RF is a delayed autoimmune response to Group A streptococcal pharyngitis. The clinical manifestation of the response and its severity in an individual is determined by host genetic susceptibility, the virulence of the infecting pathogen and a conducive environment. RF is thought to occur only after GAS infection of the upper respiratory tract although this thinking has been challenged by those working in tropical areas where skin infections are rife.

(Low rates of streptococcal pharyngitis and high rates of pyoderma in Australian aboriginal communities where acute rheumatic fever is hyperendemic.McDonald MI, Towers RJ, Andrews RM, Benger N, Currie BJ, Carapetis JR.Clin Infect Dis. 2006 Sep 15;43(6):683-9. Epub 2006 Aug 9.

(The challenge of acute rheumatic fever diagnosis in a high-incidence population: a prospective study and proposed guidelines for diagnosis in Australia's Northern Territory.

Ralph A, Jacups S, McGough K, McDonald M, Currie BJ.

Heart Lung Circ. 2006 Apr;15(2):113-8. Epub 2005 Oct 27.)