1. Interesting Case

2. • 8 years old male child, 2nd issue of NCM
B/B relatives with c/o
• Trauma to right leg 8 days back
• Fever with chills since 8 days
• Breathlessness since 1 day
• Swelling over both feet since 1 day

3. • Trauma to right leg 8 days back, treated
conservatively
• No Swelling/ Limitation of joint movements/
Discharge
• Fever with chills for 8 days, Peripheral smear
done showed Ring forms of P. vivax so treated
with Tab chloroquine with lumefantrine
combination for 3 days by private practitioner
but no relief

4. • Patient developed breathlessness, sudden onset,
1 day prior with swelling over both feet
•
•
•
•
No H/O vomiting/ Abdominal pain
No H/O bleeding from any site
No H/O palpitations/ exertional breathlessness
No H/O urinary complaints
• No past history of hospital admission

5. General Examination
•
•
•
•
•
Conscious, alert, febrile (103.9F)
Comfortable in sitting position
HR- 162/min, RR- 58/min
BP- 110/60 mm of Hg in right arm supine position
SPO2- 93% at room air, 100% with O2 by mask @
3 lit/min
• Mild pallor, B/L pitting pedal edema, No
clubbing/cyanosis
• Localized tenderness over right lower limb

6. Systemic Examination
• CVS- S1S2 well heard, Tachycardia, Systolic
murmur Gr 4/6, Pericardial friction rub, S3
Gallop
• P/A- Soft, Rt hypochondriac tenderness,
L6S2K0
• RS- Severe respiratory distress, B/L basal
crepts, Breath sounds well heard
• CNS- Conscious, No neurodeficit

7. Provisional diagnosis
•
•
•
•
Carditis
Congestive cardiac failure
Right leg cellulitis
To R/O septicemia

8. Day 1
•
•
•
•
Kept NBM, O2 continued
Higher antibiotics started, Inj lasix given
IV fluids kept 2/3rd restricted
Lab investigations sent

9. Investigations
• CBC- Hb- 10.8, TLC- 23800 (Poly- 71) Plt- 303000, ESR53
• RFT, Electrolytes- Normal
• Sr. Albumin- 2.8
• CPK MB and Total- Normal
• PT/APTT- Normal
• Urine Routine- Normal
• Sr. Lactate- 4.2
• ABG- Compensated metabolic acidosis
• ASO- Negative
• Sr. CRP- Positive (12.8)

10. Chest Xray at Day 1

11. Investigations
• USG abdomen
• Mild Hepatomegaly
• Minimal Rt plaural effusion, Mild Lt pleural
effusion
• Pericardial Effusion
• Mild Ascitis
• Fundoscopy- Normal

12. 2D Echo
•
•
•
•
•
•
Severe Mitral regurgitation
Moderate Aortic regurgitation
Mild Mitral stenosis, Mitral valve prolapse
Mild pericardial effusion 7-8mm
Large vegetation on Mitral valve
E/O abscess in mitral and aortic annulus s/o
Infective endocarditis

13. Further course
• Poor prognosis was explained to relatives and
advised early surgical management
• Medical management was continued
• Blood cultures were sterile

14. • On 5th hospital day, child had developed
tachypnea with distress, tachycardia, B/L
pedal edema again, Heart sounds muffled
• CXR and 2D echo were repeated

15. Repeat CXR

16. Repeat 2D echo
• Moderate MR, Mitral valve prolapse
• Large vegetation with e/o valvular abscess extending
to Aortic annulus
• Mild Aortic regurgitation
• Moderate PH
• Moderate to Large Pericardial effusion measuring
20mm with e/o Right atrial diastolic collapse s/o
tamponade
• ADV- Urgent USG guided pericardial tapping, To be
transferred to higher centre for further surgical
evaluation

17. • Patient was then shifted to CPR, Kolhapur
with Oxygen support after informing
concerned authority
• Child succumbed

18. Final Diagnosis
•
•
•
•
•
Rheumatic valvular heart disease
Infective endocarditis
Congestive cardiac failure
Pericarditis
Moderate Pericardial Effusion