EpistemisCarey Coombs breath
Specialty: Cardiovascular.
Why it occurs
- Acute mitral valvulitis secondary to active rheumatic fever (acute phase)
- Acute myocarditis with ventricular dilation and concomitant functional mitral insufficiency
- Acute mitral infective endocarditis with leaflet edema without complete valve destruction
Initial workup
12-lead electrocardiogram (search for prolongation of the PR interval, diagnostic criterion for rheumatic fever); Qualitative and quantitative serum determination of anti-streptolysin O (ASTO) antibodies, C-reactive protein, erythrocyte sedimentation rate and immunoglobulins; Transthoracic Doppler echocardiogram to evaluate acute thickening and edema of the mitral leaflets, quantify concurrent mitral regurgitation, and assess the presence of pericardial effusion; Blood cultures to rule out bacterial endocarditis.
red flags
Presence of a brief, dull, low-pitched diastolic murmur, heard best at the cardiac apex in the left lateral decubitus position, associated with persistent fever, migratory arthritis of large joints (knees, elbows, ankles), erythema marginatum or subcutaneous nodules, Sydenham's chorea (disordered involuntary movements), severe dyspnea at rest, orthopnea, murmurs new mitral systolic pain or precordial pain with a pericardial profile. It indicates acute rheumatic fever with active cardiac involvement (rheumatic pancarditis), requiring immediate hospitalization for hemodynamic monitoring and anti-inflammatory treatment to prevent irreversible valvular sequelae.
Standard management
- Benzathine benzylpenicillin — benzathine penicillin G indicated of choice for the eradication of group A beta-hemolytic streptococcus; 1.2 million IU intramuscularly as a single dose in adults, or 600,000 IU in children <27 kg
- Acetylsalicylic acid — salicylate indicated first line at high doses for the control of arthritis and the systemic inflammatory response in the absence of severe carditis; 75 to 100 mg/kg/day orally divided into 4 doses for 2 weeks, gradually reducing
- Prednisone — glucocorticoid indicated in cases of moderate to severe carditis with cardiomegaly or heart failure; 1 to 2 mg/kg/day orally, maximum dose of 60 mg/day for 2 to 4 weeks, with gradual decrease protecting with NSAIDs
- Furosemide (loop diuretic if there are clinical signs of decompensated heart failure; 20 to 40 mg per day orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 3
- Treatment options
- 4