Intended for healthcare professionals

Clinical Review

Acute rheumatic fever

BMJ 2015; 351 doi: (Published 14 July 2015) Cite this as: BMJ 2015;351:h3443
  1. Rachel Helena Webb, paediatric infectious diseases specialist1,
  2. Cameron Grant, associate professor, paediatrician23,
  3. Anthony Harnden, professor of primary care4
  1. 1Department of Paediatric Infectious Diseases, Starship Children’s Hospital, Auckland 1023, New Zealand
  2. 2Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
  3. 3Department of General Paediatrics, Starship Children’s Hospital, Auckland 1023, New Zealand
  4. 4Department of Primary Health Care Sciences, Oxford University, Oxford OX3 7LF, UK
  1. Correspondence to: R H Webb rwebb{at}

The bottom line

  • Acute rheumatic fever and its sequel, chronic rheumatic heart disease, are important global health problems: about 500 000 new cases occur annually and 34 million people worldwide have rheumatic heart disease

  • There is no diagnostic laboratory test for rheumatic fever

  • Diagnosis requires demonstration of the presence of major and minor criteria and laboratory evidence of a recent streptococcal throat infection

  • The recent Australian and New Zealand Diagnostic Criteria extend the 1992 Jones criteria for acute rheumatic fever by including echocardiographic evidence of carditis and a wider spectrum of joint manifestations as major criteria

  • Intramuscular benzathine penicillin (benzathine benzylpenicillin) every 3-4 weeks, for 10 years after the most recent episode of rheumatic fever, remains the most effective method for preventing rheumatic fever recurrences and progressive rheumatic heart disease

Acute rheumatic fever is an inflammatory response to group A streptococcal infection which typically occurs two to three weeks after a throat infection. Worldwide, approximately 500 000 new cases of acute rheumatic fever occur annually, and at least 15 million people have chronic rheumatic heart disease.1 2 Acute rheumatic fever is characterised by a clinical syndrome, and the most common manifestations are painful joints and carditis. Carditis occurs in about 80% of people with rheumatic fever3 and commonly affects the mitral and aortic valves, resulting in regurgitation.4 Other less common clinical features include abnormal involuntary movements (chorea), rash (erythema marginatum), and subcutaneous nodules.

The inflammatory process slowly resolves over weeks to months, but about half of individuals are left with chronic rheumatic heart disease.5 6 7 Although death from acute rheumatic carditis is not common, chronic rheumatic heart disease causes considerable morbidity including arrhythmias, stroke, infective endocarditis, pregnancy complications, and premature death.8 9 The aim of this review is to discuss acute rheumatic fever, in particular its diagnosis and management …

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