Rheumatic Mitral Valvulitis with a “Giant Vegetation”?A Case
Case Report
A 10-year-old female child was referred for echocardiographic evaluation with an apical systolic murmur. The child was having recurrent episodes of rheumatic fever (febrile illness with joint pains) at the age of 5 - 6 years and taken some treatment from the local medical practitioner, but she was not taken penicillin prophylaxis earlier. The child was remained afebrile for long period and no precipitating factors of infective endocarditis such as dental or genitourinary procedures in the past. General examination revealed normal growth and development, no cyanosis and clubbing and peripheral signs of infective endocarditis such as Osler’s nodes, Janeway lesions, Roths spots and splinter haemorrhages were not present and they are relatively rare in children.

Physical examination revealed a grade 3/6, blowing, high pitched, holosystolic murmur with a constant intensity and duration on dynamic auscultation and loudest at the apex with a radiation to left axilla and transmitted to the left infrascapular area and vertebral coloumn and it is due to the flow generating the murmur is directed posterolaterally within the left atrial cavity, suggesting the murmur of mitral regurgitation due to the rupture of chordae tendineae of anterior mitral leaflet. Blood cultures were negative. Blood chemistry revealed the positive serum ASO (anti-streptolysin O) titer, suggesting a recent streptococcal infection and other parameters were normal. X-ray chest revealed moderate cardiomegaly and ECG revealed a left ventricular volume overload pattern of eccentric hypertrophy due to LV dilatation as a result of severe mitral regurgitation and a normal sinus rhythm. Transthoracic echocardiography revealed a giant vegetation “popcorn” like in Figure 1, Figure 3 and Figure 4 and “cucumber” like in Figure 2, mainly attached to base and apical portion of anterior mitral leaflet as shown in Figure 31 and manifested in various size and shapes as shown in Figures 1-37....