Clinical Scenario:
A 12-year-old boy presents with palpitations and shortness of breath on exertion. Six months ago, he had an episode of fever associated with joint pains. On examination, his pulse rate is 120/min, respiratory rate is 28/min, and temperature is 98.8°F. Precordial bulging is noted. Both S1 and S2 are audible, and a pansystolic murmur is heard best at the apex.
What is the most likely diagnosis?
A. Ventricular septal defect (VSD)
B. Mitral valve prolapse
C. Rheumatic heart disease
D. Infective endocarditis
E. Innocent murmur
Correct answer & Explanation:
Answer: C. Rheumatic heart disease
Explanation: Rheumatic heart disease
The history of fever associated with joint pains six months earlier suggests a previous episode of acute rheumatic fever. Rheumatic fever can cause inflammatory damage to the heart valves, with the mitral valve being most commonly affected.
A pansystolic murmur best heard at the apex is characteristic of mitral regurgitation. Chronic rheumatic mitral regurgitation can lead to cardiac enlargement and symptoms such as palpitations, exertional shortness of breath, and reduced exercise tolerance. The precordial bulging in this child further supports cardiomegaly due to chronic cardiac disease.
Why not the other options?
- A. Ventricular septal defect (VSD): A VSD produces a pansystolic murmur, but it is typically best heard along the lower left sternal border. Significant VSD usually presents earlier in childhood, whereas this child’s history strongly suggests acquired rheumatic valvular disease.
- B. Mitral valve prolapse: Classically produces a mid-systolic click followed by a late systolic murmur, rather than the typical pansystolic murmur of mitral regurgitation in this setting.
- D. Infective endocarditis: Usually presents with persistent fever and other systemic features of infection. The child is afebrile and has a history suggestive of previous rheumatic fever.
- E. Innocent murmur: Innocent murmurs are not associated with structural heart disease or symptoms such as exertional dyspnea and cardiomegaly.
High-Yield Exam Point
Previous rheumatic fever + apical pansystolic murmur = think of rheumatic mitral regurgitation. Rheumatic heart disease may become clinically apparent months or years after the initial episode of acute rheumatic fever.
Reference
World Health Organization. WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease. Geneva: World Health Organization; 2024. ISBN: 978-92-4-010007-7.
Test your self by solving another MCQ on Rheumatic Heart Disease.
