|Year : 2018 | Volume
| Issue : 1 | Page : 32-34
Isolated tricuspid rheumatic valvular regurgitation
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
|Date of Web Publication||27-Mar-2018|
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Rheumatic heart disease is among the most common acquired heart disease in Nigeria; it is a global disease, but greatest disease burden is in the developing countries; 50% of these are from African. Therefore, this poses a significant challenge to our health facilities; however, over the years, there has been a significant drop in the prevalence of this disease probably due to easy access to over-the-counter medications such as antibiotics. Chronic rheumatic heart disease commonly affects the mitral valves, the aortic valves, and rarely the right heart valves. Rarely, there is isolated aortic, pulmonary, or tricuspid valves' affectation without involving the mitral valve. Therefore, the case of a 12-year-old girl who presented with anasarca; and whose electrocardiogram showed right ventricular hypertrophy; and her echocardiogram confirmed isolated thickened tricuspid valve with severe tricuspid regurgitation is reported.
Keywords: acute rheumatic fever, African child, isolated tricuspid rheumatic valvular regurgitation, right ventricular hypertrophy
|How to cite this article:|
Aliyu I. Isolated tricuspid rheumatic valvular regurgitation. Libyan J Med Sci 2018;2:32-4
| Introduction|| |
Rheumatic heart disease is among the most common acquired heart disease in Nigeria; it is estimated that about 2.4 million children are affected with this disease globally; however, 50% of them are from African. Therefore, this poses a significant disease burden; over the years, it is believed that there is a decreasing prevalence of this disease. Akinwusi et al. in their 9-year review of cases seen in Lagos, Nigeria, documented only 11 cases with a prevalence of 0.16/1000; however, Ogah et al. in their 5-year review of cases in Abeokuta, Nigeria, reported 107 cases, Akpa et al., in Port-Harcourt, Nigeria, reported only 22 cases in a 1-year review, whereas Danbauchi et al. in Zaria, Nigeria, reported only 47 cases over a 3-year period.
Rheumatic heart disease arises from acute rheumatic fever (RF) which is a nonsuppurative complication of Streptococcus pyogenes throat infection. The mitral valve is mostly affected in rheumatic heart disease, while mixed aortic and mitral valves' involvement is more common than an isolated aortic valve involvement. However, isolated involvement of the pulmonary or tricuspid valves is rare; therefore, the case of a 12-year-old girl with an isolated tricuspid valve involvement is reported.
| Case Report|| |
A 12-year-old girl presented with recurrent limb swelling for 2 months before presentation; she had associated facial, abdominal swellings; however, there was no history suggestive of reduced urine volume and there was no history of yellowness of the eyes, vomiting, diarrhea, or body itching. She had several medications including diuretics. This was usually associated with reduced swellings. The physical examination revealed anasarca, she was tachycardic (160/min), blood pressure of 100/70 mmHg reading from the supine position, right arm; with elevation of the jugular venous pressure, she had a displaced apex (6th left intercostal space lateral to the mid-clavicular line), and there were first and second heart sounds, with a pansystolic murmurs at the midsternal margin. There was hepatomegaly of 6 cm below the right costal margin. The chest X-ray revealed cardiomegaly with prominent right cardiac border [Figure 1]; similarly, the electrocardiogram showed evidence of right ventricular hypertrophy characterized by right atrial enlargement and marked right axis deviation [Figure 2], while the two-dimensional echocardiograph showed enlarged right ventricular chamber, thickened tricuspid valves with prolapsed anterior leaflet and thickened chordae, and the atrial and ventricular septa bulging toward the right side during systole; there was pathologic (severe) tricuspid regurgitation from the Doppler study; the jet length was 3 cm and tricuspid regurgitant velocity of 3.5 m/s while the mitral valve was morphologically normal [Figure 3]. The right atrium had a minor axis of 52 mm (29–45 mm). The right ventricular diameters in end-diastole and systole were 36 mm and 28 mm, respectively. The fractional area change was 45% (32%–60%), while the was E: A ratio of 2.9 (through the tricuspid valve using pulse wave) and right ventricular outflow acceleration time was 116 ms. The tricuspid annular plane systolic excursion was 19.5 mm, while the inferior vena cava diameter varied from 6.0 mm during inspiration to 10.5 mm during expiration. However all other valves were essential normal. She had normal systolic ejection fraction of 65% and shortening fraction of 34% and normal diastolic left ventricular function. Cardiac catheterization was not done in the index case due to the absence of a functional catheterization laboratory in our facility.
|Figure 2: Electrocardiogram showing features of right atrial enlargement and right ventricular hypertrophy|
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|Figure 3: echocardiogram showing thickened and prolapsed tricuspid valve|
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| Discussion|| |
Acute RF occurs in children between the ages of 5 and 15 years; overcrowding, poverty, poor hygiene, and poor health-care services are potential risk factors. Our case was 12 years old which fell within the common age group. Furthermore, females predominate in most reported studies ,, why this is so is not completely understood; however Ogah et al. proffered an explanation, that it may be due to our culture and poor health-seeking behavior; male children are more valued; therefore, they are likely to receive better care and less risk for acute RF following a throat infection. Although a history of sore throat was not obtainable in the index case, this does not exclude the diagnosis of rheumatic heart disease. Acute RF has been reported in patients with absent history of sore throat;, how this occur is poorly understood, other strains of streptococci such as Group C and G with the site of infection other than the throat maybe contributory in its pathogenesis; more so streptococcal skin pyoderma has been implicated in acute RF. McDonald et al. reported only 19% incidence of sore throat infection compared to 40% of pyoderma among Australian Aboriginal community treated for acute RF. Akinwusi et al. in their study documented childhood history of recurrent sore throat and RF in only 18.2% and skin infection in only 9.1% of the subjects. Furthermore, some researchers , have reported cases of rheumatic heart disease in subjects who could not remember preceding documented acute RF.
Color flow Doppler echocardiography is the mainstay for evaluating suspected case. Kolo et al. in their study documented 65 cases of rheumatic heart disease, of which 75.4% of the cases involved the mitral valves alone or in combination with the aortic, pulmonary, or tricuspid valves; however, isolated tricuspid valve involvement was not recorded. Similarly, Sani et al. documented isolated mitral regurgitation as the most common disease in 38% of cases, mixed mitral valve disease in 27.9%, mixed mitral and aortic valve disease in 19.5% of the cases, and no record of an isolated pulmonary or tricuspid valvular involvement, which makes our case unique. Furthermore, the clinical presentation of an isolated tricuspid valvular disease could be misinterpreted as a mitral valvular disease with tricuspid regurgitation due to pulmonary hypertension, which is similar to that reported by Fujii et al. However, a thorough clinical evaluation in addition to echocardiography simplifies the diagnosis. The inability to do cardiac catheterization in this study to ascertain the absence of pulmonary hypertension was a limitation; however, echocardiography absence of both direct and indirect signs of pulmonary hypertension makes it unlikely.
| Conclusion|| |
Isolated rheumatic tricuspid valvular heart disease (regurgitation) is a rare event; its clinical features may be easily confused with a rheumatic mitral valvular regurgitation with tricuspid regurgitation; however, the use of echocardiography will mitigate this challenge.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mayosi B, Robertson K, Volmink J, Adebo W, Akinyore K, Amoah A, et al.
The Drakensberg declaration on the control of rheumatic fever and rheumatic heart disease in Africa. S Afr Med J 2006;96:246.
Sani MU, Karaye KM, Borodo MM. Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: An echocardiographic study. Cardiovasc J Afr 2007;18:295-9.
Akinwusi PO, Peter JO, Oyedeji AT, Odeyemi AO. The new face of rheumatic heart disease in south west Nigeria. Int J Gen Med 2013;6:375-81.
Ogah OS, Adegbite GD, Udoh SB, Ogbodo EI, Ogah F, Adesemowo A, et al
. Chronic rheumatic heart disease in Abeokuta, Nigeria. Data from the Abeokuta heart disease registry. Niger J Cardiol 2014;11:98-103.
Danbauchi SS, Alhassan MA, David SO, Wammanda R, Oyati IA. Spectrum of rheumatic heart disease in Zaria, Northern Nigeria. Ann Afr Med 2004;3:17-21.
Aliyu I. Infective endocarditis in a 12-year-old with subclinical rheumatic carditis. Niger J Cardiol 2015;12:42-4.
Bode-Thomas F, Ige OO, Yilgwan C. Childhood acquired heart diseases in Jos, North central Nigeria. Niger Med J 2013;54:51-8.
] [Full text]
McDonald MI, Towers RJ, Andrews RM, Benger N, Currie BJ, Carapetis JR, et al.
Low rates of streptococcal pharyngitis and high rates of pyoderma in Australian aboriginal communities where acute rheumatic fever is hyperendemic. Clin Infect Dis 2006;43:683-9.
Zhang W, Mondo C, Okello E, Musoke C, Kakande B, Nyakoojo W, et al.
Presenting features of newly diagnosed rheumatic heart disease patients in Mulago hospital: A pilot study. Cardiovasc J Afr 2013;24:28-33.
Cole TO. Rheumatic fever and rheumatic heart disease in the tropics with particular reference to Nigeria. Niger Med J 1976;6:123-6.
Kolo PM, Adeoye PO, Omotosho AB, Katibi IA, Afolabi JK. Rheumatic valvular heart disease as seen at echocardiography in Ilorin, Nigeria. Trop J Health Sci 2009;16: 18-23.
Fujii S, Funaki K, Denzumi N. Isolated rheumatic tricuspid regurgitation and stenosis. Clin Cardiol 1986;9:353-5.
[Figure 1], [Figure 2], [Figure 3]