Rheumatic Heart Disease in a 14-Year-Old Boy with Aortic and Mitral Valve Involvement: A Case Report

Rheumatic Heart Disease in a 14-Year-Old Boy with Aortic and Mitral Valve Involvement: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rheumatic Heart Disease in a 14-Year-Old Boy with Aortic and Mitral Valve Involvement: A Case Report Babatunde Fatoke, Atinuke Richards, Olayinka Hassan, Misbau Adekunle, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5431302/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Rheumatic heart disease (RHD) continues to pose significant health challenges, especially in adolescents, where it can lead to long-lasting complications. This case report discusses a teenage patient diagnosed with RHD following recurrent streptococcal infections, highlighting the clinical presentation, management, and outcomes. Case Presentation: The patient presented with chest pain, fatigue, and dyspnoea, prompting a comprehensive evaluation. An echocardiographic assessment revealed mitral valve regurgitation and left atrial enlargement. The management strategy focused on preventing further streptococcal infections through benzathine penicillin G as a key component of secondary prophylaxis. Inflammatory symptoms were addressed using high-dose aspirin and corticosteroids, while diuretics were utilized to alleviate heart failure symptoms. Additionally, anticoagulation therapy was initiated due to the patient’s atrial fibrillation, mitigating the risk of thromboembolic events. Regular follow-up appointments and echocardiographic evaluations were instituted to monitor cardiac function and the progression of valvular disease. The patient demonstrated significant improvement in symptoms and functional capacity, now classified as NYHA Class II heart failure. Conclusion This case underscores the necessity for early diagnosis, appropriate management, and long-term follow-up in adolescents with RHD to prevent complications and optimize patient outcomes. Moreover, it emphasizes the need for awareness and preventive strategies against rheumatic fever, a preventable cause of cardiovascular morbidity. Insights from this case contribute to understanding RHD in a paediatric context, advocating for a multifaceted care approach that includes patient education, dietary modifications, and lifestyle adjustments to enhance cardiovascular health. Rheumatic heart disease adolescents clinical presentation management prevention echocardiography Case report Figures Figure 1 Figure 2 Background Rheumatic heart disease (RHD) remains a significant health challenge globally, particularly in low- and middle-income countries such as Nigeria, where socioeconomic and environmental factors contribute to its high prevalence [ 1 – 4 ]. RHD is a chronic condition resulting from an autoimmune response to GAS infections, primarily affecting the heart valves and leading to severe complications, including heart failure, infective endocarditis, and stroke [ 5 – 6 ]. Despite being preventable, RHD continues to impact children and adolescents disproportionately, highlighting the need for early detection and timely intervention [ 7 – 9 ]. RHD is the most serious long-term consequence of acute rheumatic fever (ARF), a sequela of untreated or poorly treated Group A Streptococcal pharyngitis [ 1 – 3 ]. The inflammatory process triggered by ARF primarily affects the heart valves, leading to progressive valve dysfunction, with mitral regurgitation and aortic stenosis being the most involved lesions [ 2 ]. Globally, the World Health Organization (WHO) estimates that over 39 million individuals are affected by RHD, with the majority residing in low- and middle-income countries where access to healthcare and early treatment is limited [ 11 – 13 ]. In Nigeria, RHD poses a significant public health burden, particularly among children and adolescents. Poverty, overcrowded living conditions, and inadequate access to healthcare contribute to the high incidence of RHD in the country [ 1 – 3 , 11 ]. Studies have shown that RHD remains one of the leading causes of heart failure among young populations in sub-Saharan Africa, underscoring the need for improved public health strategies to address this preventable condition [ 12 , 13 ]. The patient described in this case report presented with typical symptoms of advanced RHD, including cough, orthopnoea, easy fatigability, and bilateral leg oedema, indicative of heart failure. Additionally, the presence of arthritis and an elevated erythrocyte sedimentation rate (ESR) further pointed to the underlying inflammatory nature of the disease. Cardiomegaly, aortic stenosis, and mitral regurgitation were identified through diagnostic imaging, reinforcing the severity of valve dysfunction in this adolescent patient. Complications of RHD, particularly in adolescents, can be debilitating and include progressive heart failure, infective endocarditis, and thromboembolic events, such as strokes. Research has shown that pulmonary hypertension, secondary to valvular heart disease, occurs in over 70% of patients at the time of diagnosis [ 13 ]. These complications underscore the critical importance of early detection, as regular screening with echocardiography may help identify subclinical cases before significant damage occurs. This case report presents a 14-year-old male patient diagnosed with rheumatic heart disease, exhibiting advanced cardiovascular and systemic manifestations. The report aims to highlight the clinical presentation, risk factors, and potential complications of RHD in Nigerian adolescents, emphasizing the importance of early diagnosis and management in preventing debilitating outcomes. It also highlights the profound impact of RHD on young populations in Nigeria, where socioeconomic factors, limited healthcare access, and cultural beliefs contribute to delayed diagnosis and treatment. Effective strategies for addressing RHD must involve improved healthcare accessibility, routine echocardiographic screening, and public health interventions to educate, prevent, as well as inform the early treatment of GAS infections. Case Presentation The patient, a 14-year-old male, presented with a progressively worsening condition characterized by increasing fatigue that had persisted for several months. His fatigue was disproportionate to the minimal physical exertion he undertook, such as walking short distances or climbing stairs. This sudden and inexplicable drop in his physical stamina alarmed his parents, who observed that their previously active son could no longer participate in sports or engage in other physical activities that had once been part of his routine. He expressed frustration over his inability to carry out even basic activities without feeling exhausted, a drastic change from his earlier level of functioning. One of the patient's most troubling symptoms was dyspnoea, or difficulty in breathing, which occurred particularly during physical exertion and when lying flat. This shortness of breath restricted his daily activities, including simple tasks like walking or ascending stairs, and suggested underlying cardiac issues. His symptoms were consistent with the early stages of heart failure, a condition that may have been precipitated by valve dysfunction often associated with rheumatic heart disease. The patient’s dyspnoea became particularly severe in the supine position, hinting at the possibility of pulmonary congestion due to heart dysfunction. In addition to the breathlessness, the patient frequently experienced palpitations, characterized by an irregular and sometimes rapid heartbeat. These episodes were sporadic but had increased in both frequency and intensity over time. The palpitations occasionally caused significant discomfort, and their pattern suggested the possibility of underlying arrhythmias. This was further complicated by the potential enlargement of the atrium, a common consequence of valvular disease in rheumatic heart disease. The presence of palpitations, in this context, heightened concerns about atrial fibrillation or other cardiac rhythm disturbances, which could further compromise the patient's cardiac function and increase the risk of stroke. During the physical examination, peripheral oedema, specifically swelling in the lower extremities, was noted, particularly around the ankles and calves. This swelling is a classic sign of heart failure, indicating the heart's reduced ability to efficiently pump blood throughout the body. The resultant fluid retention in the legs is typical of congestive heart failure, where the impaired heart allows for the accumulation of fluid in dependent regions of the body. The presence of oedema in this young patient was alarming, as it provided further evidence of advanced heart failure, likely due to long-standing rheumatic heart disease. Upon auscultation, the examining physician detected a heart murmur. A pan systolic murmur, which was loudest at the cardiac apex and radiated towards the axilla, was heard. This was indicative of mitral regurgitation, a condition where the mitral valve does not close properly, allowing blood to flow backward into the left atrium from the left ventricle during systole. Additionally, a diastolic murmur was identified, suggestive of aortic regurgitation, where the aortic valve allows blood to flow backward from the aorta into the left ventricle during diastole. These findings were consistent with severe rheumatic heart disease, which often results in valvular deformities and dysfunction over time, severely impacting cardiac output and efficiency. The findings from a subsequent echocardiogram confirmed the clinical suspicions. Moderate to severe mitral regurgitation was observed, where the mitral valve, likely scarred and thickened from past episodes of rheumatic fever, failed to close adequately, leading to retrograde blood flow into the left atrium. The imaging also revealed aortic valve stenosis, a condition characterized by the narrowing of the aortic valve, which restricts blood flow from the left ventricle into the aorta, thereby increasing the heart's workload. During diastole, the echocardiogram also indicated aortic regurgitation, confirming the presence of retrograde flow from the aorta into the left ventricle. These dual valve pathologies significantly burdened the left side of the heart, causing the enlargement of both the left atrium and left ventricle, as the heart struggled to compensate for the abnormal blood flow and increased pressure. In addition to the echocardiographic findings, an electrocardiogram (ECG) provided further insights into the patient’s cardiac status. The ECG revealed a characteristic wide, bifid P wave (P mitrale), indicating left atrial enlargement due to the chronic volume overload caused by mitral regurgitation (Fig. 1 ). Moreover, there were signs of left ventricular hypertrophy, with elevated R waves observed in the lateral leads (V5, V6), reflecting the increased strain on the left ventricle as it worked harder to pump blood through the narrowed aortic valve. Sinus tachycardia was also noted, a common response to the increased workload of the heart in heart failure, though the possibility of intermittent atrial fibrillation due to left atrial enlargement could not be ruled out. A chest X-ray provided additional evidence supporting the diagnosis. The image revealed cardiomegaly, with significant enlargement of both the left atrium and left ventricle (Fig. 2 ). This finding corroborated the echocardiographic results, confirming the long-term effects of mitral regurgitation and aortic valve disease. Additionally, there were signs of mild pulmonary congestion, an indication that the heart's inability to pump blood efficiently was causing fluid buildup in the lungs, a hallmark of early-stage heart failure. Laboratory tests further supported the diagnosis of an inflammatory process. Both the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were elevated, suggesting ongoing or recent inflammation. These markers are commonly elevated in patients with active rheumatic fever, which is often responsible for the valvular damage seen in rheumatic heart disease. Their elevation in this patient pointed to the possibility of a recent or current rheumatic fever episode exacerbating his valvular dysfunction. Overall, the patient's clinical presentation pointed to advanced rheumatic heart disease, with severe mitral and aortic valve involvement leading to heart failure. The combination of escalating fatigue, dyspnoea, palpitations, peripheral oedema, heart murmurs, and the diagnostic findings from echocardiography, ECG, and chest X-ray all painted a clear picture of the underlying cardiac pathology. His condition, rooted in a previous rheumatic fever episode, had progressed to the point of causing significant cardiac enlargement and dysfunction, with both valvular regurgitation and stenosis contributing to the heart's inability to pump blood effectively, ultimately resulting in congestive heart failure. The management of rheumatic heart disease (RHD) in this patient followed a multifaceted approach that aims to control symptoms, prevent further cardiac damage, and address the underlying pathophysiology of the disease. RHD, being a sequela of acute rheumatic fever (ARF), primarily results from repeated GAS infections, which cause an autoimmune response that targets the heart valves, particularly the mitral and aortic valves. Therefore, the therapeutic strategy involves a combination of antibiotics for prophylaxis, anti-inflammatory medications to reduce inflammation, medications to manage heart failure, and anticoagulation to prevent thromboembolic complications. Antibiotic prophylaxis is the cornerstone of preventing recurrent streptococcal infections in RHD patients, which in turn mitigates the risk of recurrent ARF episodes and further valve damage. Benzathine penicillin G is the preferred choice for secondary prophylaxis, administered intramuscularly every four weeks to prevent streptococcal reinfection. In this case, the administration of 1,200,000 units of benzathine penicillin G, as recommended for individuals weighing more than 20 kg, has been crucial in preventing new streptococcal infections. Notably, there has been no recurrence of streptococcal infection in the patient since initiating penicillin prophylaxis, highlighting the effectiveness of this therapeutic measure. For patients who are allergic to penicillin, alternatives like cephalexin, azithromycin, or clindamycin can be utilized, depending on the type and severity of the hypersensitivity reaction. The patient’s adherence to regular antibiotic injections is critical for long-term prevention, as recurrent infections significantly worsen the prognosis of RHD by accelerating valvular degeneration. Anti-inflammatory medications also play an integral role in managing RHD in this patient, particularly during acute phases of ARF when inflammation affects the joints, heart, and other tissues. Aspirin, given in high doses, is the first-line treatment to reduce inflammation and alleviate symptoms such as joint pain and fever. In this patient, aspirin was initiated to control the inflammatory process, and its use resulted in a marked improvement in clinical symptoms, including reduced chest pain and joint discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen or ibuprofen may be considered when aspirin is contraindicated or not well tolerated. Additionally, corticosteroids like prednisone may be employed in cases of severe inflammation or when NSAIDs fail to provide adequate relief. In this case, corticosteroids were considered due to the significant inflammatory burden, particularly in the presence of active carditis and the need for rapid symptom control. The judicious use of anti-inflammatory agents helped in controlling the acute inflammatory phase, allowing for a reduction in the severity of symptoms and improving the patient’s overall functional capacity. Management of heart failure, which is a common complication of RHD due to chronic valvular dysfunction, is essential in this patient. The mitral and aortic valve involvement in this case led to volume overload in the left atrium and left ventricle, contributing to the development of heart failure symptoms such as dyspnoea, fatigue, and peripheral oedema. Diuretics, particularly furosemide, are the mainstay of treatment for heart failure in RHD patients, helping to relieve symptoms by reducing fluid overload. In this case, furosemide was prescribed to alleviate congestion and reduce the patient's fluid retention. The patient responded well to diuretic therapy, with noticeable improvement in symptoms of heart failure, such as decreased dyspnoea and peripheral oedema. As part of the heart failure management strategy, additional medications such as angiotensin-converting enzyme (ACE) inhibitors or beta-adrenergic antagonists may be used to reduce afterload and improve cardiac function. ACE inhibitors, like perindopril or ramipril, help by relaxing blood vessels and reducing the strain on the heart, while beta-blockers are beneficial in controlling heart rate and improving overall cardiac output. Given the presence of atrial fibrillation (AF) and the significant risk of thromboembolism in this patient, anticoagulation therapy is another vital component of management. The left atrial enlargement secondary to mitral regurgitation predisposes the patient to the formation of blood clots, particularly in the context of AF. Anticoagulants such as warfarin are typically used to prevent the formation of thrombi in patients with atrial fibrillation and significant valvular disease. In recent years, direct oral anticoagulants (DOACs) have also been considered for certain patients, though warfarin remains the standard for those with mechanical heart valves or severe valvular disease. In this case, the initiation of anticoagulation therapy has been critical in reducing the patient’s risk of thromboembolic events, such as stroke, and the patient has tolerated the therapy well without significant adverse effects. Long-term management of RHD is heavily reliant on continuous follow-up and monitoring to detect any progression of valvular disease or the development of new complications. Regular echocardiographic evaluations are essential to assess the status of the mitral and aortic valves and to monitor for any worsening of valve dysfunction. In this patient, serial echocardiograms have been planned every six to twelve months to evaluate the severity of mitral regurgitation and aortic stenosis, as well as to monitor left ventricular function. If significant progression of valve disease is detected, timely surgical intervention, such as valve repair or replacement, may be required. The timing of surgery is crucial and should be based on the severity of symptoms, the degree of valve dysfunction, and the patient’s overall functional capacity. In addition to pharmacological therapy, lifestyle modifications play a pivotal role in the management of RHD. The patient has been advised to adopt a heart-healthy diet, engage in regular physical activity within the limits of their tolerance, and avoid activities that may exacerbate symptoms of heart failure. Education on recognizing the early signs of heart failure decompensation, such as worsening dyspnoea or rapid weight gain, has been provided to the patient to ensure timely medical intervention if needed. At the time of this report, the patient’s clinical status has improved significantly, with a notable enhancement in functional capacity and an improvement in heart failure symptoms. The patient is currently classified as NYHA Class II, indicating mild heart failure with minimal limitations in daily activities. There have been no recent hospitalizations, and the current management plan appears to be effective in stabilizing the patient’s condition. There is no doubt that the management of this patient with rheumatic heart disease requires a comprehensive, multidisciplinary approach, including antibiotic prophylaxis, anti-inflammatory medications, heart failure management, and anticoagulation therapy. Long-term follow-up with regular echocardiographic monitoring is essential to detect the progression of the disease and to plan for timely surgical intervention if necessary. The patient’s favourable response to the current therapeutic regimen underscores the importance of adherence to treatment protocols and the need for ongoing surveillance to prevent complications and improve long-term outcomes. Through a combination of medical therapy and lifestyle modifications, this patient has achieved a stable clinical status, though the risk of future complications remains, necessitating vigilant monitoring and continued care. Discussion In this case report, the patient’s clinical presentation and diagnostic findings align closely with the progressive nature of rheumatic heart disease (RHD), a major sequela of acute rheumatic fever (ARF) [ 14 ]. This condition remains a significant cause of cardiovascular morbidity, especially in developing countries, where streptococcal infections and limited healthcare access contribute to its high prevalence [ 15 – 16 ]. The discussion delves into the pathophysiological aspects of this patient’s condition, emphasizing the implications of mitral and aortic valve dysfunction, left ventricular hypertrophy, atrial enlargement, and the long-term risks associated with untreated or inadequately managed RHD [ 14 – 16 ]. The primary manifestation of mitral regurgitation (MR) in this patient underscores the importance of timely diagnosis and intervention in RHD. MR, characterized by the backflow of blood from the left ventricle to the left atrium, reflects chronic rheumatic damage to the mitral valve [ 17 ]. This regurgitation is likely due to fibrotic changes in the valve leaflets and chordae tendineae, leading to incomplete closure during systole [ 18 ]. Such valvular damage is a hallmark of RHD, often resulting from cumulative episodes of acute rheumatic fever, which trigger an autoimmune response targeting cardiac tissues. The diastolic murmur detected during auscultation is a classic sign of aortic regurgitation, further supporting the diagnosis of combined valve disease secondary to RHD [ 17 ]. The presence of both mitral regurgitation and aortic stenosis in this patient suggests advanced valvular involvement [ 19 – 20 ]. The echocardiographic findings revealing moderate to severe MR and aortic stenosis (AS) are consistent with longstanding valvular dysfunction. Aortic stenosis, characterized by the thickening and narrowing of the aortic valve, impedes the outflow of blood from the left ventricle, increasing the workload on the heart. Over time, this leads to compensatory hypertrophy of the left ventricular myocardium, as seen in this case [ 21 ]. Left ventricular hypertrophy (LVH), evidenced by ECG and echocardiography, signifies the heart's attempt to maintain cardiac output in the face of increased resistance. However, this compensatory mechanism ultimately becomes maladaptive, leading to progressive heart failure, which is clinically manifested by dyspnoea, fatigue, and peripheral oedema [ 15 – 16 , 21 ]. The patient's left atrial enlargement, also detected on echocardiography and supported by the wide, bifid P wave on ECG (P mitrale), highlights another crucial aspect of this case. Chronic MR leads to volume overload in the left atrium, causing its dilation over time. Left atrial enlargement not only predisposes the patient to arrhythmias, such as atrial fibrillation (AF), but also increases the risk of thromboembolic events, particularly stroke [ 21 ]. The intermittent palpitations experienced by the patient are concerning for potential arrhythmic episodes, which are commonly observed in the context of left atrial enlargement and RHD. The diagnostic workup of this patient, particularly the elevated inflammatory markers such as ESR and CRP, points towards ongoing or recent inflammatory activity, possibly from a recurrence of ARF or another inflammatory stimulus [ 22 ]. In RHD, recurrent episodes of ARF further damage the heart valves, progressively worsening the valvopathy. The Jones criteria, which consider both clinical and laboratory findings of ARF, are instrumental in supporting the diagnosis of ARF and by extension RHD in patients with a history of streptococcal infection. While this patient’s clinical course is consistent with chronic RHD, the possibility of a subclinical or smoldering rheumatic process remains, given the elevated inflammatory markers. This case also highlights the importance of early diagnosis and intervention in rheumatic heart disease. Timely antibiotic prophylaxis against group A Streptococcus, which is the primary cause of ARF, could have potentially prevented the progression of valvular damage in this patient. Secondary prophylaxis with intramuscular benzathine penicillin is known to reduce the recurrence of ARF and slow the progression of RHD. Unfortunately, in resource-limited settings, where access to healthcare is constrained, many patients with RHD, like the one described here, present at an advanced stage when irreversible valvular damage has already occurred. In terms of management, surgical intervention is often required for patients with severe valvular dysfunction, particularly those with symptomatic MR and AS. Valve replacement or repair, depending on the extent of valvular damage, can significantly improve outcomes [ 21 ]. However, this case emphasizes the need for regular follow-up and monitoring in patients with RHD to identify the optimal timing for surgical intervention, which can be challenging in regions with limited healthcare infrastructure. The chronic nature of RHD necessitates long-term management strategies, including the use of medications like diuretics, beta-blockers, and anticoagulants to control heart failure symptoms, and arrhythmias, and prevent thromboembolic complications. Moreover, this case brings to light the global health disparities in managing rheumatic heart disease. While RHD has become relatively rare in developed countries due to improved healthcare access and routine use of antibiotics for streptococcal infections, it remains a leading cause of heart failure in low- and middle-income countries [ 1 – 3 ]. Public health strategies aimed at improving the diagnosis and treatment of streptococcal infections, along with secondary prophylaxis programs, are essential in reducing the burden of RHD in these populations. Conclusion In conclusion, this case report presents a comprehensive overview of rheumatic heart disease, illustrating its significant impact on adolescent health. The background emphasizes the ongoing challenges associated with early diagnosis and effective management of this condition, particularly in resource-limited settings. The detailed case presentation outlines the patient's clinical journey, highlighting symptoms, diagnostic findings, and the subsequent management approach, which included antibiotic prophylaxis, anti-inflammatory medications, diuretics for heart failure, and anticoagulation therapy. The discussion integrates current literature, reinforcing the importance of a multidisciplinary approach and the necessity for ongoing surveillance and patient education to prevent complications. Ultimately, this case underscores the critical need for early intervention and continuous care in optimizing outcomes for patients with rheumatic heart disease, thereby contributing valuable insights to the understanding and management of this prevalent condition. Abbreviations RHD_ Rheumatoid Heart Disease ARF_ Acute Rheumatoid Factor GAS infections_ Group A streptococcal infections ECG_ Electrocardiogram ESR_ Erythrocyte Sedimentation Rate CRP_ C-reactive protein NSAIDs_ Non steroid anti-inflammatory drugs ACE inhibitors_ Angiotensin Converting Enzyme inhibitors DOAC_ Direct oral anticoagulants NYHA class II_ New York Heart Association class II AF_ Atrial Fibrillation MR_ Mitral regurgitation AS_ Aortic stenosis LVH_ Left ventricular hypertrophy Declarations Ethical approval and consent to participate This is a case report. The hospital ethics committee has confirmed that no ethics approval is required. Informed consent was obtained from the patient for this case report. Contributions of the authors BF, AR, OH, MA, and SA were involved in the planning and therapeutic management of the case. BF. AR, and SA drafted the manuscript and reviewed the necessary literature for writing this article. BF & AR were involved in obtaining the radiological analysis & test results for the diagnosis of RHD which confirmed the diagnosis. All authors approved the final version of the manuscript. Consent for publication Written informed consent was taken from the participant through his parents for the publication of this case report. Competing interests All authors declare that they have no competing interests. Funding No assistance/financial support acquired for the case report. Author Contribution BF, AR, OH, MA, and SA were involved in the planning and therapeutic management of the case. BF. AR, and SA drafted the manuscript and reviewed the necessary literature for writing this article. BF & AR were involved in obtaining the radiological analysis & test results for the diagnosis of RHD which confirmed the diagnosis. All authors approved the final version of the manuscript. Acknowledgements The authors hereby acknowledge the role of the patient as well as the management in General Hospital Odan, Lagos Island, Lagos State, Nigeria for their support and facilitation of the data collection. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to privacy considerations of the participants but are available from the corresponding author upon reasonable request. References Belay W, Aliyu MH. Rheumatic Heart Disease is Missing from the Global Health Agenda. Ann Glob Health. 2021;87(1):110. doi: 10.5334/aogh.3426 . PMID: 34824991; PMCID: PMC8603858. Animasahun BA, Madise Wobo AD, Itiola AY, Adekunle MO, Kusimo OY, Thomas FB. The burden of rheumatic heart disease among children in Lagos: how are we fairing? Pan Afr Med J. 2018;29:150. doi: 10.11604/pamj.2018.29.150.12603 . PMID: 30050614; PMCID: PMC6057576. Simpson MT, Kachel M, Neely RC, Erwin WC, Yasin A, Patel A, et al. Rheumatic heart disease in the developing world. Structural Heart. 2023;7(6):100219. doi: 10.1016/j.shj.2023.100219 . Ogah, Okechukwu S.; Bode-Thomas, Fidelia; Yilgwan, Christopher; Ige, Olukemi; Ogah, Fisayo3; Ogunkunle, Oluwatoyin O4; Okwuonu, Chimezie; Sani, Mahmoud. Rheumatic heart disease in Nigeria: A review. Nigerian Journal of Cardiology 17(1):p 27–36, Jan–Jun 2020. | DOI: 10.4103/njc.njc_30_19 Carapetis JR, Beaton A, Cunningham MW, Guilherme L, Karthikeyan G, Mayosi BM, Sable C, Steer A, Wilson N, Wyber R, Zühlke L. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016;2:15084. doi: 10.1038/nrdp.2015.84 . PMID: 27188830; PMCID: PMC5810582. Dougherty S, Okello E, Mwangi J, Kumar RK. Rheumatic heart disease: JACC focus seminar. J Am Coll Cardiol. 2023;81(1):81–94. doi: 10.1016/j.jacc.2022.09.050 . Wirth S, Sika-Paotonu D, Beaton A, et al. Acute Rheumatic Fever and Rheumatic Heart Disease. 2024 Jun 19 [Updated 2024 Jul 4]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: Basic Biology to Clinical Manifestations [Internet]. 2nd edition. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2022 Oct 8. Chapter 25. Available from: https://www.ncbi.nlm.nih.gov/books/NBK606315/ Whalley G. Appropriate and early detection of rheumatic heart disease. Australas J Ultrasound Med. 2020;23(1):3–4. doi: 10.1002/ajum.12203 . PMID: 34760575; PMCID: PMC8411751. Wyber R, Wade V, Anderson A, Schreiber Y, Saginur R, Brown A, Carapetis J. Rheumatic heart disease in Indigenous young peoples. Lancet Child Adolesc Health. 2021;5(6):437–446. DOI: 10.1016/S2352-4642(20)30308-4 Hu Y, Tong Z, Huang X, Qin JJ, Lin L, Lei F, Wang W, Liu W, Sun T, Cai J, She ZG, Li H. The projections of global and regional rheumatic heart disease burden from 2020 to 2030. Front Cardiovasc Med. 2022;9:941917. doi: 10.3389/fcvm.2022.941917 . PMID: 36330016; PMCID: PMC9622772. Sani MU, Karaye KM, Borodo MM. Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: an echocardiographic study. Cardiovasc J Afr. 2007 Sep-Oct;18(5):295–9. Epub 2007 Oct 22. PMID: 17957324; PMCID: PMC3975544. Nkereuwem E, Ige OO, Yilgwan C, Jobe M, Erhart A, Bode-Thomas F. Prevalence of rheumatic heart disease in North-Central Nigeria: a school-based cross-sectional pilot study. Trop Med Int Health. 2020;25(11):1408–15. doi: 10.1111/tmi.13477 . Okello E, Kakande B, Sebatta E, Kayima J, Kuteesa M, Mutatina B, Nyakoojo W, Lwabi P, Mondo CK, Odoi-Adome R, Juergen F. Socioeconomic and environmental risk factors among rheumatic heart disease patients in Uganda. PLoS One. 2012;7(8). doi: 10.1371/journal.pone.0043917 . Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C. Contemporary diagnosis and management of rheumatic heart disease: implications for closing the gap: a scientific statement from the American Heart Association. Circulation. 2020;142(20). doi: 10.1161/cir.0000000000000921 . Ralph AP, Currie BJ. Therapeutics for rheumatic fever and rheumatic heart disease. Aust Prescr. 2022;45(4):104–12. doi: 10.18773/austprescr.2022.034 . Ralph AP, Noonan S, Boardman C, Halkon C, Currie BJ. Prescribing for people with acute rheumatic fever. Aust Prescr. 2017;40(2):70–5. doi: 10.18773/austprescr.2017.011 . Gomes NFA, Silva VR, Levine RA, Esteves WAM, de Castro ML, Passos LSA, Dal-Bianco JP, Pantaleão AN, da Silva JLP, Tan TC, Dutra WO, Aikawa E, Hung J, Nunes MCP. Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling. Front Cardiovasc Med. 2022;9:862382. doi: 10.3389/fcvm.2022.862382 . PMID: 35360029; PMCID: PMC8962951. Rudiktyo E, Yonas E, Cramer MJ, Siswanto BB, Doevendans PA, Soesanto AM. Impact of rheumatic process in left and right ventricular function in patients with mitral regurgitation. Glob Heart. 2023;18(1):15. doi: 10.5334/gh.1192 . Mantovani F, Barbieri A, Albini A, Bonini N, Fanti D, Fezzi S, Setti M, Rossi A, Ribichini F, Benfari G. The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention. J Clin Med. 2021;10(19):4364. doi: 10.3390/jcm10194364 . PMID: 34640380; PMCID: PMC8509644. Sannino A, Grayburn PA. Mitral regurgitation in patients with severe aortic stenosis: diagnosis and management. Heart. 2018;104(1):16–22. doi: 10.1136/heartjnl-2017-311552 . Epub 2017 Sep 13. PMID: 28903993. Anwar AM. Understanding the role of echocardiography in the assessment of mitral valve disease. Eur Soc Cardiol e-J Cardiol Pract. 2018;16(20). Ansar W, Ghosh S. Inflammation and Inflammatory Diseases, Markers, and Mediators: Role of CRP in Some Inflammatory Diseases. Biology of C Reactive Protein in Health and Disease. 2016 Mar 24:67–107. doi: 10.1007/978-81-322-2680-2_4 . PMCID: PMC7122703. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5431302","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":378289516,"identity":"b40491e0-639c-49cb-a42a-ed0fca242470","order_by":0,"name":"Babatunde Fatoke","email":"","orcid":"","institution":"General Hospital Lagos, Odan, Lagos Island, Lagos State, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Babatunde","middleName":"","lastName":"Fatoke","suffix":""},{"id":378289517,"identity":"06ff7e33-c48c-4f4b-a3f5-48ab84ca0592","order_by":1,"name":"Atinuke Richards","email":"","orcid":"","institution":"General Hospital Lagos, Odan, Lagos Island, Lagos State, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Atinuke","middleName":"","lastName":"Richards","suffix":""},{"id":378289518,"identity":"97b788e8-14d6-44dd-b10a-c6a49fa03584","order_by":2,"name":"Olayinka Hassan","email":"","orcid":"","institution":"General Hospital Lagos, Odan, Lagos Island, Lagos State, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Olayinka","middleName":"","lastName":"Hassan","suffix":""},{"id":378289519,"identity":"333af766-bd8c-4e05-9e8d-6d6bcc8bfa93","order_by":3,"name":"Misbau Adekunle","email":"","orcid":"","institution":"General Hospital Lagos, Odan, Lagos Island, Lagos State, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Misbau","middleName":"","lastName":"Adekunle","suffix":""},{"id":378289520,"identity":"ac841e81-f77e-41cd-ae7a-ed5f14f4f779","order_by":4,"name":"Stephen Olaide Aremu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDCCA3AWD+MDEMlHrBYJoGJmA5AWNlK0sEmAWAS18N0+wPi5oqKujl+691jl1xw7GTYG5oePbuDRInkugVnyzJnDEpJzzqXdlt2WDHQYm7FxDh4tBmeA2hrbDkgY3Mgxuy25jRmohYdNmoAW5p+N/+ok7IFaiiW31ROlhU2ysYFZwkAix4zx47bDhLVInmFss2w4dlhyxp0zxtKM247zsDET8AvfGebDNxtq6vj5Z/cYfvy5rdqen7354WN8WhgYGBsgNDBSmHlADGa8ypEBUAvjD6JVj4JRMApGwUgCALXdQvh9adVZAAAAAElFTkSuQmCC","orcid":"","institution":"Siberian State Medical University","correspondingAuthor":true,"prefix":"","firstName":"Stephen","middleName":"Olaide","lastName":"Aremu","suffix":""}],"badges":[],"createdAt":"2024-11-11 10:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5431302/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5431302/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71610237,"identity":"45c0bff1-3d76-43a0-9db8-f40297105334","added_by":"auto","created_at":"2024-12-17 06:44:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":164929,"visible":true,"origin":"","legend":"\u003cp\u003eCardiac echocardiography showing mitral regurgitation and aortic valve stenosis.\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5431302/v1/b12244bbc8bec76f705b4b7e.jpeg"},{"id":71610238,"identity":"26390d05-45e7-4559-ab8f-ec4c94aa0b45","added_by":"auto","created_at":"2024-12-17 06:44:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":934204,"visible":true,"origin":"","legend":"\u003cp\u003eA chest X-ray of the 14-year old boy revealing significant enlargement of both the left atrium and left ventricle.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-5431302/v1/0f6ce1abcc5a639764d82ae4.png"},{"id":71612348,"identity":"0294e92d-1efc-4b53-bf13-65c55b54dc29","added_by":"auto","created_at":"2024-12-17 07:00:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1216855,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5431302/v1/39efa666-0ee3-45cf-819e-d572364f0f18.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rheumatic Heart Disease in a 14-Year-Old Boy with Aortic and Mitral Valve Involvement: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eRheumatic heart disease (RHD) remains a significant health challenge globally, particularly in low- and middle-income countries such as Nigeria, where socioeconomic and environmental factors contribute to its high prevalence [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. RHD is a chronic condition resulting from an autoimmune response to GAS infections, primarily affecting the heart valves and leading to severe complications, including heart failure, infective endocarditis, and stroke [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite being preventable, RHD continues to impact children and adolescents disproportionately, highlighting the need for early detection and timely intervention [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. RHD is the most serious long-term consequence of acute rheumatic fever (ARF), a sequela of untreated or poorly treated Group A \u003cem\u003eStreptococcal pharyngitis\u003c/em\u003e [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The inflammatory process triggered by ARF primarily affects the heart valves, leading to progressive valve dysfunction, with mitral regurgitation and aortic stenosis being the most involved lesions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, the World Health Organization (WHO) estimates that over 39\u0026nbsp;million individuals are affected by RHD, with the majority residing in low- and middle-income countries where access to healthcare and early treatment is limited [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In Nigeria, RHD poses a significant public health burden, particularly among children and adolescents. Poverty, overcrowded living conditions, and inadequate access to healthcare contribute to the high incidence of RHD in the country [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies have shown that RHD remains one of the leading causes of heart failure among young populations in sub-Saharan Africa, underscoring the need for improved public health strategies to address this preventable condition [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patient described in this case report presented with typical symptoms of advanced RHD, including cough, orthopnoea, easy fatigability, and bilateral leg oedema, indicative of heart failure. Additionally, the presence of arthritis and an elevated erythrocyte sedimentation rate (ESR) further pointed to the underlying inflammatory nature of the disease. Cardiomegaly, aortic stenosis, and mitral regurgitation were identified through diagnostic imaging, reinforcing the severity of valve dysfunction in this adolescent patient. Complications of RHD, particularly in adolescents, can be debilitating and include progressive heart failure, infective endocarditis, and thromboembolic events, such as strokes. Research has shown that pulmonary hypertension, secondary to valvular heart disease, occurs in over 70% of patients at the time of diagnosis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These complications underscore the critical importance of early detection, as regular screening with echocardiography may help identify subclinical cases before significant damage occurs. This case report presents a 14-year-old male patient diagnosed with rheumatic heart disease, exhibiting advanced cardiovascular and systemic manifestations. The report aims to highlight the clinical presentation, risk factors, and potential complications of RHD in Nigerian adolescents, emphasizing the importance of early diagnosis and management in preventing debilitating outcomes. It also highlights the profound impact of RHD on young populations in Nigeria, where socioeconomic factors, limited healthcare access, and cultural beliefs contribute to delayed diagnosis and treatment. Effective strategies for addressing RHD must involve improved healthcare accessibility, routine echocardiographic screening, and public health interventions to educate, prevent, as well as inform the early treatment of GAS infections.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient, a 14-year-old male, presented with a progressively worsening condition characterized by increasing fatigue that had persisted for several months. His fatigue was disproportionate to the minimal physical exertion he undertook, such as walking short distances or climbing stairs. This sudden and inexplicable drop in his physical stamina alarmed his parents, who observed that their previously active son could no longer participate in sports or engage in other physical activities that had once been part of his routine. He expressed frustration over his inability to carry out even basic activities without feeling exhausted, a drastic change from his earlier level of functioning.\u003c/p\u003e \u003cp\u003eOne of the patient's most troubling symptoms was dyspnoea, or difficulty in breathing, which occurred particularly during physical exertion and when lying flat. This shortness of breath restricted his daily activities, including simple tasks like walking or ascending stairs, and suggested underlying cardiac issues. His symptoms were consistent with the early stages of heart failure, a condition that may have been precipitated by valve dysfunction often associated with rheumatic heart disease. The patient\u0026rsquo;s dyspnoea became particularly severe in the supine position, hinting at the possibility of pulmonary congestion due to heart dysfunction.\u003c/p\u003e \u003cp\u003eIn addition to the breathlessness, the patient frequently experienced palpitations, characterized by an irregular and sometimes rapid heartbeat. These episodes were sporadic but had increased in both frequency and intensity over time. The palpitations occasionally caused significant discomfort, and their pattern suggested the possibility of underlying arrhythmias. This was further complicated by the potential enlargement of the atrium, a common consequence of valvular disease in rheumatic heart disease. The presence of palpitations, in this context, heightened concerns about atrial fibrillation or other cardiac rhythm disturbances, which could further compromise the patient's cardiac function and increase the risk of stroke.\u003c/p\u003e \u003cp\u003eDuring the physical examination, peripheral oedema, specifically swelling in the lower extremities, was noted, particularly around the ankles and calves. This swelling is a classic sign of heart failure, indicating the heart's reduced ability to efficiently pump blood throughout the body. The resultant fluid retention in the legs is typical of congestive heart failure, where the impaired heart allows for the accumulation of fluid in dependent regions of the body. The presence of oedema in this young patient was alarming, as it provided further evidence of advanced heart failure, likely due to long-standing rheumatic heart disease.\u003c/p\u003e \u003cp\u003eUpon auscultation, the examining physician detected a heart murmur. A pan systolic murmur, which was loudest at the cardiac apex and radiated towards the axilla, was heard. This was indicative of mitral regurgitation, a condition where the mitral valve does not close properly, allowing blood to flow backward into the left atrium from the left ventricle during systole. Additionally, a diastolic murmur was identified, suggestive of aortic regurgitation, where the aortic valve allows blood to flow backward from the aorta into the left ventricle during diastole. These findings were consistent with severe rheumatic heart disease, which often results in valvular deformities and dysfunction over time, severely impacting cardiac output and efficiency.\u003c/p\u003e \u003cp\u003eThe findings from a subsequent echocardiogram confirmed the clinical suspicions. Moderate to severe mitral regurgitation was observed, where the mitral valve, likely scarred and thickened from past episodes of rheumatic fever, failed to close adequately, leading to retrograde blood flow into the left atrium. The imaging also revealed aortic valve stenosis, a condition characterized by the narrowing of the aortic valve, which restricts blood flow from the left ventricle into the aorta, thereby increasing the heart's workload. During diastole, the echocardiogram also indicated aortic regurgitation, confirming the presence of retrograde flow from the aorta into the left ventricle. These dual valve pathologies significantly burdened the left side of the heart, causing the enlargement of both the left atrium and left ventricle, as the heart struggled to compensate for the abnormal blood flow and increased pressure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition to the echocardiographic findings, an electrocardiogram (ECG) provided further insights into the patient\u0026rsquo;s cardiac status. The ECG revealed a characteristic wide, bifid P wave (P mitrale), indicating left atrial enlargement due to the chronic volume overload caused by mitral regurgitation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Moreover, there were signs of left ventricular hypertrophy, with elevated R waves observed in the lateral leads (V5, V6), reflecting the increased strain on the left ventricle as it worked harder to pump blood through the narrowed aortic valve. Sinus tachycardia was also noted, a common response to the increased workload of the heart in heart failure, though the possibility of intermittent atrial fibrillation due to left atrial enlargement could not be ruled out.\u003c/p\u003e \u003cp\u003eA chest X-ray provided additional evidence supporting the diagnosis. The image revealed cardiomegaly, with significant enlargement of both the left atrium and left ventricle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This finding corroborated the echocardiographic results, confirming the long-term effects of mitral regurgitation and aortic valve disease. Additionally, there were signs of mild pulmonary congestion, an indication that the heart's inability to pump blood efficiently was causing fluid buildup in the lungs, a hallmark of early-stage heart failure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLaboratory tests further supported the diagnosis of an inflammatory process. Both the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were elevated, suggesting ongoing or recent inflammation. These markers are commonly elevated in patients with active rheumatic fever, which is often responsible for the valvular damage seen in rheumatic heart disease. Their elevation in this patient pointed to the possibility of a recent or current rheumatic fever episode exacerbating his valvular dysfunction.\u003c/p\u003e \u003cp\u003eOverall, the patient's clinical presentation pointed to advanced rheumatic heart disease, with severe mitral and aortic valve involvement leading to heart failure. The combination of escalating fatigue, dyspnoea, palpitations, peripheral oedema, heart murmurs, and the diagnostic findings from echocardiography, ECG, and chest X-ray all painted a clear picture of the underlying cardiac pathology. His condition, rooted in a previous rheumatic fever episode, had progressed to the point of causing significant cardiac enlargement and dysfunction, with both valvular regurgitation and stenosis contributing to the heart's inability to pump blood effectively, ultimately resulting in congestive heart failure.\u003c/p\u003e \u003cp\u003eThe management of rheumatic heart disease (RHD) in this patient followed a multifaceted approach that aims to control symptoms, prevent further cardiac damage, and address the underlying pathophysiology of the disease. RHD, being a sequela of acute rheumatic fever (ARF), primarily results from repeated GAS infections, which cause an autoimmune response that targets the heart valves, particularly the mitral and aortic valves. Therefore, the therapeutic strategy involves a combination of antibiotics for prophylaxis, anti-inflammatory medications to reduce inflammation, medications to manage heart failure, and anticoagulation to prevent thromboembolic complications.\u003c/p\u003e \u003cp\u003eAntibiotic prophylaxis is the cornerstone of preventing recurrent streptococcal infections in RHD patients, which in turn mitigates the risk of recurrent ARF episodes and further valve damage. Benzathine penicillin G is the preferred choice for secondary prophylaxis, administered intramuscularly every four weeks to prevent streptococcal reinfection. In this case, the administration of 1,200,000 units of benzathine penicillin G, as recommended for individuals weighing more than 20 kg, has been crucial in preventing new streptococcal infections. Notably, there has been no recurrence of streptococcal infection in the patient since initiating penicillin prophylaxis, highlighting the effectiveness of this therapeutic measure. For patients who are allergic to penicillin, alternatives like cephalexin, azithromycin, or clindamycin can be utilized, depending on the type and severity of the hypersensitivity reaction. The patient\u0026rsquo;s adherence to regular antibiotic injections is critical for long-term prevention, as recurrent infections significantly worsen the prognosis of RHD by accelerating valvular degeneration.\u003c/p\u003e \u003cp\u003eAnti-inflammatory medications also play an integral role in managing RHD in this patient, particularly during acute phases of ARF when inflammation affects the joints, heart, and other tissues. Aspirin, given in high doses, is the first-line treatment to reduce inflammation and alleviate symptoms such as joint pain and fever. In this patient, aspirin was initiated to control the inflammatory process, and its use resulted in a marked improvement in clinical symptoms, including reduced chest pain and joint discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen or ibuprofen may be considered when aspirin is contraindicated or not well tolerated. Additionally, corticosteroids like prednisone may be employed in cases of severe inflammation or when NSAIDs fail to provide adequate relief. In this case, corticosteroids were considered due to the significant inflammatory burden, particularly in the presence of active carditis and the need for rapid symptom control. The judicious use of anti-inflammatory agents helped in controlling the acute inflammatory phase, allowing for a reduction in the severity of symptoms and improving the patient\u0026rsquo;s overall functional capacity.\u003c/p\u003e \u003cp\u003eManagement of heart failure, which is a common complication of RHD due to chronic valvular dysfunction, is essential in this patient. The mitral and aortic valve involvement in this case led to volume overload in the left atrium and left ventricle, contributing to the development of heart failure symptoms such as dyspnoea, fatigue, and peripheral oedema. Diuretics, particularly furosemide, are the mainstay of treatment for heart failure in RHD patients, helping to relieve symptoms by reducing fluid overload. In this case, furosemide was prescribed to alleviate congestion and reduce the patient's fluid retention. The patient responded well to diuretic therapy, with noticeable improvement in symptoms of heart failure, such as decreased dyspnoea and peripheral oedema. As part of the heart failure management strategy, additional medications such as angiotensin-converting enzyme (ACE) inhibitors or beta-adrenergic antagonists may be used to reduce afterload and improve cardiac function. ACE inhibitors, like perindopril or ramipril, help by relaxing blood vessels and reducing the strain on the heart, while beta-blockers are beneficial in controlling heart rate and improving overall cardiac output.\u003c/p\u003e \u003cp\u003eGiven the presence of atrial fibrillation (AF) and the significant risk of thromboembolism in this patient, anticoagulation therapy is another vital component of management. The left atrial enlargement secondary to mitral regurgitation predisposes the patient to the formation of blood clots, particularly in the context of AF. Anticoagulants such as warfarin are typically used to prevent the formation of thrombi in patients with atrial fibrillation and significant valvular disease. In recent years, direct oral anticoagulants (DOACs) have also been considered for certain patients, though warfarin remains the standard for those with mechanical heart valves or severe valvular disease. In this case, the initiation of anticoagulation therapy has been critical in reducing the patient\u0026rsquo;s risk of thromboembolic events, such as stroke, and the patient has tolerated the therapy well without significant adverse effects.\u003c/p\u003e \u003cp\u003eLong-term management of RHD is heavily reliant on continuous follow-up and monitoring to detect any progression of valvular disease or the development of new complications. Regular echocardiographic evaluations are essential to assess the status of the mitral and aortic valves and to monitor for any worsening of valve dysfunction. In this patient, serial echocardiograms have been planned every six to twelve months to evaluate the severity of mitral regurgitation and aortic stenosis, as well as to monitor left ventricular function. If significant progression of valve disease is detected, timely surgical intervention, such as valve repair or replacement, may be required. The timing of surgery is crucial and should be based on the severity of symptoms, the degree of valve dysfunction, and the patient\u0026rsquo;s overall functional capacity.\u003c/p\u003e \u003cp\u003eIn addition to pharmacological therapy, lifestyle modifications play a pivotal role in the management of RHD. The patient has been advised to adopt a heart-healthy diet, engage in regular physical activity within the limits of their tolerance, and avoid activities that may exacerbate symptoms of heart failure. Education on recognizing the early signs of heart failure decompensation, such as worsening dyspnoea or rapid weight gain, has been provided to the patient to ensure timely medical intervention if needed.\u003c/p\u003e \u003cp\u003eAt the time of this report, the patient\u0026rsquo;s clinical status has improved significantly, with a notable enhancement in functional capacity and an improvement in heart failure symptoms. The patient is currently classified as NYHA Class II, indicating mild heart failure with minimal limitations in daily activities. There have been no recent hospitalizations, and the current management plan appears to be effective in stabilizing the patient\u0026rsquo;s condition.\u003c/p\u003e \u003cp\u003eThere is no doubt that the management of this patient with rheumatic heart disease requires a comprehensive, multidisciplinary approach, including antibiotic prophylaxis, anti-inflammatory medications, heart failure management, and anticoagulation therapy. Long-term follow-up with regular echocardiographic monitoring is essential to detect the progression of the disease and to plan for timely surgical intervention if necessary. The patient\u0026rsquo;s favourable response to the current therapeutic regimen underscores the importance of adherence to treatment protocols and the need for ongoing surveillance to prevent complications and improve long-term outcomes. Through a combination of medical therapy and lifestyle modifications, this patient has achieved a stable clinical status, though the risk of future complications remains, necessitating vigilant monitoring and continued care.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this case report, the patient\u0026rsquo;s clinical presentation and diagnostic findings align closely with the progressive nature of rheumatic heart disease (RHD), a major sequela of acute rheumatic fever (ARF) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This condition remains a significant cause of cardiovascular morbidity, especially in developing countries, where streptococcal infections and limited healthcare access contribute to its high prevalence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The discussion delves into the pathophysiological aspects of this patient\u0026rsquo;s condition, emphasizing the implications of mitral and aortic valve dysfunction, left ventricular hypertrophy, atrial enlargement, and the long-term risks associated with untreated or inadequately managed RHD [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary manifestation of mitral regurgitation (MR) in this patient underscores the importance of timely diagnosis and intervention in RHD. MR, characterized by the backflow of blood from the left ventricle to the left atrium, reflects chronic rheumatic damage to the mitral valve [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This regurgitation is likely due to fibrotic changes in the valve leaflets and chordae tendineae, leading to incomplete closure during systole [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Such valvular damage is a hallmark of RHD, often resulting from cumulative episodes of acute rheumatic fever, which trigger an autoimmune response targeting cardiac tissues. The diastolic murmur detected during auscultation is a classic sign of aortic regurgitation, further supporting the diagnosis of combined valve disease secondary to RHD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe presence of both mitral regurgitation and aortic stenosis in this patient suggests advanced valvular involvement [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The echocardiographic findings revealing moderate to severe MR and aortic stenosis (AS) are consistent with longstanding valvular dysfunction. Aortic stenosis, characterized by the thickening and narrowing of the aortic valve, impedes the outflow of blood from the left ventricle, increasing the workload on the heart. Over time, this leads to compensatory hypertrophy of the left ventricular myocardium, as seen in this case [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Left ventricular hypertrophy (LVH), evidenced by ECG and echocardiography, signifies the heart's attempt to maintain cardiac output in the face of increased resistance. However, this compensatory mechanism ultimately becomes maladaptive, leading to progressive heart failure, which is clinically manifested by dyspnoea, fatigue, and peripheral oedema [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patient's left atrial enlargement, also detected on echocardiography and supported by the wide, bifid P wave on ECG (P mitrale), highlights another crucial aspect of this case. Chronic MR leads to volume overload in the left atrium, causing its dilation over time. Left atrial enlargement not only predisposes the patient to arrhythmias, such as atrial fibrillation (AF), but also increases the risk of thromboembolic events, particularly stroke [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The intermittent palpitations experienced by the patient are concerning for potential arrhythmic episodes, which are commonly observed in the context of left atrial enlargement and RHD.\u003c/p\u003e \u003cp\u003eThe diagnostic workup of this patient, particularly the elevated inflammatory markers such as ESR and CRP, points towards ongoing or recent inflammatory activity, possibly from a recurrence of ARF or another inflammatory stimulus [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In RHD, recurrent episodes of ARF further damage the heart valves, progressively worsening the valvopathy. The Jones criteria, which consider both clinical and laboratory findings of ARF, are instrumental in supporting the diagnosis of ARF and by extension RHD in patients with a history of streptococcal infection. While this patient\u0026rsquo;s clinical course is consistent with chronic RHD, the possibility of a subclinical or smoldering rheumatic process remains, given the elevated inflammatory markers.\u003c/p\u003e \u003cp\u003eThis case also highlights the importance of early diagnosis and intervention in rheumatic heart disease. Timely antibiotic prophylaxis against group A Streptococcus, which is the primary cause of ARF, could have potentially prevented the progression of valvular damage in this patient. Secondary prophylaxis with intramuscular benzathine penicillin is known to reduce the recurrence of ARF and slow the progression of RHD. Unfortunately, in resource-limited settings, where access to healthcare is constrained, many patients with RHD, like the one described here, present at an advanced stage when irreversible valvular damage has already occurred.\u003c/p\u003e \u003cp\u003eIn terms of management, surgical intervention is often required for patients with severe valvular dysfunction, particularly those with symptomatic MR and AS. Valve replacement or repair, depending on the extent of valvular damage, can significantly improve outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, this case emphasizes the need for regular follow-up and monitoring in patients with RHD to identify the optimal timing for surgical intervention, which can be challenging in regions with limited healthcare infrastructure. The chronic nature of RHD necessitates long-term management strategies, including the use of medications like diuretics, beta-blockers, and anticoagulants to control heart failure symptoms, and arrhythmias, and prevent thromboembolic complications.\u003c/p\u003e \u003cp\u003eMoreover, this case brings to light the global health disparities in managing rheumatic heart disease. While RHD has become relatively rare in developed countries due to improved healthcare access and routine use of antibiotics for streptococcal infections, it remains a leading cause of heart failure in low- and middle-income countries [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Public health strategies aimed at improving the diagnosis and treatment of streptococcal infections, along with secondary prophylaxis programs, are essential in reducing the burden of RHD in these populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this case report presents a comprehensive overview of rheumatic heart disease, illustrating its significant impact on adolescent health. The background emphasizes the ongoing challenges associated with early diagnosis and effective management of this condition, particularly in resource-limited settings. The detailed case presentation outlines the patient's clinical journey, highlighting symptoms, diagnostic findings, and the subsequent management approach, which included antibiotic prophylaxis, anti-inflammatory medications, diuretics for heart failure, and anticoagulation therapy. The discussion integrates current literature, reinforcing the importance of a multidisciplinary approach and the necessity for ongoing surveillance and patient education to prevent complications. Ultimately, this case underscores the critical need for early intervention and continuous care in optimizing outcomes for patients with rheumatic heart disease, thereby contributing valuable insights to the understanding and management of this prevalent condition.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eRHD_ Rheumatoid Heart Disease\u003c/p\u003e \u003cp\u003eARF_ Acute Rheumatoid Factor\u003c/p\u003e \u003cp\u003eGAS infections_ Group A streptococcal infections\u003c/p\u003e \u003cp\u003eECG_ Electrocardiogram\u003c/p\u003e \u003cp\u003eESR_ Erythrocyte Sedimentation Rate\u003c/p\u003e \u003cp\u003eCRP_ C-reactive protein\u003c/p\u003e \u003cp\u003eNSAIDs_ Non steroid anti-inflammatory drugs\u003c/p\u003e \u003cp\u003eACE inhibitors_ Angiotensin Converting Enzyme inhibitors\u003c/p\u003e \u003cp\u003eDOAC_ Direct oral anticoagulants\u003c/p\u003e \u003cp\u003eNYHA class II_ New York Heart Association class II\u003c/p\u003e \u003cp\u003eAF_ Atrial Fibrillation\u003c/p\u003e \u003cp\u003eMR_ Mitral regurgitation\u003c/p\u003e \u003cp\u003eAS_ Aortic stenosis\u003c/p\u003e \u003cp\u003eLVH_ Left ventricular hypertrophy\u003c/p\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis is a case report. The hospital ethics committee has confirmed that no ethics approval is required. Informed consent was obtained from the patient for this case report.\u003c/p\u003e \u003ch2\u003eContributions of the authors\u003c/h2\u003e \u003cp\u003eBF, AR, OH, MA, and SA were involved in the planning and therapeutic management of the case. BF. AR, and SA drafted the manuscript and reviewed the necessary literature for writing this article. BF \u0026amp; AR were involved in obtaining the radiological analysis \u0026amp; test results for the diagnosis of RHD which confirmed the diagnosis. All authors approved the final version of the manuscript.\u003c/p\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eWritten informed consent was taken from the participant through his parents for the publication of this case report.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eAll authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo assistance/financial support acquired for the case report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBF, AR, OH, MA, and SA were involved in the planning and therapeutic management of the case. BF. AR, and SA drafted the manuscript and reviewed the necessary literature for writing this article. BF \u0026amp; AR were involved in obtaining the radiological analysis \u0026amp; test results for the diagnosis of RHD which confirmed the diagnosis. All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors hereby acknowledge the role of the patient as well as the management in General Hospital Odan, Lagos Island, Lagos State, Nigeria for their support and facilitation of the data collection.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to privacy considerations of the participants but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBelay W, Aliyu MH. Rheumatic Heart Disease is Missing from the Global Health Agenda. Ann Glob Health. 2021;87(1):110. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5334/aogh.3426\u003c/span\u003e\u003cspan address=\"10.5334/aogh.3426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34824991; PMCID: PMC8603858.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnimasahun BA, Madise Wobo AD, Itiola AY, Adekunle MO, Kusimo OY, Thomas FB. The burden of rheumatic heart disease among children in Lagos: how are we fairing? Pan Afr Med J. 2018;29:150. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj.2018.29.150.12603\u003c/span\u003e\u003cspan address=\"10.11604/pamj.2018.29.150.12603\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30050614; PMCID: PMC6057576.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimpson MT, Kachel M, Neely RC, Erwin WC, Yasin A, Patel A, et al. Rheumatic heart disease in the developing world. Structural Heart. 2023;7(6):100219. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.shj.2023.100219\u003c/span\u003e\u003cspan address=\"10.1016/j.shj.2023.100219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgah, Okechukwu S.; Bode-Thomas, Fidelia; Yilgwan, Christopher; Ige, Olukemi; Ogah, Fisayo3; Ogunkunle, Oluwatoyin O4; Okwuonu, Chimezie; Sani, Mahmoud. Rheumatic heart disease in Nigeria: A review. Nigerian Journal of Cardiology 17(1):p 27\u0026ndash;36, Jan\u0026ndash;Jun 2020. | DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/njc.njc_30_19\u003c/span\u003e\u003cspan address=\"10.4103/njc.njc_30_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarapetis JR, Beaton A, Cunningham MW, Guilherme L, Karthikeyan G, Mayosi BM, Sable C, Steer A, Wilson N, Wyber R, Z\u0026uuml;hlke L. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016;2:15084. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrdp.2015.84\u003c/span\u003e\u003cspan address=\"10.1038/nrdp.2015.84\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 27188830; PMCID: PMC5810582.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDougherty S, Okello E, Mwangi J, Kumar RK. Rheumatic heart disease: JACC focus seminar. J Am Coll Cardiol. 2023;81(1):81\u0026ndash;94. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2022.09.050\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2022.09.050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWirth S, Sika-Paotonu D, Beaton A, et al. Acute Rheumatic Fever and Rheumatic Heart Disease. 2024 Jun 19 [Updated 2024 Jul 4]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: Basic Biology to Clinical Manifestations [Internet]. 2nd edition. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2022 Oct 8. Chapter 25. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK606315/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK606315/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhalley G. Appropriate and early detection of rheumatic heart disease. Australas J Ultrasound Med. 2020;23(1):3\u0026ndash;4. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ajum.12203\u003c/span\u003e\u003cspan address=\"10.1002/ajum.12203\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34760575; PMCID: PMC8411751.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyber R, Wade V, Anderson A, Schreiber Y, Saginur R, Brown A, Carapetis J. Rheumatic heart disease in Indigenous young peoples. Lancet Child Adolesc Health. 2021;5(6):437\u0026ndash;446. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2352-4642(20)30308-4\u003c/span\u003e\u003cspan address=\"10.1016/S2352-4642(20)30308-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Y, Tong Z, Huang X, Qin JJ, Lin L, Lei F, Wang W, Liu W, Sun T, Cai J, She ZG, Li H. The projections of global and regional rheumatic heart disease burden from 2020 to 2030. Front Cardiovasc Med. 2022;9:941917. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fcvm.2022.941917\u003c/span\u003e\u003cspan address=\"10.3389/fcvm.2022.941917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 36330016; PMCID: PMC9622772.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSani MU, Karaye KM, Borodo MM. Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: an echocardiographic study. Cardiovasc J Afr. 2007 Sep-Oct;18(5):295\u0026ndash;9. Epub 2007 Oct 22. PMID: 17957324; PMCID: PMC3975544.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNkereuwem E, Ige OO, Yilgwan C, Jobe M, Erhart A, Bode-Thomas F. Prevalence of rheumatic heart disease in North-Central Nigeria: a school-based cross-sectional pilot study. Trop Med Int Health. 2020;25(11):1408\u0026ndash;15. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/tmi.13477\u003c/span\u003e\u003cspan address=\"10.1111/tmi.13477\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkello E, Kakande B, Sebatta E, Kayima J, Kuteesa M, Mutatina B, Nyakoojo W, Lwabi P, Mondo CK, Odoi-Adome R, Juergen F. Socioeconomic and environmental risk factors among rheumatic heart disease patients in Uganda. PLoS One. 2012;7(8). doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0043917\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0043917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Rem\u0026eacute;nyi B, Sliwa-H\u0026auml;hnle K, Z\u0026uuml;hlke LJ, Sable C. Contemporary diagnosis and management of rheumatic heart disease: implications for closing the gap: a scientific statement from the American Heart Association. Circulation. 2020;142(20). doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/cir.0000000000000921\u003c/span\u003e\u003cspan address=\"10.1161/cir.0000000000000921\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRalph AP, Currie BJ. Therapeutics for rheumatic fever and rheumatic heart disease. Aust Prescr. 2022;45(4):104\u0026ndash;12. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18773/austprescr.2022.034\u003c/span\u003e\u003cspan address=\"10.18773/austprescr.2022.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRalph AP, Noonan S, Boardman C, Halkon C, Currie BJ. Prescribing for people with acute rheumatic fever. Aust Prescr. 2017;40(2):70\u0026ndash;5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18773/austprescr.2017.011\u003c/span\u003e\u003cspan address=\"10.18773/austprescr.2017.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomes NFA, Silva VR, Levine RA, Esteves WAM, de Castro ML, Passos LSA, Dal-Bianco JP, Pantale\u0026atilde;o AN, da Silva JLP, Tan TC, Dutra WO, Aikawa E, Hung J, Nunes MCP. Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling. Front Cardiovasc Med. 2022;9:862382. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fcvm.2022.862382\u003c/span\u003e\u003cspan address=\"10.3389/fcvm.2022.862382\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35360029; PMCID: PMC8962951.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudiktyo E, Yonas E, Cramer MJ, Siswanto BB, Doevendans PA, Soesanto AM. Impact of rheumatic process in left and right ventricular function in patients with mitral regurgitation. Glob Heart. 2023;18(1):15. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5334/gh.1192\u003c/span\u003e\u003cspan address=\"10.5334/gh.1192\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMantovani F, Barbieri A, Albini A, Bonini N, Fanti D, Fezzi S, Setti M, Rossi A, Ribichini F, Benfari G. The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention. J Clin Med. 2021;10(19):4364. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm10194364\u003c/span\u003e\u003cspan address=\"10.3390/jcm10194364\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34640380; PMCID: PMC8509644.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSannino A, Grayburn PA. Mitral regurgitation in patients with severe aortic stenosis: diagnosis and management. Heart. 2018;104(1):16\u0026ndash;22. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/heartjnl-2017-311552\u003c/span\u003e\u003cspan address=\"10.1136/heartjnl-2017-311552\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Sep 13. PMID: 28903993.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnwar AM. Understanding the role of echocardiography in the assessment of mitral valve disease. Eur Soc Cardiol e-J Cardiol Pract. 2018;16(20).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnsar W, Ghosh S. Inflammation and Inflammatory Diseases, Markers, and Mediators: Role of CRP in Some Inflammatory Diseases. Biology of C Reactive Protein in Health and Disease. 2016 Mar 24:67\u0026ndash;107. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-81-322-2680-2_4\u003c/span\u003e\u003cspan address=\"10.1007/978-81-322-2680-2_4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMCID: PMC7122703.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rheumatic heart disease, adolescents, clinical presentation, management, prevention, echocardiography, Case report","lastPublishedDoi":"10.21203/rs.3.rs-5431302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5431302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRheumatic heart disease (RHD) continues to pose significant health challenges, especially in adolescents, where it can lead to long-lasting complications. This case report discusses a teenage patient diagnosed with RHD following recurrent streptococcal infections, highlighting the clinical presentation, management, and outcomes.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eThe patient presented with chest pain, fatigue, and dyspnoea, prompting a comprehensive evaluation. An echocardiographic assessment revealed mitral valve regurgitation and left atrial enlargement. The management strategy focused on preventing further streptococcal infections through benzathine penicillin G as a key component of secondary prophylaxis. Inflammatory symptoms were addressed using high-dose aspirin and corticosteroids, while diuretics were utilized to alleviate heart failure symptoms. Additionally, anticoagulation therapy was initiated due to the patient\u0026rsquo;s atrial fibrillation, mitigating the risk of thromboembolic events. Regular follow-up appointments and echocardiographic evaluations were instituted to monitor cardiac function and the progression of valvular disease. The patient demonstrated significant improvement in symptoms and functional capacity, now classified as NYHA Class II heart failure.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case underscores the necessity for early diagnosis, appropriate management, and long-term follow-up in adolescents with RHD to prevent complications and optimize patient outcomes. Moreover, it emphasizes the need for awareness and preventive strategies against rheumatic fever, a preventable cause of cardiovascular morbidity. Insights from this case contribute to understanding RHD in a paediatric context, advocating for a multifaceted care approach that includes patient education, dietary modifications, and lifestyle adjustments to enhance cardiovascular health.\u003c/p\u003e","manuscriptTitle":"Rheumatic Heart Disease in a 14-Year-Old Boy with Aortic and Mitral Valve Involvement: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 06:44:32","doi":"10.21203/rs.3.rs-5431302/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1cac23c0-b983-4257-8bf8-08ef1dfc3196","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-17T06:44:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-17 06:44:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5431302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5431302","identity":"rs-5431302","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}