An update from Dr Jo Scott-Jones, clinical director.
We all know the lifelong impact of rheumatic fever, and whilst not every case is clearly linked to a sore throat, and not everyone who gets it presents with a sore throat to their GP, we all are acutely aware of the value add we can make by simply recognising and treating people at risk.
Rheumatic fever itself is on the rise again with 183 cases nationally reported in 2023.
This can be a difficult disease to recognise, but it's important to keep it on our list of differential diagnoses for pateints with:
We can all see ourselves making the same decisions as the clinical teams involved in the following cases but it is a useful reminder to review an audit of the 17 ARF notifications from 2020 to 2024 in Tairāwhiti which demonstrated a delay in diagnosis in over half (n=9).
Be vigilant for ARF symptoms in our at-risk populations, particularly after a Group A Streptococcus (GAS) infection - and whilst whether skin infection can trigger rheumatic fever is unclear, remember in up to 50 per cent of cases of rheumatic fever there is no clear history of a recent strep infection.
Read more in the Evidence summary: Group A Streptococcus and acute rheumatic fever in Aotearoa New Zealand.
Recognise signs of carditis, new heart murmur, arthritis, or chorea as possible ARF manifestations.
Case summaries:
Case A presented with a GAS+ sore throat that was treated and then developed migrating polyarthritis in the knees, hips and ankles. It was documented they had x-rays and were advised to attend physio. About a week later they had ongoing symptoms, and a Kaiawhina contacted a paediatrician. Following this, they presented to the Emergency Department (ED) and were admitted into hospital.
Case B presented to GP with a sore throat, fever and flu-like illness and a family history of ARF. The throat swab tested positive for both GAS and EBV, and was treated with antibiotics. She presented to ED two months later with joint pain in her knees and feet; and CRP of 44. A viral illness was diagnosed.
Two weeks later she developed involuntary limb movements and facial grimacing that became so severe she was unable to feed or dress herself. She was referred by ED to mental health in the belief that her symptoms were ‘substance induced’. The chorea worsened, and she was referred back to ED, where ARF diagnosis was made by paediatrics. ECG showed PR prolongation and an echocardiogram showed mild to moderate mitral regurgitation.
Case C had several ED visits prior to diagnosis. The first, was for abdominal and back pain. Two weeks later with right ankle pain. Then, 3 weeks later with a swollen and painful right wrist. In addition to this two-month history of migratory polyarthralgia, the patient had an elevated ESR and CRP, PR prolongation, and echocardiogram showed mild to moderate aortic and mitral regurgitation.
Case D was referred to ED by their GP with a 3-day history of fever and myalgia. In ED, a viral infection was diagnosed, with temperature 39.1oC and CRP 99. They re-presented a week later with ongoing symptoms, including pain in both knees, elbows, neck, and back. At this time, they were found to have PR prolongation on ECG, elevated CRP and ESR, and elevated streptococcal antibodies.
Case E presented with a one-month history of progressive fevers (measured at >38oC), polyarthralgia, and abnormal lower limb neurology; CRP was 155. He hadn’t sought treatment for a sore throat, attributing it to heavy smoking. Referred to Waikato with a working diagnosis of sepsis secondary to endocarditis, he was discharged without a definitive diagnosis.
He re-presented two weeks later with a relapse of symptoms, including fever, joint pain and stiffness so severe that he struggled to walk and was unable to open jars. His CRP rebounded to 130 from a pre-discharge low of 57. A repeat echocardiogram was highly suspicious for carditis, showing trace regurgitation of all four heart valves. ARF was diagnosed, confirmed by an elevated streptococcal titre.
Initially published by NZ Doctor, Jo Scott-Jones discusses what you can do to reduce the number of phone calls, prescriptions and consultations for respiratory illnesses this winter.
Read moreIn the first 10 days of 2025 there were x3 pertussis cases in Tairawhiti, x5 cases in Taranaki, x5 cases in Lakes, x6 cases in Waikato, and x18 cases in the Bay of Plenty. Please continue to be on alert. View the key messages for GPs here.
Treatment of patients with an acute or sub-acute COPD exacerbation that can be safely managed in the community
View detailsThis BPAC resource assists to predict risk of serious illness in children with fever