Severe mitral insufficiency from rheumatic disease: a case report

Abstract Acute rheumatic fever continues to be a major health problem in many parts of thw world. It’s more common in low–income or developing parts of the world. Antibiotics for bacterial infections may not be available in these areas. In developed countries, cardiac involvement is quite rare. Although traditionally considered to be a disease associated with poverty, rheumatic fever continues to persist even among the middle–class population in developed countries. Children and teenagers with intreated strep infections are the most likely to get rheumatic fever. Signs of heart damage can develop years after the infection. Rheumatic heart disease is the result of valvular damage caused by an abnormal immune response to Streptococcus pyogenes infection. After multiple episodes of rheumatic fever, progressive fibrosis of the heart valves can occur: mitral regurgitation is the most common valvular lesion. We report the case of a 13–year–old, Italian, middle–class girl with rheumatic mitral valve involvement. A 13–years–old comes to the clinic for onset of worsening dyspnea ad easy fatigability. History turns out to be negative for cardiovascular disease and history of recent infections. Echocardiographic examination showed a dilated left ventricle (VTD 148ml, 98 m/mq) with preserved chinese. Severe dilatation of the left atrium with atrio–aortic ratio 2.3 and atrial volume 91 ml/mq. The mitral valve presented a myxomatous, thickened leaflets, predominantly the posterior which appeared retracted and hypomobile with thickening of the subvalvular apparatus with coaptation deficit along the entire coaptation rhyme realizing severe degree insufficiency (CV 7mm, ERO 0.8 cm2, CO 39 l/min). A small cleft at the level of A1, main lesion jet (A1–P3–P2) was also visible. The Echocardiographic appearance suggested outcomes from rheumatic disease so antistreptolysin titer and anti–DNase B antibodies were assayed with high levels found. Penicillin prophylaxis was therefore initiated. For the continuation of the therapeutic course, the case was discussed collegially and a valve replacement rather tan repair was advocated because the valvular and subvalvular apparatus were far too damaged.