International Journal of Cardiology 103 (2005) 217 – 218 www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiac tamponade in acute rheumatic fever Nurettin Unalb, Mustafa Kosecika,T, Gul Sagin Saylamb, Mustafa Kirb, Sebnem Paytoncub, Soner Kumtepeb a Faculty of Medicine, Department of Pediatrics, Harran University, Sanliurfa, Turkey Faculty of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, Dokuz Eylul University, Izmir, Turkey
b
Received 13 April 2004; received in revised form 25 June 2004; accepted 7 August 2004 Available online 17 February 2005
Keywords: Acute rheumatic fever; Pericarditis; Cardiac tamponade
1. Introduction Nowadays, acute rheumatic fever is still an important health problem and the most important reason of acquired heart diseases in children and young adults in developing countries [1]. Acute rheumatic fever is a common cause of pericarditis, but cardiac tamponade, due to large pericardial effusion, is extremely uncommon [1,2]. In this report we describe a case presenting cardiac tamponade due to acute rheumatic fever.
2. Case report
massive pericardial effusion (Fig. 2), severe mitral insufficiency and moderate aortic insufficiency in echocardiography was found. Pericardiocentesis was performed to the patient who was accepted as cardiac tamponade and approximately 450-cc exudative hemorrhagic fluid was discharged. In laboratory tests, WBC 12.800/mm3 (90% neutrophil), erythrocyte sedimentation rate 158 mm/h, Creactive protein 151 mg/dl, Anti-Streptolyzine O 1600 IU. Pericardial fluid cytology and cultures of bacteria and mycobacteria were negative. Mitral and aortic insufficiency murmurs were easily heard on her examination performed 1 day after pericardiocentesis. Control echocardiography showed an evident decrease in pericardial fluid. Our patient
A 12 year-old girl admitted to the hospital had fever, cough, respiratory distress and orthopnea. Her complaints had started 7 days ago and her respiratory distress increased gradually. On physical examination the patient appeared uncomfortable, tachypneic and orthopneic. Her temperature was 38.3 8C, pulse rate 112 beats/min., blood pressure 90/60 mmHg and respiratory rate 48/min. Jugular venous distention, pallor, large hepatomegaly, and facial and pretibial edema were detected. Heart sounds were muffled, and friction rub was present, but not a distinct murmur. On chest X-ray enlarged cardiac shadow (Fig. 1), low QRS voltage and normal PR interval in electrocardiography, and a
T Corresponding author. Tel.: +90 414 3141170; fax: +90 414 3151181. E-mail address:
[email protected] (M. Kosecik). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.08.063
Fig. 1. A grossly globular heart on chest X-ray.
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Fig. 2. A large pericardial effusion on echocardiography. PE: pleural effusion, RV: right ventricle, LV: left ventricle.
who was accepted with acute rheumatic carditis with one major (carditis), and two minor (elevated acute phase reactants and fever) criteria, plus an elevated ASO according to Jones criteria began corticosteroid therapy. She responded to steroid therapy with the resolution of carditis.
raphy and a massive pericardial effusion in echocardiography, and pericardiocentesis was performed. Until pericarditis is resolved, mitral and/or aortic insufficiency murmur can not be heard because of a large pericardial effusion and/or friction rub [1,2]. In the presented case, mitral and aortic insufficiency murmurs could be easily heard after pericardiocentesis. A large pericardial effusion, which is presented with cardiac tamponade and underwent a drainage procedure, may be idiopathic or secondary to neoplastic, uremic and infectious causes, and most rarely acute rheumatic fever, acquired immunodeficiency and SheehanTs syndrome [3–6]. The literature contains only a few documented cases of cardiac tamponade related to acute rheumatic fever that underwent a drainage procedure [3,4] and this presented case will be one of them. In conclusion, cardiac tamponade secondary to severe pericarditis is an extremely uncommon complication of acute rheumatic fever. If it was associated with involvement of mitral and/or aortic valve, firstly acute rheumatic fever should be considered and an urgent pericardiocentesis should be performed.
3. Discussion References Carditis is usually pancarditis in acute rheumatic fever and almost always associated with valvulitis. In this case, murmurs of systolic apical mitral insufficiency and basal diastolic aortic insufficiency are heard. Pericardial effusion causes distant heart sounds, friction rub and chest pain. A large pericardial effusion in acute rheumatic fever is unusual. However, it can cause cardiac tamponade accompanied by jugular venous distention, large hepatomegaly, narrow pulse pressure, and pulses paradoxes. This is confirmed by low voltage of QRS voltage and ST-T changes in electrocardiography, enlarged cardiac shadow on chest X-ray and a massive pericardial effusion and late diastolic compression of right atrium and ventricle in echocardiography [1,2]. The presented case was identified as cardiac tamponade with enlarged cardiac shadow on chest roentgenogram, low QRS voltage in electrocardiog-
[1] Ayoub EM. Acute rheumatic fever. In: Allen HD, Clark EB, Gutdesell DJ, Driscoll DJ, editors. Moss and adam’s heart disease in infants, children, and adolescents. Philadelphia7 Lippincott Williams & Wilkins; 2001. p. 1226. [2] Special Writing Group of the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease of the Council on Cardiovascular Disease in the Young the American Heart Association (Dajani AS, Ayoub EM, Bierman FZ et al.). Guidelines for the diagnosis of rheumatic fever. Jones criteria, 1992 update. JAMA 1992;268:2069 – 73. [3] Tan AT, Mah PK, Chia BL. Cardiac tamponade in acute rheumatic carditis. Ann Rheum Dis 1983;42:699 – 701. [4] Colombo A, Olson HG, Egan J, Gardin JM. Etiology and prognostic implications of a large pericardial effusion in men. Clin Cardiol 1998; 11:389 – 94. [5] Gowda RM, Khan IA, Sacchi TJ, Vasavada BC. Cardiac tamponade in acquired immunodeficiency syndrome. Int J Cardiol 2003;88:313 – 4. [6] Sahin I, Taskapan H, Yildiz R, Kosar F. Cardiac tamponade as initial presentation of Sheehan’s syndrome. Int J Cardiol 2004;94:129 – 30.
