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Fátima Derlene Rocha Araújo, Kelly Nascimento Brandão, Fabiana Arantes Araújo, Gláucia Maria Vasconcelos Severiano, Zilda Maria Alves Meira
American Heart Hospital Journal Volume 8 No.1

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In this article the authors describe a clinical case of acute rheumatic fever (according to revised Jones criteria, American Heart Association [AHA], 1992) with cardiac tamponade, emphasizing this uncommon presentation. An adolescent patient with a clinical picture of cardiac tamponade was seen in the emergency department. Clinical progression and tests demonstrated rheumatic carditis with an initial manifestation of pericarditis with cardiac tamponade. This report aims to warn physicians about the diagnosis of rheumatic carditis in an unusual clinical presentation, in cases of cardiac tamponade, particularly in school-aged children and adolescents in countries with a high prevalence of rheumatic fever. The literature contains only two documented cases of cardiac tamponade related to acute rheumatic fever, and this case represents a third.

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An 11-year-old female adolescent who was previously healthy was admitted to the emergency department presenting severe tachypnea and dyspnea, pale skin and mucosa, tachycardia, slightly muffled heart sounds, mild mitral regurgitation murmur, normal blood pressure, and hepatomegaly.

The chest X-ray (see Figure 1) showed significant cardiomegaly, the electrocardiogram (ECG) was normal, and Doppler echocardiography (see Figure 1) showed large pericardial effusion with signs of cardiac tamponade, cardiac chambers of normal size, mitral and aortic valves with normal morphology, mild mitral insufficiency, and no vegetation in the valves.

Pericardiocentesis was performed and 1,200ml of exudate was drained; culture of this fluid was negative for fungi, bacteria, and mycobacterium. Blood cultures were negative. Serology tests for HIV, cytomegalovirus (CMV), rubella, toxoplasmosis, and mononucleosis were also negative. Clinical and laboratory investigations for tuberculosis, neoplasm, and collagen diseases were negative. The laboratory tests revealed C-reactive protein (CPR) of 105.1mg/dl, antistreptolysin O (ASO) of 200IU/ml, and an erythrocyte sedimentation rate (ESR) of 55mm/hour.

The patient was initially treated with antibiotics (oxacillin and gentamicin). Fever persisted even after 12 days of antibiotic therapy, and more intense mitral regurgitation murmur, onset of aortic regurgitation murmur, and worsening of heart failure signs were observed. Doppler echocardiography showed mild pericardial effusion, severe mitral insufficiency, mild to moderate aortic insufficiency, and enlarged left cardiac chambers. CRP was 82.6mg/l, ASO 600IU/ml, and ESR 45mm/hour, and the PR interval was prolonged on the ECG.

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