Dear Sir,

I thank Dr Fesslova for her comments, which highlight important remaining questions about the approach to rheumatic fever. It is a fact that this intriguing disease continues to present a daunting challenge. Among the problems which still need to be addressed are the diagnostic difficulties, along with our incomplete understanding of the factors responsible for the changes in epidemiology, specifically the reason for its disappearance and reappearance. After a marked decline, the sudden resurgence of focal epidemics in civilian populations through the 1980s in the United States of America, and the more recent episode of a sixfold increase during a period of 7 months over the average annual incidence of 4–5 cases seen in Northern Italy, as described by Dr Fesslova et al., highlight these ongoing difficulties. As has been pointed out, many physicians are unfamiliar in these situations with the varied presentations of rheumatic fever. This fact in itself could result in late diagnosis, with all its consequences. Even in the areas where rheumatic fever is highly prevalent, however, the identification of mild carditis can present problems on some occasions for those involved with the clinical diagnosis, even when they are experienced cardiologists. The more accurate description of the morphological and functional abnormalities of the cardiac segments by Doppler echocardiography, and the contribution of this technique in identifying the subclinical valvitis, have emphasised the potential difficulties in diagnosing mild valvar lesions by auscultation. In our experience, many patients have no murmur. Even when a murmur is audible, its character is similar to that of the innocent murmur heard in healthy children, these characteristics being well described by Ozkutlu et al. Taking into consideration the lack of a specific diagnostic test, besides the unknown pathogenesis, we must continue to recognise that, unfortunately, the diagnosis of rheumatic fever is still dependent on the impression gained by the physician from a set of nonpathognomonic signs and symptoms.