Clinical Case 2: Echoes of a Sore Throat

MBBS
1

15-year-old girl
Chief Complaint: Breathlessness and palpitations for 2 weeks

History: Fatigue, orthopnea, and leg swelling
No fever or chest pain
Had untreated sore throat ~6 months ago
Irregular heartbeat noticed recently

On examination:
Irregularly irregular pulse
Raised JVP

Auscultation:
Loud S1
Opening snap
Mid-diastolic murmur at apex (best heard in LLDP)

Investigations:

ECG: Atrial fibrillation
Echo: Mitral stenosis (MVA 1.2 cm²), LA enlargement, mild MR

What is your probable diagnosis?
Which criteria would confirm that?
What is the line of management?

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2

Revised Jones Criteria for Rheumatic Fever, particularly for a retrospective diagnosis
Probable diagnosis: Rheumatic Mitral Stenosis with Atrial Fibrillation
Line of Management

  • B-blockers
  • Warfarin
  • Diuretics
3

Case of rheumatic heart disease .
Jones criteria can be used for confirmation .
Management involves antibiotics , diuretics to reduce volume overload , anticoagulants & beta blockers

4

Pretty text book style presentation of the case.
The patient also needs to be put on Penicillin prophylaxis.

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5

The probable diagnosis is mitral stenosis with atrial fibrillation.

Diagnostic criteria: Clinical findings (breathlessness, palpitations, irregular pulse, murmur), ECG (atrial fibrillation), and echocardiogram (mitral stenosis).

Management: Rate control, anticoagulation, diuretics, valve intervention, and treatment of the underlying cause.

Mitral stenosis with atrial fibrillation.

6

Rheumatic Heart Disease complicated with Atrial fibrillation

Symptoms: Breathlessness, fatigue, orthopnea, leg swelling, and palpitations.

Major Criteria:

  • Carditis and sub-clinical carditis
  • Polyarthritis and Oligoarthritis
  • Erythema marginatum
  • chorea

Minor Criteria:

  • Arthralgia and Fever
  • high inflammatory markers like ESR/CRP
  • Prolonged PR interval

management:-

  • Beta blockers for AF
  • Warfarin for thromboembolism prevention
  • Diuretics
  • Penicillin prophylaxis
  • regular monitoring and follow-up
7

This is a classic case of rheumatic heart disease with mitral valve involvement.

Jones criteria is used to confirm this.
Major Criteria:

  • Carditis (clinical/echo evidence)
  • Polyarthritis
  • Sydenham’s chorea
  • Erythema marginatum
  • Subcutaneous nodules

Minor Criteria:

  • Arthralgia
  • Fever
  • Elevated ESR/CRP
  • Prolonged PR interval

Plus evidence of recent streptococcal infection:

  • Positive throat culture or Rapid Antigen Test
  • Elevated ASO titers

Management includes:

  • medical management: beta blockers, anticoagulants, diuretics
  • secondary prophylaxis: benzathine penicillin G
  • definitive management: percutaneous balloon mitral valvotomy