• infectious disease medicine
• paediatrics
• epidemiology

Post-streptococcal diseases include some of the most classical clinical presentations in medicine. From the early diastolic murmur in a young adult with rheumatic heart disease to the uncontrolled movements of a child with Sydenham’s chorea, these signs and symptoms triggered some of the earliest attempts of modern medicine to classify undifferentiated disease.

Driven by an abnormal immune response to Streptococcus pyogenes—widely known among clinicians as group A streptococcus (GAS)—these diseases are now predominantly seen in low-income settings.1 Consequently, in most high-income settings, many clinicians may now go an entire career without seeing a single case of poststreptococcal disease.

Nonetheless, while unusual, post-streptococcal diseases persist in high-income settings, and should not be forgotten.2 Following the surge in GAS infections among children in the winter of 2022–2023, exemplified by very high UK rates of scarlet fever and invasive GAS disease, there are once again reasons for concern about post-streptococcal disease,3 especially in the form of acute rheumatic fever and post-streptococcal glomerulonephritis. And yet, while this epidemiological picture may trigger suspicion, there are several challenges for clinicians and public health specialists in diagnosing and quantifying the burden of post-streptococcal disease in the UK.

The first barrier is clinical: diagnosing a case of rheumatic fever and other post-streptococcal sequelae can be difficult. The non-specific nature of symptoms mean that patients may present to a variety of different services: primary care, emergency departments, general paediatrics, cardiology, infectious diseases, rheumatology, nephrology and psychiatry. Patients may experience significantly different diagnostic workups, depending on which pathway …