Symptoms of acute rheumatic fever
Diagnosing acute rheumatic fever (ARF) can be challenging as there is no single diagnostic laboratory test – diagnosis is based on clinical decisions plus supporting laboratory evidence. The Jones diagnosis criteria was introduced in 1944 and has been periodically modified and updated in the Australian guideline for prevention, diagnosis and management of ARF and rheumatic heart disease (RHDAustralia 2022).
Specific manifestations occurring in ARF that are reliably collected by jurisdictions and are related to an increased risk of rheumatic heart disease (RHD) are presented in this report. These manifestations are carditis, prolonged P-R interval, and Sydenham chorea (Box 3.1). People with carditis, a prolonged P-R interval and/or atrioventricular (AV) junctional arrhythmias are more likely to sustain heart damage (and hence to develop RHD) than those without.
Box 3.1: ARF manifestations associated with an increased risk of RHD*
- Carditis
- inflammation of the heart muscle and heart tissue, including the membrane which lines the chambers of the heart and forms the surface of the heart valves (endocardium). It causes a rapid heart rate, fatigue, shortness of breath and exercise intolerance, and in ARF is associated primarily with the mitral valve. Carditis occurs in about 40% to 50% of people with ARF.
- Prolonged P-R interval and other AV conduction abnormalities
- detected through electrocardiography (ECG). Refers to delayed or blocked conduction of the electrical impulse from the atria to the ventricles. Often the person has no symptoms.
- Sydenham chorea
- A neurological disorder, most commonly seen in childhood, resulting from infection with group A beta-haemolytic streptococcus, the bacterium that causes rheumatic fever. It is characterised by involuntary movements of the hands, feet, tongue and face, which stop during sleep. This is more common in females – globally it affects up to 36% of cases and is associated with carditis.
*A complete list of major and minor manifestations of ARF is provided in the Australian guideline for prevention, management and diagnosis of ARF and RHD and in Table T1 of this report.
Source: RHDAustralia 2022.
In 2024, of the 472 ARF diagnoses among First Nations people, about 29% had at least one manifestation of carditis, prolonged P-R interval, or Sydenham chorea (Supplementary table 3.6).
Diagnostic categories for acute rheumatic fever
In 2024, of all 472 acute rheumatic fever (ARF) diagnoses among First Nations people:
- 189 (40%) diagnoses were definite diagnoses
- 131 (28%) diagnoses were probable diagnoses
- 152 (32%) were possible diagnoses (Box 3.2; Supplementary table 3.7).
Box 3.2: ARF diagnostic categories
There is no one specific diagnostic test for ARF. Instead, it is diagnosed based on medical history and a pattern of clinical features (‘manifestations’) as follows:
- Definite ARF, first episode
- 2 major or one major and 2 minor manifestations plus evidence of preceding Strep A infection.
- Definite ARF, recurrent episode
- 2 major or one major and 2 minor manifestations or 3 minor manifestations plus evidence of preceding Strep A infection.
- Probable ARF
- clinical presentation falls short by either one major or one minor manifestation, or the absence of streptococcal serology results, but where ARF is the most likely diagnosis.
- Possible ARF
- strong clinical suspicion of ARF, but insufficient signs and symptoms for diagnosis of definite or probable ARF.
The new guidelines were released in 2025, but these data were collected using the 2020 definitions.
For more information on types of manifestations, see Technical notes.
Source: RHDAustralia 2022.
RHDAustralia (ARF/RHD writing group) (2022) ‘The 2020 Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease- external site opens in new window’, (3.2 edition, March 2022), RHDAustralia, Menzies School of Health Research, Darwin.