In many developing countries and indigenous communities within developed countries rheumatic heart disease (RHD) remains a burden. Rheumatic fever is an inflammatory autoimmune disease that can result from untreated group A betahemolytic streptococcal infection such as pharyngitis, scarlet fever and, in some cases, skin sepsis. The autoimmune reaction is due to the cross-reactivity between streptococcal proteins and human proteins. In many cases it follows an exudative tonsillo-pharyngitis caused by group A beta-hemolytic streptococci as shown below in another patient (age 15) who acutely presented with sore throat, fever and joint pain. Its complications range enormously from lifelong morbidity and reduced productivity, need for open heart surgery for valvular repair or replacement (often requiring long-term anticoagulation), risk of strokes, increased financial burden on individuals and health care systems, and much more. Many cardiac valve replacement surgeries are still a result of rheumatic valvular heart disease even in developed countries. Yet a number of physicians remain very uncertain about how to understand this disorder and avoid it.

Rheumatic fever may be seen in early adulthood but mainly seen in children (age 5-15 years). Its most dreaded complication is that of heart disease following recurrent acute rheumatic fever outbreaks. "About 60 percent of all acute rheumatic fever patients will develop carditis and join the more than 15 million rheumatic heart disease patients (worldwide)”. Inflammatory heart changes may include, or all, pericarditis and/or myocarditis and/or endocarditis (known as Pancarditis). Diagnosis of rheumatic fever is complicated by the absence of a "gold standard" or standardized confirmatory test for the disease but the well-known Duckett Jones criterion, which suggests the existence of two major or one major and two minor requirements, in addition to proof of recent streptococcal infection, serve as a useful guide for firm diagnosis.

Major criteria include evidence of carditis, polyarthritis, chorea, erythema marginatum or subcutaneous nodules, whereas minor criteria include fever, arthralgia, previous rheumatic fever or rheumatic heart disease, acute phase reactants (such as leucocytosis, elevated erythrocyte sedimentation rate, ESR, and elevated C-reactive protein, CRP) or extended electrocardiogram PR intervals. Evidence of recent streptococcal infection is supported by increased anti-streptococcal titrate O (ASOT) or other streptococcal antibodies, positive throat culture for Group A beta-haemolytic streptococci, positive rapid direct group A strep carbohydrate antigen test or recent scarlet fever (mostly 2-10 years old with sore throat, fever >101°F, bright red sandpaper-like rash in the neck, chest and axillae.

Once diagnosed, treatment of rheumatic fever should be as recommended in most standard textbooks but emphasis should be placed on awareness, prompt treatment of all suspected streptococcal infections and prevention of recurrent infections that are responsible for the heart complications that often result in a lifetime of misery.

Although rheumatic fever is no longer a serious health issue in the countries of the first world, and its incidence may be on the decline in developing countries, it still accounts for significant valvular diseases. Every child or young adult diagnosed with structural valvular heart disease of rheumatic origin, often requiring valvular repair or replacement, is suffering a long-term tragedy that could otherwise be prevented. It should not be forgotten that rheumatic heart disease still causes havoc in developing countries around the world especially. Awareness, recognition, and prevention of this condition should continue to be emphasised.

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