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Case report
Atypical presentation of acute rheumatic fever (ARF) in a 25-year-old woman in the Caribbean: a challenging diagnosis
  1. Stephen John Bordes1,
  2. Ian Victor Joseph Murray2 and
  3. Johansen A Sylvester3
  1. 1Department of Anatomical Sciences, Medical Student Research Institute, St. George's University School of Medicine, St. George's, Grenada
  2. 2Department of Medical Physiology Physiology, Engineering Medicine, Texas A&M University, Houston, Texas, USA
  3. 3University Health Services, St. George's University, St. George's, Grenada
  1. Correspondence to Dr Johansen A Sylvester; jsylvester{at}


A 25-year-old woman presented a challenging diagnosis of acute rheumatic fever (ARF). Initial symptoms included dry cough and three minor Jones criteria (unabating fever (38.4°C, 0d), elevated acute phase reactants (C-reactive protein, 13d) and joint pain (monoarthralgia) in her neck (0d)). ARF was diagnosed only after presentation of two major Jones criteria (polyarthritis/polyarthralgia (16d) and erythema marginatum (41d)) and positive antistreptolysin O titre (44d). Parotid swelling, peripheral oedema, elevated liver enzymes and diffuse lymphadenopathy complicated the diagnosis. Throat swab, chorea and carditis were negative or absent. Atypical ARF is challenging to recognise. There is no diagnostic test and its presentation is similar to that of other diseases. While the 2015 Jones criteria modification increased specificity of ARF diagnosis, atypical cases may still be missed, especially by physicians in developed countries. Suspicion of atypical ARF, especially after travel to high incidence regions, would allow for earlier treatment and prevention of rheumatic heart disease.

  • general practice / family medicine
  • global Health
  • infectious diseases
  • medical management

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  • Contributors JAS: identified the case, ordered tests, interpreted results, wrote and edited the paper; SJB: analyzed data, wrote and edited the paper, IVJM: initiated the project, analyzed data, wrote and edited the paper. SJB, JAS and IVJM composed, reviewed, researched, edited and approved this manuscript. JAS was the attending physician overseeing this case.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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