SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Acute rheumatic fever and subsequently rheumatic heart disease (RHD) has been significantly reduced in developed countries during the 20th century. Although uncommon, RHD remains present in undeveloped countries and immigrant populations. Knowledge of common presentations of this once ubiquitous disease thus remains clinically useful. CASE PRESENTATION: A 32-year-old African-American male presented for 7 days of progressive dyspnea, diaphoresis with exertion, and pleuritic chest pain. Prior evaluation was concerning for community acquired pneumonia treated with azithromycin and doxycycline without improvement. On admission, the patient reported subjective fever without recent travel or known sick contacts. He is a naturalized citizen who lived in Sierra Leone until age 16 and currently works with a predominantly immigrant population as a pig butcher. The patient’s past medical history was grossly unremarkable. Physical exam was significant for right lung crackles on inspiration and grade 3 holosystolic murmur with normal respiratory rate and oxygen saturation on room air. Chest x-ray at the time of presentation was notable for progressive worsening of a right upper lobe (RUL) infiltrate. Patient was started on Levaquin and admitted to the hospital for pneumonia versus tuberculosis. CT of the chest was completed for concern of non-resolving pulmonary symptoms and noted for RUL infiltrate and left ventricular hypertrophy (LVH). ECG also suggested LVH and transthoracic echocardiogram showed a dilated cardiomyopathy with severely reduced ejection fraction (20-25%), severe mitral regurgitation and severe aortic regurgitation. This presentation was highly suggestive of RHD with pulmonary infiltrate secondary to retrograde flow secondary to significant valvular disease, confirmed with transesophageal echocardiogram. The patient was transferred to a tertiary surgical center on hospital day 6 for valve replacement. DISCUSSION: This case represents classic findings of RHD with secondary mitral valve regurgitation and RUL pulmonary infiltrates. Per the REMEDY trial, the patient’s presentation of chronic rheumatic valvular disease leading to acute heart failure is the most common presentation of RHD. This exemplifies the need to suspect this disease in patients with the appropriate clinical history and in patients from countries where rheumatic fever and RHD are still common. CONCLUSIONS: RHD continues to be clinically relevant despite significant decrease in incidence among the US population. Presentation with signs of pulmonary infiltrate due to retrograde flow via the pulmonary veins is more than a theoretic presentation and supports maintenance of a broad differential especially in patients tied to the developing world. Reference #1: Essop MR, Nkomo VT. Rheumatic and nonrheumatic valvular heart disease: epidemiology, management, and prevention in Africa. Circ. 2005;112(23),3584-3591. Reference #2: Watkins DA., Johnson CO, Colquhoun SM, et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. N Engl J Med. 2017;377:713-722. Reference #3: Zuhlke L, Engel ME, Karthikeyan G, et al. Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study). Eur Heart J. 2015; 36(18),1115-1122. DISCLOSURES: no disclosure on file for Travis Bentz; No relevant relationships by Nathan Boyer, source=Web Response No relevant relationships by Aaron Farmer, source=Web Response No relevant relationships by Samone Franzese, source=Web Response No relevant relationships by John Lammie, source=Web Response No relevant relationships by Michael Phillips, source=Web Response
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