation, especially if it is a repeat attack. Typically the first episode occurs 4-8 weeks after an episode of GABHS pharyngitis.
Features of chorea are:

• Involuntary movements
• Hypotonia
• Muscular weakness
• Psychological features

Movement disorders⁵

• Chorea is an involuntary and random movement such as an arm flying up. This is worse when "under pressure". The child may try to convert this into an apparently purposeful movement by pushing back her hair or scratching her nose.
• Hemichorea occurs in about 20% but careful examination will often show milder features on the other side.
• It involves the extremities and the face and they may be accused of "making faces". Movements occur at rest and disappear in sleep.
• Chorea interferes with voluntary movements and causes a clumsy gait, dropping and spilling, and explosive bursts of dysarthric speech.
• Ask the patient to extend their arms and spread their fingers. Their fingers will move in a way like playing the piano. Muscular weakness leads to inability to maintain a steady grip. Ask the patient to grip your hand or wrist tightly and maintain it. The fluctuating strength of the grip is called "milkmaid's grip."
• The "pronator sign" is hyperpronation of the hands, with the palms facing outward when the arms are held over the head.
• Tone is typically decreased, drastically in some: about 2% of children become bedridden (chorea paralytica).
• Other motor findings include motor impersistence and tics.

Psychological symptoms

Psychological symptoms precede chorea and may be relapsing and remitting. They include:

• Emotional lability
• Obsessive-compulsive behaviour⁶
• Cognitive defects
• Personality change
• Attention deficit and hyperactivity

Many of the laboratory features of rheumatic fever may be absent, especially if the onset of the disease was a significant time after the streptococcal infection, and rheumatic fever may not have been apparent. Chorea can lag up to 6 months behind the streptococcal infection. There is no single diagnostic test. Other causes of chorea need to be excluded and often the diagnosis is one of exclusion in a child of the appropriate age.

• By the time that chorea presents it is unusual to be able to isolate GABHS from the pharynx.
• Blood count may be normal and ESR and CRP returned to normal.
• ASO titre and other serological tests described with rheumatic fever may still be helpful.
• Antineuronal antibodies have been described⁷ but they do not form part of routine diagnosis. The antibody titre falls as the disease improves and rise again in relapse.
• MRI studies have shown enlargement of caudate, putamen and globus pallidus in patients with the disease⁸ and changes in the basal ganglia that resolved 2 weeks later.⁹

This is a descriptive rather than an aetiological diagnosis. It simply refers to chorea in pregnancy. In 1900, its incidence was described as high as 1 in 300 deliveries¹¹ but now it is an extreme rarity in the UK.

• Most cases are a resurgence of Sydenham's chorea in the hormonal milieu of pregnancy but it can also be precipitated by the use of oral contraceptives.
• In the 1930s, at least 35% of patients had a definite history of acute rheumatic fever or Sydenham's chorea and 4% of those with chorea gravidarum had acute rheumatic fever.¹²
• 21% of women experience recurrent chorea with subsequent pregnancies,¹² and several cases have been described in which attacks occurred in 3, 4, and even 5 pregnancies.^13,14
• If left untreated, the disease resolves in 30% of patients before delivery but, in the other 70%, it persists until the puerperium. Symptoms frequently fade rapidly in the days after delivery.
• Death is now rare but the mortality rate in the 1930s was 12% due to underlying rheumatic heart disease.

In the 1930s, if a doctor saw a patient with chorea, especially if the patient were a child or young woman, it was a reasonable assumption that the diagnosis was Sydenham's chorea. In western societies today, such a presentation is unlikely to be Sydenham's chorea and considerable thought must be given to the differential diagnosis. The time course of the chorea is useful diagnostically: most previously healthy children with an acute or subacute chorea have an autoimmune aetiology.¹⁵Additional causes of childhood choreas include:

• Other autoimmune causes, such as seen in systemic lupus erythematosus.
• Genetic causes:
  • Benign hereditary chorea¹⁶ starts in childhood, and is a non-progressive chorea. Inheritance is usually autosomal dominant, although rare cases of autosomal-recessive and X-linked inheritance have been reported.
  • Wilson's disease is an autosomal recessive disorder of copper metabolism.
  • Ataxia telangiectasia and other related conditions.
  • Huntington's chorea presents most often between the ages of 35 and 45 but it can be younger, especially if inherited from the paternal line. There is usually, but not invariably, a family history. A juvenile form exists that should be seen as a variation of the normal form and not a distinct entity.¹⁷
• Athetoid cerebral palsy.
• Drug-induced causes - metoclopramide, phenothiazines and haloperidol are the most important.
• Primary and metastatic brain tumours affecting the basal ganglia.
• Metabolic - bilirubin encephalopathy and toxins, especially carbon monoxide, manganese and organophosphate poisoning.

Most patients with Sydenham's chorea will have other manifestations of rheumatic fever:¹

• 60-80% have cardiac involvement, particularly of the mitral valve.
• 30% have arthritis and joint involvement.

• Rest is usually advocated, as traditional teaching is that this reduces the risk of rheumatic heart disease, although this is not evidence-based.
• The most important consideration is secondary prophylaxis, usually with penicillin, to prevent further streptococcal infections.
• A number of drugs may help control the chorea, although many of these can have extrapyramidal effects of their own. Probably the best documented of these is haloperidol but valproate is now most specialists' first-line choice.¹
• Dopamine receptor blocking drugs such as pimozide are used for non-responders or those with chorea paralytica.
• Immune therapies, e.g. plasma exchange, intravenous immunoglobulins, may play a role in selected patients.¹⁸
• See the separate article Rheumatic Fever for discussion of the treatment of cardiac complications.

• Commonly, Sydenham's chorea is self-limiting with spontaneous remission. Symptoms generally improve in a week or two and are better by 8-9 months, rarely lasting a year; however, they may occasionally wax and wane for up to 10 years.
• There is evidence that, despite apparent recovery, a degree of minor neurological impairment remains with an abnormal EEG but not behavioural problems.¹⁹
• About 20% of patients have a recurrence, usually within 2 years of the initial attack.

1. Cardoso F, Seppi K, Mair KJ, et al; Seminar on choreas. Lancet Neurol. 2006 Jul;5(7):589-602. [abstract]
2. Jones TD: Diagnosis of rheumatic fever.; JAMA 1944;126: 481-85.<
3. No authors listed; Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73. [abstract]
4. Nausieda PA, Grossman BJ, Koller WC, et al; Sydenham chorea: an update. Neurology. 1980 Mar;30(3):331-4. [abstract]
5. Robertson WC; Chorea in Childhood; emedicine. September 2008
6. Swedo SE, Leonard HL, Schapiro MB, et al; Sydenham's chorea: physical and psychological symptoms of St Vitus dance. Pediatrics. 1993 Apr;91(4):706-13. [abstract]
7. Husby G, van de Rijn I, Zabriskie JB, et al; Antibodies reacting with cytoplasm of subthalamic and caudate nuclei neurons in chorea and acute rheumatic fever. J Exp Med. 1976 Oct 1;144(4):1094-110. [abstract]
8. Giedd JN, Rapoport JL, Kruesi MJ, et al; Sydenham's chorea: magnetic resonance imaging of the basal ganglia. Neurology. 1995 Dec;45(12):2199-202. [abstract]
9. Konagaya M, Konagaya Y; MRI in hemiballism due to Sydenham's chorea. J Neurol Neurosurg Psychiatry. 1992 Mar;55(3):238-9.
10. Ramachandran TS; Chorea Gravidarum; emedicine. Feb 2009.
11. Black M: Two cases of chorea in pregnancy.; Glasgow Medical Journal 1900; 441-444.
12. Willson P, Preece AA: Chorea gravidarum.; Arch Intern Med 1932; 49: 471-533, 671-697.
13. Fleischman MJ: A case report of chorea gravidarum complicating five pregnancies.; Am J Obstet Gynecol 1953; 66:
14. Ghanem Q; Recurrent chorea gravidarum in four pregnancies. Can J Neurol Sci. 1985 May;12(2):136-8. [abstract]
15. Gilbert DL; Acute and chronic chorea in childhood. Semin Pediatr Neurol. 2009 Jun;16(2):71-6. [abstract]
16. OMIM 215410; Benign Familial Chorea
17. van Dijk JG, van der Velde EA, Roos RA, et al; Juvenile Huntington disease. Hum Genet. 1986 Jul;73(3):235-9. [abstract]
18. Gordon N; Sydenham's chorea, and its complications affecting the nervous system. Brain Dev. 2009 Jan;31(1):11-4. Epub 2008 Jun 16. [abstract]
19. Bird MT, Palkes H, Prensky AL; A follow-up study of Sydenham's chorea. Neurology. 1976 Jul;26(7):601-6. [abstract]

• whonamedit.com; Thomas Sydenham; Brief biography
• Bonthius DJ, Karacay B; Sydenham's chorea: not gone and not forgotten. Semin Pediatr Neurol. 2003 Mar;10(1):11-9. [abstract]