Which of the following is not a feature of Syndenham's chorea?

Sydenham chorea (SC) is a neurological disorder of childhood resulting from infection Group A beta-hemolytic streptococcus (GABHS), the bacterium that causes rheumatic fever. SC is characterized by rapid, irregular, and aimless involuntary movements of the arms and legs, trunk, and facial muscles. Sydenham's chorea is characterized by the abrupt onset (sometimes within a few hours) of neurologic symptoms, classically chorea, usually affecting all four limbs. Other neurologic symptoms include behavior change, dysahria, gait disturbance, loss of fine and gross motor control with resultant deterioration of handwriting, headache, slowed cognition, facial grimacing, fidgetiness and hypotonia. Also, there may be tongue fasciculations ("bag of worms") and a "milk sign", which is a relapsing grip demonstrated by alternate increases and decreases in tension, as if hand milking. Non-neurologic manifestations of acute rheumatic fever are carditis, ahritis, erythema marginatum, and subcutaneous nodules. The PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) syndrome is similar, but is not characterized by Sydenham's motor dysfunction. PANDAS presents with tics and/or a psychological component (e.g., OCD) and occurs much earlier, days to weeks after GABHS infection rather than 6-9 months later. It may be confused with other conditions such as lupus and Tourette syndrome. Movements cease during sleep, and the disease usually resolves after several months. Unlike in Huntington's disease, which is generally of adult onset and associated with an unremitting autosomal dominant movement disorder and dementia, neuroimaging in Sydenham's chorea is normal and other family members are unaffected. Other disorders that may be accompanied by chorea include abetalipoproteinemia, ataxia-telangiectasia, biotin-thiamine-responsive basal ganglia disease, Fahr disease, familial dyskinesia-facial myokymia (Bird-Raskind syndrome) due to an ADCY5 gene mutation, glutaric aciduria, Lesch-Nyhan syndrome, mitochondrial disorders, Wilson disease, hypehyroidism, lupus erythematosus, pregnancy (chorea gravidarum), and side effects of ceain anticonvulsants or psychotropic agent Ref Davidson 23rd edition pg 1025