Você está na página 1de 60

CLINICO--PATHOLOGICAL CONFERENCE

DEPARTMENT OF MEDICINE
CASE PRESENTATION:
CHRONIC RHEUMATIC VALVULAR HEART
DISEASE CAUSING MITRAL REGURGITATION,
AORTIC REGURGITATION AND
PULMONARY HYPERTENSION
CASE HISTORY:

Personal Identifying data:

Patient’s name: Muhammad Bilal


Father’s name: Muhammad Shahid
Age: 10 years
Occupation: Student of grade 1
Resident of Pasrur District Sialkot
Reported in Medical OPD of ITH on 28th Feb 2018 with the
following presenting complaints:
PRESENTING COMPLAINTS:

1. Chest pain – for 2 months


2. Fever – for 2 months
HISTORY OF PRESENT ILLNESS:

History of present illness dates back to 2 months when


the patient was alright. One day when he came home
after playing with his friends and complained of
pain in the precordial area of the left side of chest. The pain
was gradual in onset, intermittent, moderate to severe in
intensity, throbbing in nature and radiated to epigastrium
but did not go to left or right arm or shoulders or left side of
the neck and was neither felt in the retrosternal area.
Sometimes the pain would become severe at night and make it
difficult for Bilal to sleep.
The pain used to be aggravated on activities like playing,
running and used to subside on rest.
Along with the pain the patient also started having fever
which was gradual in onset, intermittent in nature,
fever was low grade most of the times but sometimes it used
to be high and accompanied with rigors and chills.
The fever used to come down to normal on medications for
some days but the fever use to recur.
During this period the patient did not complain of any
palpitation, edema feet, paroxysmal nocturnal dyspnea and
he neither complained of vertigo or syncope.
SYSTEMIC INQUIRY:

RESPIRATORY SYSTEM:
There is history of episodic dry cough and
breathlessness on exertion. There is no history of sore throat,
hoarsness, whooping cough or blood in the sputum.

ALIMENTARY SYSTEM :
No history of dysphagia, vomiting, abdominal pain,
hematemesis, diarrhea or constipation.
MUSCULOSKELETAL SYSTEM:
There is history of pain in small joints of hands
about six months back.
Since 2 months Bilal has again developed mild pain in the
ankle joint and small joints of hands.

SKIN:
There was history of small suppurative areas on planter
aspect of the feet which resulted in pain in ankle joint area.
There is no history of rash, subcutaneous nodules on
any part of the body.
CNS:
There is no history of involuntary movements,
Headache, vertigo or numbness of hands and feet.

GENITOURINARY:
No history of pain and burning during
micturition, bleeding in urine or pain in the flanks.

ENDOCRINE SYSTEM:
No history of excessive thirst, excessive appetite,
excessive urination, heat or cold intolerance.
TREATMENT AND ITS EFFECTS:
During this period of 2 months the patient has been going to
different doctors for treatment which used to give
temporary relief.
PAST MEDICAL AND SURGICAL HISTORY:

Patient had episodic dry cough few months ago for


which he took Anti tussives.
He is not a known case of Congenital Heart disease,
Rheumatic Fever, Diabetes Mellitus,
Hypertension, Epilpesy or Hepatitis B and C.

He has never been operated in past for any reason.


FAMILY HISTORY:
There is no known case of Congenital anomaly, DM, HTN,
Hepatitis B and C, epilepsy or venereal diseases.

PERSONAL AND SOCIAL HISTORY:


The patient lives in his own house with his healthy parents
and 5 siblings. The house is properly constructed with
proper ventilation and sewage system. His father is a hawker
by profession and earns about 500 Rs per day . His mother
Is a house wife.
And there is no history of Child abuse or child labour.
BIRTH AND FEEDING HISTORY:
The birth and feeding history is uneventful.

VACCINATION HISTORY:
The child is fully vaccinated against major diseases
according to the EPI schedule,
no additional vaccination was given.

DEVELOPMENTAL MILESTONES AND SCHOOLING HISTORY:


Developmental milestones were normal for his age.
He started going to school at an age of 7 years.
GENERAL PHYSICAL EXAMINATION
A fully conscious,sick looking boy sitting in
bed without any apparent respiratory distress. He has
pale complexion and the patient appears underweight.

His vital signs are:


Pulse 104 /min ,
regular , high volume and
collapsing in character.
Blood Pressure= 160/100mmHg
Temprature: Afebrile at the
Moment.
Respiratory Rate: 40/min
Other findings on GPE starting from the hands are:
Hands were normal in shape and size, no congenital
deformity of fingers was present however grade 3
clubbing was present.
No splinter hemorrhages or Osler’s nodes were present.
No palmer erythema rather the palms were pale.
Accessible lymph nodes were not palpable.
No conjunctival pallor was present.
Neck veins were engorged and pulsatile.
JVP was raised and it was 3.5 cm at angle of 45 °
Thyroid was not enlarged.
No edema feet or legs.
There was no rash on chest,abdomen or extremities.
No subcutaneous nodules were palpable.
Round scar marks were present on the the dorsum of the feet.
HIS ANTHROPOMETRIC PARAMETERS ARE:

Height= 119cm which lies below 5th percentile

Weight= 18.5kg which lies below 5th percentile

Weight for age= 5½years

Height for age= 7½ years


SYSTEMIC EXAMINATION
EXAMINATION OF CARDIOVASCULAR SYSTEM

1. EXAMINATION OF PULSE:
Pulse rate was 104 /min, regular in rhythm, high volume,
collapsing in character,wall of radial artery was not palpable.
Both radial arteries were equal in volume and same in timing.
There was no radiofemoral delay. Both posterior tibial
arteries were equal in volume and same in timing. There was
no systolic bruit over the axillary, subclavian, or
popliteal arteries. There was no Duroziez’s murmur on
auscultation or pistol shot femorals palpable, no capillary
pulsation in nails,lips and tongue. No varicose veins were
visible on calves and thighs.
2. EXAMINATION OF PRECORDIUM:

A.INSPECTION:
On inspection, there was slight bulging of the precordium
which is moving upwards with beating of the heart.
Apex beat was visible on the 6th intercostal space 1cm lateral
to the mid axillary line. No other visible pulsation in left and
right 2nd intercostal space or suprasternal notch. Although a
pulsation is visible in the epigastrium. There was no
engorgement of chest veins , no chest deformity or scar mark.
There was no deformity of the thoracic spine.
B.PALPATION:

On palpation, apex beat was palpable in the 6th intercostal


space 1cm lateral to the mid axillary line and was heaving in
character .
Systolic Thrill was present in the apical area.
Left parasternal heave was present.
2nd heart sound was palpable in the pulmonary area.
Epigastric thud was present. There was no chest tenderness.
Trachea was central in position.
C.AUSCULTATION:

Mitral area:
1st heart sound was not audible,2nd heart sound was
audible, there was Pansystolic murmur radiating to axilla
and was loud on expiration.
Tricuspid area:
2nd heart sound is audible. There was no murmur.
Pulmonary area:
2nd heart sounds was accentuated in Pulmonary area. No
murmur was audible. No spliting of second heart sound
Aortic area 1: Second heart sound was less loud in the aortic
area as compared to the pulmonary area.
Aortic area 2: 2nd heart sound was audible. Early diastolic
murmur was audible in the 2nd aortic area.
Examination of other systems did not reveal any
remarkable physical signs including:
that there was no strawberry tongue and the liver was
also not enlarged or tender.
DIAGNOSIS:
Based on History and Clinical Examination in my opinion
the diagnosis of this patient is Chronic Rheumatic Valvular
Heart Disease causing Mitral Regurgitation, Aortic
Regurgitation and Pulmonary Hypertension.
DIFFERENTIAL
DIAGNOSIS
I. RHEUMATIC HEART DISEASE:
⚫ Fever , Anorexia , lethargy

⚫ Joint pain 2-3 weeks after an episode

of streptococcal infection
⚫ Pancarditis: Palpitations, Chest pain, Cardiac enlargement,

soft systolic murmur, aortic regurgitation, mitral stenosis and


mitral regurgitation.
Pericardial friction rub, precordial tenderness.
⚫ Arhtritis: migratory polyarthritis

⚫ Skin lesions: Erythema marginatum and

subcutaneous nodules.
⚫ Sydenham’s Chorea (more common in females)
II. CONGENITAL HEART DISEASES:
Majority of these cases are diagnosed in early childhood.
Features include:
⚫ Central cyanosis

⚫ Pulmonary Hypertension

⚫ Clubbing of fingers

⚫ Paradoxical embolism

⚫ Reduced growth

⚫ Syncope

⚫ No history of painful swelling of joints.


III- SUBACUTE BACTERIAL ENDOCARDITIS:
⚫ Mostly occur on the site of pre existing endocardial
damage.
⚫ It presents with high grade fever, night sweats,

weight loss and heart failure.


⚫ Other feathers include purpura and petechial

hemorrhages in skin,mucosa of pharynx


and conjunctiva.
⚫ Roth spots in retina

⚫ Splinter hemorrhages under nails

⚫ Osler nodes : painful tender swelling

at finger tips
⚫ Janeway lesions

⚫ Digital clubbing

⚫ Hepatosplenomegaly

⚫ Varying murmurs

⚫ Hematuria due to glomerulonephritis


IV - STILL’S DISEASE:

⚫ Fever
⚫ Arhtritis

⚫ Rash

⚫ Serositis

⚫ Hepatosplenomegaly

⚫ Raised CRP & ESR

⚫ Valvular involvement
V. FELTY’S SYNDROME

⚫ Polyarhtritis
⚫ Neutropenia

⚫ Valvular involvement

⚫ Splenomegaly

⚫ Lymphadenopathy

⚫ Skin pigmentation

⚫ Leg ulcer ( vasculitis )

⚫ Recurrent infections

⚫ Nodules
VI- KAWASAKI DISEASE:

⚫ Fever for more than 5 days


⚫ Chest pain due to involvement of coronary arteries

⚫ Red eyes

⚫ Red, dry, cracked lips and inflamed tongue

(strawberry tongue)
⚫ Swollen lymph nodes

⚫ Widespread rash

⚫ Swelling and redness in hands and feet

⚫ Peeling of skin around fingernails and toenails


VII- MYOCARDITIS:

Pain is felt retrosternally to right or left shoulder and


varies in intensity with movement and phase of
respiration.
There is history of prodromal viral infection. Patient may
present with dilated cardiomyopathy leading to
mitral or tricuspid regurgitation.
VIII – MITRAL VALVE PROLAPSE :

It is caused by congenital anomalies or degenarative


Myxomatous changes and is a feature of connective
tissue disorders such as Marfan syndrome.
Features of mitral regurgitation are present.
LITERATURE
REVIEW
RHEUMATIC HEART DISEASE:
Rheumatic fever is an acute
immunologically mediated multisystem
Inflammatory disease that occurs after group A
Streptococcal infection (usually pharyngitis, but also
rarely with infections at other sites such as skin)
Rheumatic Heart Disease is cardiac manifestation of
rheumatic fever. It is inflammation of all parts of heart but
valvular inflammation and scarring produces the most
important clinical features.
CHRONIC RHEUMATIC HEART DISEASE:
Chronic Rheumatic Heart Disease is characterized by
organization of acute inflammation and subsequent scarring.
Aschoff bodies are replaced by fibrous scar.
Most characteristically valve cusps and leaflets become
predominately thickened and retracted.
Classically the mitral valves exhibit leaflet thickening,
commisural fusion,
shortening, thickening and fusion of chordae tendineae.
PATHOPHYSIOLOGY:

Due to fibrotic thickenings on mitral valve, regurgitation


into left atrium produces left atrial dilatation.

Left atrial pressure increase slightly if the regurgitation is


long standing because regurgitant flow is accommodated by
large left atrium. But when the regurgitation is acute,
normal compliance of left atrium does not allow much
dilatationand left atrial pressure rises which in turn increases
pulmonary venous pressure resulting in pulmonary
hypertension.
Atrial fibrillation is due to atrial dilatation.
In aortic regurgitation, blood is regurgitated from aorta
through the aortic valve into left ventricle. If net cardiac
output is to be maintained, the total volume of the blood
pumped into the aorta must increase and consequently the
left ventricular size must enlarge.

Due to aortic regurgitation and mitral regurgitation,


Left ventricular enlargement also causes shifting of apex beat.

Due to mitral regurgitation Pansystolic murmur is


heard over the mitral area that radiates to axilla.
DUCKET JONES CRITERIA:

A- Major:
1. Carditis 2. Polyarhritis
3. Chorea 4. Erythema marginatum
5. Subcutaneous nodules

B- MINOR:
1. Fever 2. Arthralgia
3. Previous rheumatic fever
4. Raised ESR/C reactive proteins
5. Leukocytosis
6. Prolonged PR interval on ECG

C- REQUIRED CRITERIA:
Supporting evidence of preceding streptococcal
infection:recent scarlet fever, raised ASO or other
streptococcal antibody titre,positive throat culture
Diagnostic criteria:
⚫ 2 major criteria and 1 minor criteria

⚫ 1 major criteria and 2 minor criteria


COMPLICATIONS:

1. Mitral stenosis and regurgitation


Hyperkinetic left ventricle (prominent apical impulse)
Pansystolic murmur
Soft S1, Apical S3

2. Aortic regurgitation
Collapsing pulse
Increased pulse pressure
Early diastolic, Systolic murmur
Austin Flint murmur
Bounding peripheral pulses
Quincke’s sign
Duroziez’s sign
de Musset’s sign: head nodding with pulse
3. Pulmonary hypertension
Elevated JVP
Loud P2

4. Spontaneous Bacterial Endocarditis

5. Congestive cardiac failure


Oedema
Ascites

6. Arrhythmias
7. Severe Anemia
8. Pericardial effusion
9. Thromboembolism
Stroke
Ischaemic limb
INVESTIGATIONS
NON SPECIFIC: (evidence of systemic illness)

⚫ CBC: Raised ESR


⚫ raised CRP
SPECIFIC:
1. Throat swab cultures:
group A beta hemolytic streptococci
2. Anti streptolysin O antibodies(ASO titers)
3. Anti DNAse B
4. Chest X ray
RHD: cardiomegaly
MR: enlarged Left atrium and Left ventricle
AR: Aortic dilation and dilatation of left ventricle.
ECG:
Rate is 100 /min.
Rhythm is regular.
Axis is normal.
ECG showed positive finding of Left ventricular enlargement.
V1:
Biphasic P wave: may be normal
Or due to left atrial enlargement if prolonged descending limb
deep S wave and asymmetrical T wave.
MR: Dilated LA, LV
Prolapse of posterior leaflet
Doppler shows regurgitation
Into left atrium

AR: Dilated LV
Doppler detects reflex

Pulmonary HTN:
PAP = 4×(TRV) 2 + RAP
Figure shows elevated Tricuspid
Regurgitation velocity consistent
With pulmonary hypertension .
TREATMENT
TREATMENT OF OUR PATIENT:

1. Tab Inderal 10mg BD


2. Tab Spiromide 20mg OD
3. Tab Capoten 12.5mg TDS
RHEUMATIC FEVER:

ACUTE ATTACK;

A. Bed rest and supportive therapy


B. Anti infective therapy: long acting benzathine penicilline
is the drug of choice. Single IM injection of
0.6-1.2 million units is given.
Alternatively, give Penicilline V
125-250mg orally four times a day for 10 days.
C. Anti inflammatory agents:
Aspirin 30-60mg/kg/d in 4 divided doses for 2-6 weeks.
Predinsolone 1-2mg/kg/d until the ESR is normal.
MITRAL REGURGITATION:

A) MEDICAL:
⚫ Diuretics: Furosemide

⚫ Vasodilators e.g ACE Inhibitors (Captopril)

⚫ Digoxin if atrial fibrillation is present

⚫ Antibiotic prophylaxis for subacute bacterial endocarditis

B) SURGERY:
⚫ EF is less than 60%

⚫ End systolic dimension greater

than 4.5cm
⚫ If pulmonary hypertension

or atrial fibrillation
AORTIC REGURGITATION:

No proven medical therapy except:


Vasodilators in acute regurgitations,
Beta blockers in Marfan patients and
ACE inhibitors in patients with left ventricular dysfunction.

SURGERY:
⚫ Acute severe aortic regurgitation e.g endocarditis

⚫ Symptomatic patients(dyspnea, NYHA class II-IV, angina)

with chronic severe aortic regurgitation


⚫ In asymptomatic patients with an LVEF of ≤50%

⚫ In asymptomatic patients with an LVEF of >50% but with a

dilated left ventricle


⚫ In those undergoing CABG or surgery of the ascending aorta

or other cardiac valve


PULMONARY HYPERTENSION:

GENERAL:
Diuretic therapy for right heart failure
Long term oxygen for hypoxemia
Avoid excessive physical activity
Pneumococcal and influenza vaccination.

SPECIFIC:
Calcium channel blockers
Prostacyclin
Phosphodiesterase type 5 inhibitor
Endothelin antagonist(bosentan)
Atrial septostomy
ANY QUESTION?
60 / 58

Você também pode gostar