From January, 1987, until July, 1988, a significant increase in newly diagnosed cases of acute rheumatic fever was noted at our hospital. In sharp contrast to the 3 cases seen in 1986, 14 cases were diagnosed in 1987 (a significant increase from 1985 to 1986, P = 0.001). In the first 6 months of 1988 an additional 12 new cases were diagnosed (a further significant increase from 1987, P = 0.02). No further cases were diagnosed between July, 1988, and September, 1989. The major clinical manifestations were carditis in 73%, polyarthritis in 58% and chorea in 31%. In 15 of 26 patients an antecedent illness which included pharyngitis was noted; the remainder of patients were asymptomatic. Group A beta-hemolytic streptococci were isolated from 13 of 19 children cultured. Isolates from two patients with acute rheumatic fever were submitted for M typing: one isolate was mucoid M18/T18; the other isolate was a mucoid nontypable strain. The demographic characteristics of the 26 patients agree with classic descriptions in that patients were more likely to be urban, to come from large families and to have low incomes; racial breakdown of the group mirrored the Tennessee pediatric population. These characteristics stand in contrast to reports of recent outbreaks which describe suburban high income patients. These data suggest that practitioners should be again aware of acute rheumatic fever and that aggressive identification and treatment of streptococcal pharyngitis should continue to be a relevant public health concern.