We thank John Lawrenson and his colleagues for the interest shown in our article. All of their suggestions are well taken, except for their comment on our proposed system for scoring. Based on our experience of treating more than 1000 cases of acute rheumatic fever in the last few years, we continue to press for the need for such a scoring system to permit early and accurate echocardio-graphic diagnosis of carditis and subclinical valvitis. If, as they suggest, significant mitral regurgitation in isolation, with a score of 2 rather than the minimum of 6 as we recommended, was used as the criterion, we submit this would result in the over-diagnosis of carditis. In the past, many patients without rheumatic disease, but with significant mitral regurgitation, such as those with aortoarter-itis, dilated cardiomyopathy, and prolapsing myx-omatous mitral valves, were wrongly diagnosed as carditis in the setting of fever, arthralgia, a cardiac murmur on auscultation, a raised erythrocyte sedimentation rate, and a positive test for C-reactive protein. Such patients would have one major, and three minor, criterions according to the Jones' approach, but echocardiographic interrogation would reveal thin and redundant myxomatous leaflets permitting prolapse of the third grade. Such findings using our system would give a score of 4 (Fig. 1a and b).
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