Clinically Manifested Myocarditis in Acute Rheumatic Fever\nJosé
The patient was a 23-year-old Caucasian female, born and raised in São Paulo, who came\nto the emergency department complaining of dyspnea at rest (functional class IV of the\nNew York Heart Association), palpitations, nausea, unmeasured fever and increased\nabdominal volume for six days. She reported a personal history of rheumatic fever, with\ntwo mitral and tricuspid valve plastic surgeries, in 1996 and 2011, and subsequent\nmitral valve replacement with a biological prosthesis four months before, in 2012. She\nalso had chronic atrial fibrillation on anticoagulation. She denied other symptoms and\ncomorbidities. She was an irregular user of warfarin, furosemide 40 mg / day,\nspironolactone 50 mg/day, captopril 37.5 mg/day, diltiazem 180 mg/day and sulfadiazine 1\ng/day (due to allergy to penicillin).\nIn February 2012, the patient started to have dyspnea at rest due to symptomatic mitral\nvalve regurgitation and remained hospitalized until heart surgery for mitral valve\nreplacement with a biological prosthesis. At this time she was submitted to preoperative\nmyocardial scintigraphy with gallium-67, which was negative for myocardial inflammatory\nprocess. The surgery had no complications and the postoperative transthoracic\nechocardiography showed left atrium (LA) with 50 mm in diameter, left ventricle (LV) of\n56 x 39 mm, ejection fraction (EF) of 57% and unchanged mitral bioprosthesis structure.\nShe was discharged receiving the medications listed above.\nOn physical examination, the patient was in good general health status, afebrile,\ntachycardic (heart rate = 180 beats per minute), blood pressure of 90 x 60 mmHg,\ntachydyspneic (respiratory rate = 25 breaths per minute), arterial oxygen saturation in\nambient air was 93% and she had intercostal retraction. Apex beat was visible and\npalpable in the fifth intercostal space on the left midclavicular line; presence of\narrhythmic heart sounds with a loud B2 sound, holosystolic mitral regurgitation murmur\nof 2 +/6+ intensity, breath sounds present with fine rales in the lung bases\nbilaterally, hardened liver that was palpable about 7 cm from the right costal margin\nand bilateral and symmetric 2+/ 4+ lower limb edema.\nAt this time, a diagnosis of heart failure due to probable infective endocarditis or\nactive rheumatic fever was attained, considering the presence of fever and clinical\nsigns of pulmonary and systemic congestion, after which three pairs of blood cultures\nwere collected, an echocardiogram was requested and empirical antibiotic therapy with\nintravenous ceftriaxone and oxacillin was initiated.\nThe electrocardiogram initially showed atrial fibrillation with high ventricular\nresponse. Chest X-ray showed interstitial infiltrates in the lower two-thirds of both\nhemithoraxes, as well as cardiomegaly.\nTransesophageal echocardiography showed LA = 56 mm, LV = 71 x 62 mm, EF 20% with diffuse\nhypokinesis of LV and bioprosthetic mitral valve with no signs dysfunction or evidence\nof vegetation. Blood cultures were negative. At this time, we chose to maintain adequate\ncontrol of heart rate and administration of intravenous furosemide. To confirm the\nrheumatic myocarditis, myocardial scintigraphy with gallium-67 was requested, which\nshowed positive for ongoing inflammatory process (). Cardiac magnetic resonance imaging was performed, which showed significant\ndiffuse biventricular dysfunction and presence of myocardial inflammatory process (). Laboratory assessment showed C-reactive\nprotein of 89.3 mg/L, brain natriuretic peptide (BNP) of 2,553 pg/mL, ASLO = 693 IU/mL,\nerythrocyte sedimentation rate of 50 mm and alpha-1-acid glycoprotein = 136 mg/dL.\nDue to the diagnosis of myocarditis, Prednisone 2 mg/kg/day was started. Two hypotheses\nwere then considered: postoperative myocarditis (procedure-related) and acute attack of\nrheumatic fever. The patient showed significant symptom improvement and was discharged\non the 14th day after admission using prednisone 1 mg/kg/day, captopril,\nfurosemide, spironolactone, carvedilol, digoxin and warfarin. In addition, she was\nreferred to immunology for desensitization to penicillin and started to receive a dose\nof benzathine penicillin of 1.200.000 IU every 15 days without complications.