Rheumatic Heart Disease: Model Clinical Case and Viva Q&A
1. Clinical Case of Rheumatic Heart Disease in Adolescents
Clinical Case: Rheumatic Heart Disease in an Adolescent
Patient Information
Name: Sarah J.
Age: 15 years
Gender: Female
Chief Complaint: Shortness of breath and fatigue
History of Present Illness
Sarah J., a 15-year-old female, presents to the pediatric cardiology clinic with complaints of progressive shortness of breath and fatigue over the past 3 months. She reports difficulty keeping up with her peers during physical education classes and has had to quit her school's soccer team due to these symptoms. Sarah also mentions occasional palpitations and two episodes of dizziness in the past month.
Past Medical History
- Recurrent strep throat infections during childhood
- Diagnosed with acute rheumatic fever at age 10, treated with antibiotics and anti-inflammatory medications
- No known allergies
Physical Examination
- Vital Signs: BP 110/70 mmHg, HR 88 bpm, RR 22/min, Temp 37.0°C, SpO2 97% on room air
- General: Alert, cooperative, mild pallor
- HEENT: No tonsillar erythema or exudates
- Cardiovascular: Regular rhythm, grade 3/6 systolic murmur at the apex radiating to the axilla, diastolic rumble at the lower left sternal border
- Respiratory: Clear to auscultation bilaterally
- Abdomen: Soft, non-tender, no hepatosplenomegaly
- Extremities: No edema, clubbing, or cyanosis
Investigations
- ECG: Sinus rhythm, left atrial enlargement, left ventricular hypertrophy
- Chest X-ray: Cardiomegaly with prominent left atrial appendage
- Echocardiogram: Severe mitral regurgitation, moderate mitral stenosis, mild aortic regurgitation, left atrial and left ventricular enlargement
- Blood tests: Elevated ESR (30 mm/hr), positive ASO titer (400 IU/mL), negative blood cultures
Diagnosis
Based on the patient's history of rheumatic fever, clinical presentation, and echocardiographic findings, Sarah is diagnosed with Rheumatic Heart Disease with predominant mitral valve involvement.
Management Plan
- Initiate penicillin prophylaxis (Benzathine penicillin G 1.2 million units IM every 4 weeks)
- Start medical management with diuretics (Furosemide) and ACE inhibitors (Enalapril)
- Refer for cardiac surgery evaluation for potential mitral valve repair or replacement
- Provide education on importance of adherence to prophylaxis and regular follow-ups
- Recommend endocarditis prophylaxis for high-risk procedures
- Schedule follow-up in 1 month with repeat echocardiogram
Prognosis
With appropriate medical management and timely surgical intervention, Sarah's prognosis can be significantly improved. However, she will require lifelong cardiac follow-up and continued prophylaxis against recurrent rheumatic fever.
Clinical Presentations of Rheumatic Heart Disease
Clinical Presentations of Rheumatic Heart Disease
-
Asymptomatic Valve Lesions
Some patients may have no symptoms despite having significant valve damage. The disease is often discovered during routine physical examinations or when investigating other health issues.
- Heart murmur detected on routine examination
- Abnormal chest X-ray or ECG findings
- No overt symptoms of heart disease
-
Mitral Regurgitation Predominant
This is one of the most common presentations in RHD, especially in the early stages.
- Dyspnea on exertion
- Fatigue and decreased exercise tolerance
- Palpitations
- Holosystolic murmur at the apex radiating to the axilla
- Possible signs of pulmonary hypertension in advanced cases
-
Mitral Stenosis Predominant
This presentation is more common in later stages of the disease or in cases of recurrent rheumatic fever.
- Progressive dyspnea
- Orthopnea and paroxysmal nocturnal dyspnea
- Hemoptysis
- Diastolic rumble at the apex with presystolic accentuation
- Opening snap following S2
- Signs of right heart failure in advanced cases
-
Aortic Regurgitation Predominant
While less common than mitral valve involvement, aortic regurgitation can occur in RHD.
- Exertional dyspnea
- Palpitations
- Angina-like chest pain
- Early diastolic murmur at the left sternal border
- Wide pulse pressure
- Corrigan's pulse (water-hammer pulse)
-
Mixed Valve Disease
Many patients with RHD have involvement of multiple valves, leading to complex hemodynamic abnormalities.
- Combination of symptoms from different valve lesions
- Multiple murmurs on auscultation
- Signs of both left and right heart failure
- Complex echocardiographic findings
-
Acute Rheumatic Fever Recurrence
Patients with RHD are at risk for recurrent episodes of acute rheumatic fever, which can present with:
- Fever
- Migratory polyarthritis
- Erythema marginatum
- Subcutaneous nodules
- Chorea
- Worsening of existing cardiac symptoms
-
Heart Failure
Advanced RHD can lead to heart failure, presenting as:
- Severe dyspnea and orthopnea
- Peripheral edema
- Hepatomegaly and ascites
- Elevated jugular venous pressure
- Pulmonary rales
- Cardiomegaly
-
Atrial Fibrillation
Chronic rheumatic valve disease, especially mitral stenosis, can lead to atrial fibrillation:
- Irregular pulse
- Palpitations
- Increased risk of thromboembolism
- Worsening of heart failure symptoms
-
Infective Endocarditis
Patients with RHD are at increased risk of infective endocarditis, which can present as:
- Fever and chills
- Fatigue and malaise
- New or changing heart murmurs
- Petechiae or splinter hemorrhages
- Embolic phenomena
Knowledge Check: Question and Answers for Medical Students & Professionals
This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.
Disclaimer
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