---
title: Acute rheumatic fever
description: How acute rheumatic fever develops after a streptococcal sore throat, why inflammation of the heart (rheumatic carditis) is its main danger, how it is found, which approaches to treatment and prevention the guidelines describe, and how rheumatic carditis leads to rheumatic heart disease.
type: disease
aliases:
  - ARF
  - rheumatic fever
  - rheumatic carditis
  - acute rheumatic carditis
sources:
  - tier: guideline
    org: who
    title: WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease
    year: 2024
    isbn: 978-92-4-010007-7
    url: https://iris.who.int/handle/10665/379374
  - tier: guideline
    org: who
    title: Rheumatic heart disease (WHO fact sheet)
    year: 2025
    url: https://www.who.int/news-room/fact-sheets/detail/rheumatic-heart-disease
  - tier: guideline
    org: minzdrav-rf
    title: Острый тонзиллит и фарингит (Острый тонзиллофарингит)
    year: 2024
    url: https://cr.minzdrav.gov.ru/view-cr/306_3
  - tier: guideline
    org: minzdrav-rf
    title: Митральный стеноз
    year: 2025
    url: https://cr.minzdrav.gov.ru/view-cr/945_1
  - tier: reference
    org: msd-manuals
    title: Rheumatic Fever (MSD Manual Professional Version)
    year: 2024
    url: https://www.msdmanuals.com/professional/pediatrics/miscellaneous-bacterial-infections-in-infants-and-children/rheumatic-fever
  - tier: reference
    org: msd-manuals
    title: Rheumatic Fever (MSD Manual Consumer Version)
    year: 2024
    url: https://www.msdmanuals.com/home/children-s-health-issues/bacterial-infections-in-infants-and-children/rheumatic-fever
sources_checked: 2026-10-14
review: null
---

Acute rheumatic fever (ARF) is the body's inflammatory reaction to a streptococcal throat infection: tonsillitis or pharyngitis (strep throat).<Cite n={[1, 6]} /> ARF itself is not an infection: in responding to the germ, the immune system damages the body's own tissues.<Cite n={[1, 6]} /> It can affect the heart, the large joints, and sometimes the brain (chorea) and the skin.<Cite n={1} /> The joints later recover completely, but inflammation of the heart, rheumatic carditis, can leave lasting damage to the valves.<Cite n={[5, 6]} />

This article is about rheumatic carditis and how it leads to [rheumatic heart disease](../rheumatic-heart-disease/). The diagnostic criteria, how common the disease is, and prevention are described in detail in the article on rheumatic heart disease.

<Diagram name="acute-rheumatic-fever">
  <p slot="normal">
    The diagram shows a section through the heart wall next to the mitral valve. The wall has three
    layers: the inner lining (endocardium), the heart muscle (myocardium) and the outer covering
    (pericardium).<Cite n={5} /> For comparison, in the normal state the valve leaflet is drawn
    thin and the layers of the pericardium lie close together.
  </p>
  <p slot="disease">
    Rheumatic carditis usually affects the heart from the inside out: first the valves and the
    endocardium, then the myocardium and finally the pericardium.<Cite n={5} /> Its main and most
    consistent feature is inflammation of the valve: the leaflet swells, and small nodules may
    appear along its edge.<Cite n={5} /> Foci of inflammation form in the heart muscle, and fluid
    sometimes collects in the pericardium (an effusion).<Cite n={5} />
  </p>
</Diagram>

## Why it happens

<Patient>

ARF does not start during the tonsillitis or pharyngitis caused by group A streptococcus but some time after it.<Cite n={[1, 5]} /> The proteins of this germ resemble proteins of the heart valves, heart muscle and joints, and the immune system attacks them by mistake.<Cite n={[1, 5]} /> Not everyone remembers having a sore throat.<Cite n={5} />

The Russian Ministry of Health guideline lists ARF and rheumatic heart disease among the complications of a streptococcal sore throat that was not treated or was treated inadequately.<Cite n={3} /> The first episode of ARF most often occurs in children and adolescents.<Cite n={[1, 5]} /> The risk is higher in people who have had ARF before and in their close relatives, and in people living in overcrowded, poor conditions.<Cite n={[2, 3, 6]} />

</Patient>

<Student>

ARF is a nonsuppurative, acute inflammatory complication of pharyngitis caused by group A streptococcus; the mechanism is autoimmune, through molecular mimicry.<Cite n={[1, 5]} /> Acute interstitial valvulitis may cause valvular oedema, and Aschoff bodies (granulomatous collections of leukocytes, myocytes and interstitial collagen) often develop in the myocardium and other parts of the heart.<Cite n={5} /> Fibrinous pericarditis, sometimes with an [effusion](../pericardial-effusion/), occurs only with endocardial inflammation and usually subsides without permanent damage.<Cite n={5} /> ARF typically does not cause chronic, smouldering carditis, but scars left by acute valve damage may contract and change.<Cite n={5} /> The chronic structural and functional changes in the myocardium and valves caused by inflammation and scarring after ARF are [rheumatic heart disease](../rheumatic-heart-disease/).<Cite n={1} />

</Student>

<HeartModel highlight={['mitral-valve', 'aortic-valve']} />

## Symptoms

<Patient>

Joint pain and fever usually come first.<Cite n={6} /> Involvement of the joints, skin and nervous system is described in the article on [rheumatic heart disease](../rheumatic-heart-disease/).

Inflammation of the heart can cause a high fever, chest pain and a fast heartbeat.<Cite n={6} /> Chest pain can come from inflammation of the sac around the heart, [pericarditis](../pericarditis/).<Cite n={6} /> The doctor may hear new or changed heart murmurs: this is the sound of affected valves.<Cite n={6} /> But rheumatic carditis can also pass unnoticed and be found only years later, when a damaged valve is discovered.<Cite n={6} />

If the inflammation of the heart is severe, [heart failure](../heart-failure/) can develop: the child tires quickly and is short of breath, and may have nausea, vomiting, stomach ache and a dry cough.<Cite n={6} /> Inflammation of the heart fades gradually, usually over several months, but it can permanently damage the valves.<Cite n={6} />

</Patient>

<Student>

Carditis occurs in about 50–70% of patients in the first episode of ARF; it is considered a pancarditis (endocardium, [myocardium](../myocarditis/), pericardium), but its most consistent feature is valvulitis: if the valves are not involved, the rheumatic nature of the carditis is in doubt.<Cite n={5} /> In the acute phase the most common lesions are [mitral regurgitation](../mitral-regurgitation/) and pericarditis, sometimes [aortic regurgitation](../aortic-regurgitation/); [mitral stenosis](../mitral-stenosis/) is a feature of the chronic disease.<Cite n={5} />

Tachycardia is common, especially during sleep; pericarditis may present with chest pain and a pericardial rub.<Cite n={5} /> Murmurs are usually evident early but may be absent at the first examination, so repeated examinations and echocardiography are recommended.<Cite n={5} /> If there is no worsening during the next 2–3 weeks, new manifestations of carditis seldom follow.<Cite n={5} />

Recurrent episodes often mimic the first one: carditis tends to recur in patients who have already had moderate or severe carditis.<Cite n={5} />

</Student>

## How it is diagnosed

<Patient>

The doctor assesses the combination of signs using the Jones criteria and looks for evidence of a recent streptococcal infection; more about this in the article on [rheumatic heart disease](../rheumatic-heart-disease/).<Cite n={[1, 5]} />

The main test for rheumatic carditis is an ultrasound scan of the heart ([echocardiography](../../diagnostic/echocardiography/)).<Cite n={1} /> It is recommended for everyone with suspected ARF: it finds inflammation of the valves even when no murmur can be heard.<Cite n={5} /> An [ECG](../../diagnostic/ecg/) and blood tests are also done.<Cite n={5} />

</Patient>

<Student>

WHO recommends diagnosing ARF with the Jones criteria (strong recommendation): with evidence of streptococcal infection, an initial episode requires 2 major or 1 major and 2 minor manifestations.<Cite n={[1, 5]} /> Carditis is a major criterion, clinical and/or subclinical: subclinical carditis is valvulitis seen only on echocardiography.<Cite n={[1, 5]} /> To avoid overdiagnosis, strict Doppler and morphological criteria are used: isolated trivial valve regurgitation or a trivial pericardial effusion may be a nonspecific finding.<Cite n={5} />

Signs of acute rheumatic carditis on the mitral valve include annular dilation, chordal elongation or rupture with a flail leaflet, prolapse of the tip of the anterior (less often the posterior) leaflet, and beading or nodularity of the leaflet tips.<Cite n={5} /> Where standard echocardiography is not available, WHO allows handheld echocardiography to diagnose rheumatic carditis (strong recommendation; very low certainty of evidence for carditis).<Cite n={1} />

A prolonged PR interval, after accounting for age, is a minor criterion that is not counted when carditis is already a major criterion.<Cite n={1} /> It does not correlate with other evidence of carditis; higher-degree [AV block](../av-block/) may occur but is uncommon.<Cite n={5} /> Throat cultures and rapid antigen tests are often negative by the time ARF appears, so antibodies to streptococcus are measured; the Russian Ministry of Health guideline says antistreptolysin O should be measured when rheumatic fever is suspected.<Cite n={[3, 5]} />

</Student>

## How it is treated

<Patient>

Treatment is prescribed by a doctor. Its goals are to get rid of any remaining streptococci, relieve acute symptoms, suppress inflammation and prevent new infections so that the heart is not damaged again.<Cite n={[5, 6]} /> Anti-inflammatory treatment may reduce inflammation and symptoms.<Cite n={[1, 6]} /> If [heart failure](../heart-failure/) develops, it is treated with the usual treatments for heart failure.<Cite n={5} />

Activity is limited when there is joint pain, chorea or heart failure; if the heart was not affected, no restrictions are needed after the episode, and long bed rest does not help.<Cite n={[5, 6]} />

After ARF the doctor prescribes long-term antibiotic prophylaxis to prevent repeat episodes, each of which can damage the valves again.<Cite n={[1, 5]} /> How long to continue it is decided by the doctor; it often depends on how severe the disease was.<Cite n={6} />

A first episode can be prevented by treating a streptococcal sore throat promptly and completely; but most sore throats are caused by viruses, and the doctor decides whether an antibiotic is needed.<Cite n={[2, 3, 6]} /> If an antibiotic is prescribed, it is important to take it as the doctor said and not to stop the course early.<Cite n={3} />

</Patient>

<Student>

WHO makes no recommendation for or against anti-inflammatory agents to prevent progression of ARF to rheumatic heart disease.<Cite n={1} /> Glucocorticoids are commonly given for moderate or severe carditis and may improve general symptoms, but more data are needed to support this practice.<Cite n={1} /> Drugs and regimens are chosen by the doctor according to current guidelines.

WHO recommends antibiotic prophylaxis against recurrence for all patients with ARF or rheumatic heart disease (strong recommendation): in its view, reducing recurrences is important for reducing the severity and progression of valve disease.<Cite n={1} /> The optimal duration of prophylaxis is uncertain.<Cite n={5} />

The prognosis depends mostly on how severely the heart is affected and on recurrences.<Cite n={5} /> After mild carditis without major cardiac enlargement or decompensation, murmurs eventually disappear in about half of patients, but many others develop chronic valve disease, including some who had no signs of valve disease after the episode.<Cite n={5} /> The chronic disease develops years to decades later, mainly as valve stenosis; the most common cause of mitral stenosis is rheumatic carditis.<Cite n={[4, 5]} />

</Student>

## When to call an ambulance

ARF itself does not usually need an ambulance. But if a child develops joint pain, fever, chest pain, a fast heartbeat or jerky, uncontrollable movements after a sore throat, see a doctor.<Cite n={6} />

Severe rheumatic carditis can cause heart failure.<Cite n={[5, 6]} /> If a child with ARF becomes severely short of breath or feels as if they are suffocating, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK). The complications of chronic valve disease are described in the article on [rheumatic heart disease](../rheumatic-heart-disease/).

<Quiz />