Clinical case presentation A 9 year old male, hailing from Kerala, presented with

complaints of:Cough and breathlessness since 2 years which was

increased since the last 15 dayspalpitations since 15 daysFever , on and off since 15 daysJoint pain, since 15 days

Breathlessness insidious in onset, initially present on increased activity now present even with

ordinary activity since past 15 days . Breathlesness is not present on lying downNo diurnal variation.No seasonal variationNot associated with bluish discoloration of skin or squatting

episodesBreathlesness is associated with cough

Cough associated with scanty mucoid expectoration since the

past 15 dyas, non blood stained.Not associated with rise in temperatureNot associated with wheezeNo diurnal variation , not increased on exposure to

cold(seasonal variation)Cough is associated with chest pain, which is present only

during coughing, pricking in type, present diffusely, non radiating.

PalpitationsPresent even at rest.Not associated with chest painAssociated with dizziness but there was no loss of

consciousness.

FeverHigh gradePresent on and off since 15 daysNot associated with rigors

Pain and swelling of the left knee joint since 15 daysAssociated with limitation of movement, the child could not

walk due to the painNot history of traumaafter a week the pain in the knee joint subsided, and the child

had pain in the left ankle joint and right elbow joint.No history of morning stiffness. pain subsided immediately after the initiation of

treatment

Negative historyno history of reduced urine outputno history of pedal oedemaNo history of abdominal painNo history of recurrent sore throat. No history of rash or bleeding manifestations

(petechial hemorrhages, purpura)No history of recurrent respiratory tract

infections history of weight loss present but could not

be quantified

PAST HISTORYHistory of similar complaints in the past.3 years back he presented with fever

associated with fleeting type of joint pain , and was admitted in the hospital and treated for the same.

He was advised to take injections every 3 weeks until the age of twenty five(suggestive of acute rheumatic fever) but the injections were discontinued one year back due to reasons unknown.

No history of asthma.No history of contact with tuberculosis

BIRTH HISTORYNo complications in the antenatal periodInstitutional delivery at term, normal vaginal

delivery, baby cried immediately. Birth weight- not known.No complications during the deliveryNo post natal complications. NO ICU

admissions after birth.No problems during infancy.

DEVELOPMENTAL HISTORYall milestones were achieved on time.

IMMUNISATION HISTORYImmunisation up to dateOPV, BCG, DPT and boosters , Measles vaccine

given.

DIET HISTORY

MEAL FOOD ITEM CALORIES PROTEIN

Morning 1 cup milk with sugar2 biscuits

127 4.1

Breakfast 2 dosa , half cup dal

200 6

Lunch 1 cup rice1 cup sambar1 cup of vegetables

376 10

Evening snack 1 cup milk with sugar

87 3.3

dinner 2 rotiHalf cup dal1 fish

287 24

Calories requirement = 1620 kcalCalories obtained= 1047Defecit= 573

Protein requiremnt=33.2 g/dayObtained= 35 gNo defecit

SOCIAL HISTORY He is in 3rd standard. He performs averagely

at school. He has been held back a year due to missing school due to poor health and his performance.

FAMILY HISTORY Non consanguineous marriage. No history of similar

complaints in the family Socioeconomic status- Upper lower class as per modified

Kuppuswamy scale. Total family members- 4. The child has two siblings, both healthy and active, going to

school.

9 yrs 7 yrs 5 yrs

SummaryA 9 year old boy, with previous history

suggestive of rheumatic fever, advised monthly injections since the last 3 years which were discontinued the past 1 year, presented with cough, breathlessness, palpitations, along with fever and fleeting type of joint pain and swelling of knee, ankle and elbow joint since past 15 days.

Probable diagnosisRecurrence of rheumatic fever with rheumatic

carditis.

PHYSICAL EXAMINATION

Patient is conscious, cooperative, well oriented with time, place and person

1. Pallor present2. No Icterus, Clubbing, Cyanosis,

Lymphadenopathy or Edema

GENERAL PHYSICAL EXAMINATION

Signs of Infective endocarditis: Absent(except pallor)

Head to toe examination: Sunken eyes Thyroid- normal. Spine- normal. No skeletal deformities.

Anthropometry:1. Height: 126cmInference: Normal (Between 10th and 25th centiles)2. Weight: 18.5kg Inference: Below the 3rd centile.

BMI=12.85Kg/m2Impression:UNDERWEIGHT3.Arm span:125cm.4.US:LS=1:1

Vitals:1. BP:90/60mmHg Right arm supine position.2. Pulse: 120bpm, Increased rate, regular

rhythm, normal volume & character. No radioradial or radiofemoral delay.All peripheral pulses felt.

3. Respiratory rate: 30 cycles/minute. Abdominothoracic.

4. Temperature: 37.2°C5. JVP: Not raised.

Cardiovascular system

Inspection:Precordium appears normal.Apical impulse: diffuse, Left 6th ICS 1cm

lateral to MCL.Visible pulsation seen in Left 2nd ,3rd,4th ICS.No visible epigastric pulsations.No scars, sinuses or dilated veins.

Palpation:Apex beat is in Left 6th ICS 1cm lateral to

MCL, Hyperdynamic in character, Systolic thrill present.

Parasternal heave present.Palpable P2.No epigastric pulsations.No carotid thrill.No palpable pericardial rub/tracheal tug.

Percussion:Right heart border corresponds to sternum,

Left heart border corresponds to the apex.

Auscultation:Mitral area: S1normal, S2 muffled. A high pitched, pansystolic murmur of grade IV intensity,soft blowing in character,heard with the diaphragm of stethoscope, in left lateral position of the patient and at the height of expiration.The murmur is radiated to the left axilla and the back.

Pulmonary area: S1 heard, loud P2,ejection systolic

murmur of grade III intensity heard.Aortic area: S1 S2 heard.Tricuspid area:S1 S2 heard. Pansystolic

murmur of gradeIII intensity.No carotid bruit.

Respiratory systemInspection: Upper respiratory tract: normal Lower respiratory tract: Trachea central Movements B/L symmetrical No signs of volume loss. No scars, sinuses or dilated veins

Palpation: Trachea central Movements B/L symmetrical Vocal fremitus: B/L equalPercussion: Normal resonant note B/LAuscultation: Normal vesicular breath

sounds heard in all areas. No added sounds.

Gastrointestinal system Oral cavity:Normal Per Abdomen: Soft, nontender Liver is palpable 2cm below the RCM. Liver span 8cm. Spleen not palpable. No shifting dullness. Traube’s space tympanic on

percussion. Normal bowel sounds heard

1. Nervous system examination: Higher mental functions: No abnormalities

detected No cranial nerve abnormalities Motor system: No abnormalities detected;

Bilateral flexor plantar Sensory system: No abnormalities detected Stance and Gait: No abnormalities detected Co-ordination: No abnormalities detected Signs of meningeal irritation: Absent Skull and spine: No abnormalities detected

SummaryA 9 yr old child with dyspnoea,on& off fever,cough, chest pain,palpitation since the past10days.O/E: Found to have tachycardia, pallor, apex is shifted outwards & is hyperdynamic, systolic thrill at the apex, parasternal heave, palpable P2, pansystolic murmur (grade IV)in mitral area radiated to the left axilla and the back. loud P2

DiagnosisACUTE RHEUMATIC CARDITIS WITH

MITRAL REGURGITATION WITH FEATURES OF PULMONARY HYPERTENSION.

PATIENT IS IN SINUS RHYTHM AT PRESESNT

NOT IN CCF OR INFECTIVE ENDOCRDITIS.

Investigation

Complete blood counts:1. Total count: increased2. Differential count: polymorphonuclear

leucocytosis3. Hb: anemia4. Peripheral smear5. ESR:

Raised: acute rheumatic feverDecreased: CCF, mild carditis, chorea

6. Acute phase reactants:ESR: increasedCRP: increased (beta-globulin in a/c rheumatic fever)

7. Blood cultureLiver Function TestsRenal Function TestsUrinalysisABG

Evidence of streptococcal infection1. ASO titer2. Other antibodies:

Antihyaluronidase (AH)Anti-streptokinase (ASK)Antistreptozyme (ASTZ)Anti-DNAse B

3. Positive throat culture4. Rapid streptococcal antigen detection test

Evidence of carditis1. CXR2. ECG3. ECHO

Investigations Results Inference

Hemoglobin 9.5 g% Moderate anemia

Total Count 15,800 cells/cumm Elevated

Differential Count N70, L17, M1.3 Normal

ESR 13mm/L/hr ??? Normal

Platelets 3.79lakhs Normal

Serum urea 22mg/dl Normal

Serum Creatinine 1.5mg/dl Raised

Na+ 131mEq/L Slightly low

K+ 4.4mEq/L Normal

Cl- 93.3mEq/L Slightly low

HCO3- 17.5mEq/L Low

Ca2+ 8.6mg/dl Normal

Phosphate 4.2mg/dl Normal

Investigation Result Inference

Total bilirubin 0.6g/dl Normal

Direct bilirubin 0.17g/dl Normal

Serum globulin 3.7g/dl Slightly elevated

SGOT/AST 29IU/L Normal

SPGT/ALT 30IU/L Normal

ALP 215IU.L Normal

Urinanalysis Albumin: 2+2-4 pus cells8-10 RBCs

AlbuminuriaNormal

Elevated

pH 7.45 Normal

pCO2 28.2 Low

pO2 187 High

SpO2 99.7% Normal

HCO3- 19.3 Low

Peripheral smear:

Blood culture: Negative

CXR:Cardiomegaly presentNo signs of pulmonary congestion

ECHO:Rheumatic heart diseaseMildly dilated LA/LVSevere mitral regurgitationMild pericardial effusionNo pulmonary arterial hypertensionNo vegetation

ImpressionAcute rheumatic carditis with severe MR,

cardiomegaly & mild pericardial effusionAnemiaRespiratory alkalosis - compensated (low

pCO2, low HCO3- and normal pH)

Management

Management

Management of Acute Episode

Bed Rest

For carditis and arthritis Prednisolone 2 mg/kg/day for 2 weeks Taper over next 2-4 weeks Start Aspirin 50-75 mg/kg/day

simultaneously to complete total 12 weeks Antistreptococcal therapy 200,000 units/ kg/ day for 10 days

Infective EndocarditisBased on culture and sensitivityEmpirical Therapy : Add aminoglycoside

Secondary ProphylaxisUp to 40 years of age or Lifelong

Benzathine Penicillin 0.6 MU single dose every 15 days

Management Of Malnutrition And Anemia

Health Education – non compliance!!Increase Calorie intake Increase frequencyVitaminsOral Iron – 3-6 mg/kg/day. Continue for 4-

6 months after correctionDietary counseling

Current MedicationsInj. Crystalline Penicillin 1 MU IV 6 hourlyInj. Furosemide 20 mg IV BDInj. Ranitidine 20 mg IV 8 hourlyTab. Paracetamol 500 mg (1/2) SOSInj. Gentamicin 60 mg IV OD (3

mg/kg/day)Inj. Digoxin Tab. Prednisolone 10 mg 6 hourlyNeb. Asthalin 1 respule 4 hourly

Atrial FibrillationRate Control – DigoxinRhythm Control – AmiodaroneAnticoagulants

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