Rheumatic Fever

Updated: Mar 23, 2021
  • Author: Mark R Wallace, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Acute rheumatic fever (ARF) is an autoimmune inflammatory process that develops as a sequela of streptococcal infection. ARF has extremely variable manifestations, and remains a clinical syndrome for which no specific diagnostic test exists. Persons who have experienced an episode of ARF are predisposed to recurrence following subsequent group A streptococcal infections. The most significant complication of ARF is rheumatic heart disease, which usually occurs after repeated bouts of acute illness.

Clinical manifestations and time course. Clinical manifestations and time course.


ARF is characterized by nonsuppurative inflammatory lesions of the joints, heart, subcutaneous tissue, and central nervous system. An extensive literature search has shown that, at least in developed countries, rheumatic fever follows pharyngeal infection with rheumatogenic group A streptococci. [1, 2, 3, 4] The risk of developing rheumatic fever after an episode of streptococcal pharyngitis has been estimated at 0.3-3%. [1]  Investigations of rheumatic fever occurring in the aboriginal populations of Australia suggest that streptococcal skin infections might also be associated with the development of rheumatic fever. [5, 6]  and that group C and G streptococci may also serve as initiating pathogens. [7]  Although several classic group A streptococcal emm types are considered to be rheumatogenic and most likely to be associated with acute rheumatic fever, in Oceania and  Hawaii, group A streptococcal strains not traditionally associated with rheumatic fever have been found to cause the disease. [8]  This diversity of potential inciting group A streptococcal strains also appears to be a common phenomenon in lower and middle income countries. [9]

Molecular mimicry accounts for the tissue injury that occurs in rheumatic fever. Both the humoral and cellular host defenses of a genetically vulnerable host are involved. In this process, the patient's immune responses (both B- and T-cell mediated) are unable to distinguish between the invading microbe and certain host tissues. [10] T helper 1 and cytokine Th17 appear to be key mediators of rheumatic heart disease. [11, 12] The resultant inflammation may persist well beyond the acute infection and produces the protean manifestations of rheumatic fever.




United States

The incidence of ARF has declined markedly in the past 50 years in both the United States and Western Europe. Most Western physicians see only the late sequelae of rheumatic heart disease; the diagnosis of an acute case is usually reason enough for a grand rounds presentation. This remarkable decline of rheumatic fever likely reflects improved socioeconomic conditions, as well the decline in prevalence of the classically described rheumatogenic strains of group A streptococci.

Following 2 decades of almost total absence, a resurgence of ARF occurred in the 1980s among middle-class White children in Salt Lake City, Utah. [13] Clusters were also reported in US Army and Navy training camps during the same period. [14] These limited outbreaks were associated with mucoid rheumatogenic strains that were rarely seen in the preceding 20 years. Today, ARF remains a rarity in most of the United States, although Hawaii and American Samoa continue to see a significant number of cases, many of which are caused by streptococcal strains not usually associated with rheumatic fever in persons of Polynesian descent. [8, 15]


In developing countries, the magnitude of ARF is enormous. Recent estimates suggest that 33.4 million people worldwide have rheumatic heart disease and that 300,000-500,000 new cases of rheumatic fever (approximately 60% of whom will develop rheumatic heart disease) occur annually, with 230,000 deaths resulting from its complications. Almost all of this toll occurs in the developing world. [16, 17, 18]

The incidence rate of rheumatic fever is as high as 50 cases per 100,000 children in many areas. Areas of hyperendemicity (eg, indigenous populations of Australia and New Zealand) see an incidence of 300-500 cases per 100,000 children, whereas the rates are approximately 50-fold lower in their nonindigenous compatriots. [6] Rheumatic fever in the 21st century appears to be largely a disease of crowding and poverty.

Even within developing countries with overall high rates of ARF, the segments of populations of poorer socioeconomic status and with higher rates of malnutrition suffer disproportionately. [19]


Cardiac involvement is the most serious complication of rheumatic fever and causes significant morbidity and mortality. As stated above, about 60% of the approximately 470,000 patients diagnosed with ARF annually eventually develop carditis, joining the approximately 33 million worldwide with rheumatic heart disease. Those with rheumatic heart disease are at a high risk for additional cardiac damage with subsequent bouts of ARF and require secondary prophylaxis. Morbidity due to congestive heart failure (CHF), strokes, and endocarditis is common among individuals with rheumatic heart disease, and about 1-1.5% of persons with rheumatic carditis die of the disease annually. [6, 16, 18]


ARF is predominantly a disease of developing countries and is concentrated in areas of deprivation and crowding. It is rampant in the Middle East, in sub-Saharan Africa, in the Indian subcontinent, in certain areas of South America, in Oceania, and especially among the indigenous populations of Australia and New Zealand. Although a genetic predisposition to ARF clearly exists, [1, 20, 21] the disease does not seem to have a major racial predisposition, as it was once common in the United States and Europe and seems to decline in any locale where living conditions improve.


Rheumatic fever does not have a clear-cut sexual predilection, although certain clinical manifestations, such as mitral stenosis and Sydenham chorea, are more common in females who have gone through puberty.


ARF is most common among children aged 5-15 years. It is relatively rare in infants and uncommon in preschool-aged children. ARF occurs in young adults, but the incidence of first episodes of ARF falls steadily after adolescence and is rare after age 35 years. [6] The lower rate of ARF in adults may represent a decreased risk of streptococcal infections in this cohort. Recurrent episodes, with their predisposition to cause or exacerbate valvular damage, occur until middle age.