Rheumatic Fever



  • Acute rheumatic fever (ARF) is an autoimmune, inflammatory response to infection with group A Streptococcus (GAS) that affects multiple organ systems.
  • Untreated acute disease can lead to chronic rheumatic heart disease (RHD).
  • Recurrence is common without adequate antibiotic treatment.

Pediatric Considerations
Most cases occur in children aged 5 to 15 years; rare in children aged <5 years


  • ARF and RHD are largely restricted to low-income countries and marginalized sections of wealthy countries.
  • Male = female; females more likely to develop chorea and RHD.
  • Endemic regions include South Pacific, indigenous populations of Australia and New Zealand, Africa, and Asia (1).


  • Worldwide, incidence has been declining for 25 years. The large majority of new cases are in developing countries (1).
  • Mean worldwide incidence ranges from 8 to 51/100,000 school-aged children; in endemic regions, prevalence can be >1,000 cases per 100,000 people (1).
  • Incidence of ARF in the United States is currently <3.4 to 2/100,000 school-aged children (1).


  • In developing areas, RHD affects >33 million people and is the leading cause of cardiovascular death during the first 5 decades of life.
  • Prevalence has been rising due to improved medical care and longer survival.

Etiology and Pathophysiology

  • ARF most commonly occurs 2 to 3 weeks after GAS pharyngitis infection, but GAS impetigo may also be a proceeding infection.
  • Although pathogenicity is not completely understood, expert consensus implicates genetic and molecular mimicry leading to an inflammatory cascade as key to disease development.
  • Immune cross reactive response contributes to joint involvement due to accumulation of immune complexes.


  • Susceptibility is associated with certain indigenous populations.
  • ARF is heritable, polygenic, and displays variable and incomplete penetrance.

Risk Factors

Poverty, household crowding, genetic susceptibility, ethnic predisposition, and social disadvantage are the strongest risk factors.

General Prevention

  • Primary prevention: Appropriate treatment of streptococcal infection prevents ARF in most cases.
  • Secondary prevention: long-term antibiotic prophylaxis (up to 5 to 10 years) to prevent recurrence (1)

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