Presentation on rheumatic heart disease it's epidemiology, pathophysiology,clinical presentation and management

1. MEDICAL
CASE PRESENTATION
BY DR BRENDA NJENGA FACILITATOR-DR RARAMA M.K.

2. BIODATA
EK
16 Years
Female
Imenti
DOA 22/08/2023

3. CHIEF COMPLAINT
Cough- 6/12
Easy fatiguability- 6/12

4. HPI
Well till 6/12 ago when she developed sudden onset cough, nonproductive associated with
centralized chest pain
Associated easy fatiguability NYHA class 2 and bilateral pitting lower limb swelling
Associated on and off joint pain for 2yrs
No orthopnea/ PND
No dyspnea nor yellowing of the eyes
No previous fever, throat infection preceding the symptoms
No skin rashes reported or episodes of being unwell.

5. Past Medical and Surgical history
Has been treated as outpatient for the above symptoms
Index admission
No hx of chronic illness ; DM ,HTN
NKFDA

6. Family social history
Form 1 student in school
2nd born in family of 4 siblings
Reports no chronic illness in the nuclear family ;DM ,HTN, CKD
Parents all alive and well.

7. Summary
16 year old female form 1 student presented with easy fatiguability and cough for 6months
associated with bilateral lower limb swelling, chest pain with no hx of orthopnea,PND with on
and off joint pains

8. O/E (admission)
Sick looking
Mild pallor
(JCCLOWD)0
VITALS
BP -106/58 mmHg
P- 110 b/min
RR-16 breathes / min
Body Temp - 36.7o C
SPO2- 87% on RA

9. REVIEW OF SYSTEMS
CVS
Hyperactive precordium
Parasternal heave
S1,S2 S3 gallop
+ve hepatojugular reflex
RESP
In resp distress
Mild bilateral crepitations on the lower lung zones

10. REVIEW OF SYSTEMS
CNS
GCS 9/15 ( E-3, V-1, M-5)
P/A
Abdomen with normal contour- flat not distended
Right upper quadrant tenderness
No hepatomegaly

11. Impression
Heart failure r/o valvular heart disease

12. PLAN
Admit to ward 3
FHG/ LFTS/ UECS
Echo/ ECG
Oxygen therapy at 5l/min

13. Investigations
Full hemogram done on 22/08/2023
WBC – 6.6
HB- 9.5 ↓
MCV – 70.0 ↓
MCH- 23.6 N
PLT- 393 N

14. UECs
Urea- 4.7 mmol/L normal
Sodium- 138 mmol/L normal
Potassium- 4.4 mmol/L normal
Chloride- 107 mmol/L normal
Creatinine- 40 mmol/L normal

15. LFTS

16. Chest radiograph

17. Echocardiogram
Both atria dilated left severely @6.58cm
Dilated LV @5.96cm
EF- 60.3%
Thickened aortic valve with severe AR
Thickened leaflet tip, motion restriction of posterior mitral valve leaflet with severe MR
Impression- Acute decompensated heart failure secondary to rheumatic valvular heart disease
with aortic and mitral regurgitation

18. PLAN CTND
IV Lasix 40mg bd
Carvedilol 6.25mg bd po
Spironolactone 25mg od po
IM 1.2MU Benzathine penicillin monthly
Enalapril 2.5mg od po

19. D1Post admission
Sick looking, Mild pallor (JCCLOWD)0
VITALS
BP -112/61mmHg
P- 78 b/min
RR-18 breathes / min
Body Temp - 36.7o C
SPO2- 95% on O2 via NRM at 10l/min
Plan
Reduce carvedilol dose to 3.125 mg bd
Monitor vitals 4 hrly
Ct mngt as per t-sheet

20. D2 Post admission
FGC Mild pallor (JCCLOWD)0
VITALS
BP -78/51mmHg
P- 98 b/min
RR-18 breathes / min
Body Temp - 36.7o C
SPO2- 96% at RA
Plan
Increase carvedilol dose to 6.25 mg bd
Reduce spironolactone dosage to 12.5mg od
Reduce Lasix po to 20mg bd
Ranferon 10mls tds po
Monitor vitals 4 hrly
Ct mngt as per t-sheet

21. D3 Post admission
FGC Mild pallor (JCCLOWD)0
VITALS
• BP -79/61mmHg
• P- 96 b/min
• RR-18 breathes / min
• Body Temp - 36.7o C
• SPO2- 96% at RA
Plan
Discharge home TCA 2/52 at MOPC
carvedilol dose to 6.25 mg bd
spironolactone dosage to 12.5mg od
Lasix po to 20mg bd
Ranferon 10mls tds po
IM 1.2MU Benzathine penicillin monthly
Enalapril 2.5mg od po
Referral to interventional cardiologist for valvular repair.

22. Acute Rheumatic
Fever& Rheumatic
Heart Disease

23. Definition
Rheumatic fever is an immunologically mediated inflammatory disorder ,which
occurs as a sequel to group A streptococcal pharyngeal infection.
Multisystem disease affecting connective tissue particularly pf the heart, joints,
brain, cutaneous and subcutaneous tissues.
Rheumatic heart disease (RHD) is heart valve damage that arises as a
complication of rheumatic fever years after the illness has resolved.
It develops as a result of chronic inflammation and scarring of the heart valves
triggered by rheumatic fever, If not treated, rheumatic heart disease can
progress to heart failure.

24. Epidemiology
Worldwide, rheumatic heart disease remains the most common form of acquired heart disease
in all age groups, accounting for as much as 50% of all cardiovascular disease and as much as
50% of all cardiac admissions in many developing countries.
There are approximately 470,000 new cases of ARF and 233,000 attributable deaths to ARF or
RHD yearly worldwide.(1)
High-risk patients with a history of ARF have an estimated 50% recurrence rate of ARF following
untreated GAS pharyngitis.
Globally, the reported incidence of ARF is likely underestimated due to a lack of data, primarily
from developing areas. While anyone can develop ARF, the disease is most commonly seen in
children between 5 and 15 years old.
There is no gender predilection for ARF, but females are more likely to progress to RHD
CHOWDHURY S, KOZIATEK CA, RAJNIK M. ACUTE RHEUMATIC FEVER. [UPDATED 2023 AUG 2]. IN:
STATPEARLS [INTERNET]. TREASURE ISLAND (FL): STATPEARLS PUBLISHING; 2023 JAN-. AVAILABLE
FROM: HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK594238/

25. pathogenesis
An immune mediated pathogenesis, in which there is Antigenic molecular mimicry between the
mammalian tissues and the GABHS cell wall.
GABHS antigens stimulate the activation of CD4+ T cells which then cross react with similar
peptides in the heart. The M protein moiety and N-acetyl-β-D-glucosamine (NABG) of GAS
species exhibit structural similarity to myosin, leading to cardiac myositis and valvulitis.(1)
Antibody-antigen complexes may also deposit in joints leading to the characteristic migratory
polyarthritis in the skin, brain and subcutaneous tissues resulting in erythema marginatum,
chorea, subcutaneous nodules respectively.
CHOWDHURY S, KOZIATEK CA, RAJNIK M. ACUTE RHEUMATIC FEVER. [UPDATED 2023 AUG 2]. IN:
STATPEARLS [INTERNET]. TREASURE ISLAND (FL): STATPEARLS PUBLISHING; 2023 JAN-. AVAILABLE
FROM: HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK594238

28. Diagnosis

29. Supporting evidence of a preceding strep
infection within last 45 days
Elevated or rising antistreptolysin-O or other streptococcal antibody
Positive throat culture
Rapid antigen test for Group A streptococci
Recent scarlet fever
KENYA NATIONAL GUIDELINES FOR CARDIOVASCULAR DISEASES MANAGEMENT 2022

30. Revised Jones criteria
CHOWDHURY S, KOZIATEK CA, RAJNIK M. ACUTE RHEUMATIC FEVER. [UPDATED 2023 AUG 2]. IN:
STATPEARLS [INTERNET]. TREASURE ISLAND (FL): STATPEARLS PUBLISHING; 2023 JAN-. AVAILABLE
FROM: HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK594238/

31. Migratory Polyarthritis
Occurs in about 75% of patients with ARF and typically involves larger joints; knees, ankles,
wrists and elbows.
Joints are generally hot, red, swollen and tender with no obvious deformity.
Involvement of the spine, small joints of the hand and feet is uncommon.
Rapidly improves on NSAIDS.
Usually runs a self-limited course lasting about 4 weeks
Monoarthritis may be presenting feature in high-risk population
KENYA NATIONAL GUIDELINES FOR CARDIOVASCULAR DISEASES MANAGEMENT 2022

32. Carditis
Most serious manifestation of ARF account for essentially all associated morbidity and mortality.
Manifests as pancarditis involving endocardium, myocardium and pericardium
Presents as a new murmur, cardiomegaly, congestive heart failure, pericardial friction rub,
and/or pericardial effusion.
KENYA NATIONAL GUIDELINES FOR CARDIOVASCULAR DISEASES MANAGEMENT 2022

34. management
All pts should be placed on bed rest and closely monitor for carditis.
Antibiotic treatment- benzathine penicillin IM single monthly injection. erythromycin if
penicillin allergic or oral penicillin for 10days.
Anti inflammatory with salicylates
Heart failure treatment

38. ECG?