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Chapter 46: Acute Rheumatic Fever

Acute rheumatic fever (ARF) is a multisystem autoimmune response to untreated or partially treated group A Streptococcus (GAS) pharyngitis. Which of the following statements about ARF is false?

A. First attacks are rare in the very young

B. The peak incidence of ARF occurs in those age 5 to 15 years

C. ARF is rare in adults older than age 35

D. ARF is equally common in males and females

E. No association with ethnic origin has been found

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 46) Acute rheumatic fever is equally common in males and females, but RHD is more common in females in almost all populations.1,2 First attacks are rare in the very young (option A); only 5% of first episodes arise in children younger than age 5, and the disease is almost unheard of in those younger than age 2 (option A). The peak incidence of ARF occurs in those age 5 to 15 (option B), with a decline thereafter such that cases are rare in adults older than age 35 (option C).3 No association with sex or ethnic origin has been found (options D and E).

The incidence of ARF began to decline in developed countries toward the end of the 19th century, and by the second half of the 20th century, ARF had become rare in most affluent populations. Which of the following factors contributed least to this decline?

A. More hygienic living conditions

B. Less crowded living conditions

C. Better nutrition

D. Improved access to medical care

E. The advent of antibiotics

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 46) This decline is attributed to more hygienic and less crowded living conditions, better nutrition, improved access to medical care, and, to a lesser extent, the advent of antibiotics in the 1950s. The decline in the prevalence of RHD in wealthy countries has followed a similar pattern, albeit with a delay compared to ARF incidence, which is explained by the chronic nature of RHD.

A 31-year-old man with a prior history of rheumatism in every joint at the age of 15 presented to the emergency department complaining of pain in the left hip and right knee. His physical examination revealed a systolic murmur, loudest at the apex and radiating to the axilla. ...

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