A Spanish speaking man in his late 20s is brought in by ambulance for severe dyspnea. Given the language barrier and his clinical status you are unable to obtain any history. He is tachypnic, had a low pulse ox, and was placed on BiPAP. On exam you hear bibasilar rales and a faint holosystolic murmur.
Clinical Question:
What should be included in the differential?
Answer:
Rheumatic heart disease is the result of valvular damage due to an abnormal immune response following a group A streptococcal infection. It affects 15.6 to 19.6 million people worldwide. Most patients present with dyspnea between the ages 20-50. The most common valvular disease is mitral insufficiency, but it may present with mitral stenosis or aortic regurgitation. The disease is most prevalent in sub-Saharan Africa and among the Indigenous population of Australia but it can be found in many developing countries. People who live in rural areas without access to medical care are those at highest risk for developing rheumatic fever and subsequently rheumatic heart disease.
Bottom Line:
Rheumatic heart disease should be considered in patients who present from an endemic region.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
References
Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet. 2012 Mar 10;379(9819):953-64. doi: 10.1016/S0140-6736(11)61171-9.
(Not really a reference but a short documentary nominated for an Oscar this year.)
