appendicitis due to inflammatory changes in the right rectus abdominalis muscle, or to inflammator

prominences. Sign of virulent process. Occur relatively late (G weeks-G months) in the course of the disease and remain for several weeks. (ii) Rheumatic tendinitis, tenosynovitis, myositis and bursitis may seldom occur. Nodules indicate chronicity and associated with significant heart disease. G. Respiratory - (i) Epistaxis may be an atypical manifestation. ii) Rheumatic pneumonia - uncommon and almost always occurs in patients with severe carditis: Chest X-ray may show changing areas of pulmonary infiltration which do not respond to antibiotics but respond dramatically to steroid therapy. 7. Gastro-intestinal- (i). ild gastro­enteritis may be one of the prodromal features. Occasionally signs of acute appendicitis due to inflammatory changes in the right rectus abdominalis muscle, or to inflammatory changes in the mesentery, or to enlargement of abdominal lymph glands. (ii) Repeated vomiting spells. 8. Nutrition - Loss of weight or failure to gain weight. 9. Central nervous system - Rheumatic chorea late manifestation. Psychic disturbances like insomnia and delirium. Occasionally acute rheumatic fever is ushered in by headache, nuchal rigidity and meningism, or with high fever and delirium, convulsion or coma. 10. Polyarteritis - rare, may affect vessels in brain, lung, heart and mesentery. Laboratory findings: 1. EVIDENCE OF PRECEDING STREPTOCOCCAL INFECTION - Antistreptolysin-O (ASO) determination useful in 80 per cent of cases. Titre <250>