A 72 year old female presents to the Emergency Department with shortness of breath for the past two days. She has a past medical history of HTN and hypothyroidism. Vital signs are as follows- Temp 36.2 C, BP 135/74, HR 87 bpm, SpO2 91% on RA, RR 18. Patient reports she recently had a week of sore throat and rash that resolved spontaneously. On your exam, the patient has rales bilaterally without wheezing. She has trace pitting edema in the lower extremities. On EKG, the patient has diffuse PR depression in all leads. What murmur do you expect to auscultate in this patient? 

A- Holosystolic murmur loudest at the apex

B- Mid-systolic click followed by crescendo murmur

C- Loud opening snap followed by rumbling diastolic murmur 

D- High pitched blowing diastolic murmur

Answer: Holosystolic murmur auscultated loudest at the apex 

This patient is presenting in acute heart failure following a recent sore throat concerning for strep pharyngitis and rheumatic heart disease. In the acute setting, these patients may present with pericarditis, myocarditis, or acute heart failure secondary to valvular regurgitation. Most commonly, the mitral valve is affected, however, the aortic and tricuspid valves are at risk as well. Treatment includes antibiotics, anti-inflammatories, and management of acute heart failure. Steroids and IVIG are controversial and should be discussed depending on the care. Patients are at high risk to develop valvular complications years after their initial presentation. Mitral stenosis is the most common complication seen long-term. Stenosis is caused by chronic fibrosis and scarring of the valve leaflets.

References:

Albert DA, Harel L, Karrison T. The treatment of rheumatic carditis: a review and meta-analysis. Medicine (Baltimore). 1995;74(1):1-12. doi:10.1097/00005792-199501000-00001​

Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016;2:15084. Published 2016 Jan 14. doi:10.1038/nrdp.2015.84​