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Title

ATYPICAL MITRAL INJURY IN RHEUMATIC CARDIAC DISEASE: A CASE REPORT

Background

Rheumatic heart disease is a chronic valvulopathy due to rheumatic fever, a systemic inflammatory disease resulting from pharyngotonsillitis caused by group A β-hemolytic Streptococcus. Valvulitis, especially mitral and aortic, is the most relevant clinical manifestation of the condition, the main cause of morbidity and mortality due to rheumatic fever. We present the case of a patient aged 12 years, with cardiac involvement, presenting mitral regurgitation in two centers: a central one and another due to perforation due to valvular perforation due to rheumatic fever.

Case report

Male, 12 years old, presented at the rheumatologic clinic with complaints of pain in the joints, left knee, coxofemorals, vertebral columns. There were signs of inflammation in all of them except column. He had involuntary movements of the hands and face. Tonsils bilaterally hypertrophied with large pultáceus points. Echocardiogram showed mitral valve with slightly thickened anterior leaflet, showing small perforation of 1 mm; mitral insufficiency moderate degree with 2 jets: one central and another as a result of perforation and left atrium with slight increase. Given the diagnosis of rheumatic fever with arthritis, carditis and chorea, in addition to tonsillitis. It was prescribed prednisolone 40 mg, bezentacil 120.000.000 U, volproic acid 250 mg. 20 days after the first consultation with rheumatologist, patient was already without choreic movements, without fever and without pain, besides good disposition. The breath was no longer auscultated. Exams showed as alteration: leukocytes 1900 / uL, VHS of 25 mm, ASLO of 80, EBV presence of IgG and monoteste negative. Two months later, the patient had a favorable evolution with remission of rheumatic fever, interrupted the prednisolone and maintained the bezentacil every 21 days, and requested echocardiogram and blood tests. Two months later he returned with echocardiogram with mitral valve thickening and 1 mm perforation, other normal laboratory tests. 6 months after a new echocardiogram showed closure of the mitral valve perforation. Two months later, he repeated another echocardiogram that showed remission of the findings of the first echo with normal valve and patient was totally asymptomatic.

Conclusion

Valve involvement is very common in untreated rheumatic fever, but its most common presentations are stenosis and mitral valve insufficiency, and there are few reports in the literature of valve perforation. Therefore, the rheumatologist should be aware of the more complicated cases of heart valve involvement in rheumatic fever.