|Year : 2015 | Volume
| Issue : 1 | Page : 42-44
Infective endocarditis in a 12-year-old with subclinical rheumatic carditis
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
|Date of Web Publication||5-Jan-2015|
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Infective endocarditis is rare in children. It occurs mostly in children with an underlining heart defect. The clinical feature could be variable and most of the immunological features seen in adults are often absent in children. Rheumatic fever is a huge disease burden in developing countries and rheumatic valvular heart disease remains a risk factor for infective endocarditis. Therefore the case of a 12-year-old girl who hitherto had no complaint suggestive of underlining cardiac defect was diagnosed with infective endocarditis and subclinical rheumatic carditis which was confirmed by echocardiography; she responded to antibiotics and aspirin treatment and was discharged after 6-weeks on admission; she is being currently followed-up in the cardiac clinic.
Keywords: Infective endocarditis, rheumatic fever, rheumatic heart disease
|How to cite this article:|
Aliyu I. Infective endocarditis in a 12-year-old with subclinical rheumatic carditis. Nig J Cardiol 2015;12:42-4
| Introduction|| |
Infective endocarditis occurs less commonly in children than in adults, accounting for 1 in every 1300 to 2000 pediatric admissions annually. ,, Though the frequency of infective endocarditis among children appears to have increased in recent years, ,, the diagnosis in children is often difficult because its symptoms are often non-specific.  It is commonest in patients with underlining heart defect and may also affect native heart valves as in drug addicts with septicemia. The clinical features in children are variable and may include fever, weight loss, heart failure or complications of septic embolization;  however, most of the immunological features seen in adults are often absent. Though the revised Duke's criteria for diagnosing infective endocarditis is applicable to children, a high index of suspicion should be entertained when evaluating children with prolonged febrile illness, especially in those with background heart disease. Therefore, the case of a 12-year-old girl with prolonged fever diagnosed with concurrent infective endocarditis and acute rheumatic fever is reported.
| Case report|| |
A 12-year-old girl presented to the emergency pediatric unit with complaints of continuous fever, headache and dizziness of four weeks duration. She had associated difficulty in breathing and palpitations, but no cough, cyanosis of the mucous membranes, or body swelling. There was also history of poor appetite, malaise and joint pains involving both knees and ankles. There was no prior history of trauma, body rash, or past history of sore throat. She had been seen and admitted twice in a general hospital on account of this illness with no significant improvement. She had no adverse previous medical history, although had pustules which had healed about three months prior to onset of this illness. She had not been able to attend school since onset of illness. She was also yet to achieve menarche. On examination, she was ill-looking, febrile with axillary temperature of 39˚C, pale, not jaundiced, not dehydrated, and no petechiae. She had left axillary lymph node enlargement measuring 2 × 3 cm. There was no peripheral edema.
She was tachycardic with a pulse rate of 120 beats per minutes which was regular but bounding. The blood pressure was 120/50 mmHg right arm sitting; jugular venous pressure was not raised. The precordium was hyperactive with the apex beat displaced to the 6 th LICS lateral to the mid-clavicular line. The heart sounds were 1 st and 2 nd with a pansystolic murmur, grade 3/6 maximal at the apex radiating to the axilla, and a diastolic murmur at the upper right sternal margin. She had a respiratory rate of 24 cycles/min; oxygen saturation was 100% in room air. The breath sounds were vesicular with no adventitious sounds. Abdominal examination was essentially normal. Musculoskeletal system examination revealed tenderness at both knees and ankles but no swelling. She was fully conscious with no focal neurological deficit. An initial diagnosis of rheumatic fever with mixed aortic and mitral valvular regurgitation was made.
Investigations done include full blood count: The low packed cell volume of 20.9%; elevated white cell count of 34.9 × 10 9 /l (granulocytes 80.4%, lymphocytes 15.4%, others 4.2%), platelet count of 388 × 10 9 /l, elevated erythrocyte sedimentation rate of 132 mm/hr, and elevated ASO titer of 350 Todd's unit. Peripheral blood film showed predominantly microcytic hypochromic red cells with marked rolex formation; neutrophilic leukocytosis with left shift and toxic granulations. Chest radiograph showed cardiomegaly [Figure 1]. The electrocardiogram showed sinus tachycardia. 2-D transthoracic echocardiography revealed left ventricular dilatation, thickened mitral valves with poor mobility of the posterior leaflet with thickened chordae tendonae; also mitral and aortic valvular regurgitation was seen in the Doppler studies. An echo-dense freely independently oscillating mass measuring 6 × 8 mm was also seen arising from the right cusps of the aortic valve with aortic regurgitation [Figure 2]. Based on the echocardiographic finding, a definitive diagnosis of infective endocarditis with acute rheumatic fever was made. She was commenced on intravenous ceftriaxone, genticin, and aspirin. Her blood culture revealed Staphylococcus aureus as the isolated organism, sensitive to ciprofloxacin, gentamycin, and ceftriaxone. She improved significantly and was subsequently discharged home after six weeks on admission.
|Figure 1: Echocardiogram (left parasternal long axis view) showed thickened aortic valves with vegetation on the right aortic leaflet and thickened mitral valve leaflets|
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|Figure 2: Chest X-ray showing cardiomegaly and prominent pulmonary vascular markings|
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| Discussion|| |
Our patient was apparently healthy prior to onset of the illness and never had complaint of sore throat but had skin pyoderma, which healed three months to the onset of the illness. Though reports of acute rheumatic fever had been documented in patient with absent history of sore throat which may explain the case in our patient  though the exact mechanism is not clear but some authors attribute it to the role played by other strains of streptococci such as group C and G in the pathogenesis. Similarly, there are concerns of streptococcal skin pyoderma being involved in the pathogenesis of acute rheumatic fever; Mac-Donald et al. reported a point prevalence of 19% of sore throat infection compared to 40% of pyoderma in Australian Aboriginal community hyperendemic for acute rheumatic fever;  this contrasts with the held dogma that acute rheumatic fever follows group A beta-hemolytic Streptococci throat infections only. Our patient possibly had an initial subclinical rheumatic carditis, which was not detected resulting in mitral and aortic valves damages as seen on echocardiogram. Therefore, strict adherence to the revised Jones criteria may result in under-diagnosis of rheumatic fever in febrile children, especially in areas endemic for rheumatic fever. 
Infective endocarditis mostly affect individuals with underlining structural heart defect as reported in about 66% of Nigerian children and staphylococci aureus was the commonest organism isolated  as was also observed in our patient. This patient as in most reports in children lacked the immunologic features of infective endocarditis often seen in adults.
The unique experience in this case was that the diagnosis of rheumatic fever and infective endocarditis were all made simultaneously because she met the criteria for these diagnoses.
This buttresses the need for high index of suspicion of the possibility of rheumatic fever, especially in any febrile 5-15 year-old child in an endemic environment like Nigeria even with the absence of history of sore throat so far the patient meets the criteria for diagnosing rheumatic fever.
Furthermore, the importance of echocardiography in managing this category of patients cannot be overemphasized, and had the right diagnosis been made earlier and prophylaxis for rheumatic fever and infective endocarditis started, it might have averted a severe disease.
| Conclusion|| |
Concomitant infective endocarditis and rheumatic fever is a rarity; therefore, a high index of suspicion of this possible co-existence should be entertained in febrile children, especially those in the 5-15 -year age-group; hence, the usefulness of echocardiography cannot be overemphasized especially in those with heart murmur.
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[Figure 1], [Figure 2]