A 13-year-old girl is brought to the clinic for a routine health maintenance examination. She recently immigrated from Southeast Asia and has no known health concerns. Medical history includes a febrile illness a year ago that was followed by development of pain and swelling in the knees and wrists. At that time, the patient was treated with nonsteroidal anti-inflammatory medications, and her symptoms resolved. Her last physical examination, 2 years ago, was prior to her immigration and was normal. She plays soccer and swims every weekend. Blood pressure is 110/70 mm Hg and pulse is 70/min and regular. Cardiac examination reveals a diminished S1 and a grade 2/6, high-pitched, holosystolic murmur that is loudest at the apex and radiates to the left axilla. The lungs are clear to auscultation. The abdomen is soft, nontender, and has no hepatosplenomegaly. Echocardiogram demonstrates mild mitral regurgitation. Which of the following is the most appropriate treatment for this patient?

Question

A 13-year-old girl is brought to the clinic for a routine health maintenance examination.  She recently immigrated from Southeast Asia and has no known health concerns.  Medical history includes a febrile illness a year ago that was followed by development of pain and swelling in the knees and wrists.  At that time, the patient was treated with nonsteroidal anti-inflammatory medications, and her symptoms resolved.  Her last physical examination, 2 years ago, was prior to her immigration and was normal.  She plays soccer and swims every weekend.  Blood pressure is 110/70 mm Hg and pulse is 70/min and regular.  Cardiac examination reveals a diminished S1 and a grade 2/6, high-pitched, holosystolic murmur that is loudest at the apex and radiates to the left axilla.  The lungs are clear to auscultation.  The abdomen is soft, nontender, and has no hepatosplenomegaly.  Echocardiogram demonstrates mild mitral regurgitation.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d639_782d_bc81_111eeaaf0a74_MD0003_00 This patient's history of polyarthritis after a febrile illness and presence of mitral regurgitation on echocardiogram are suggestive of rheumatic heart disease (RHD). RHD is chronic valvular damage (eg, mitral regurgitation/stenosis) resulting from one or more episodes of acute rheumatic fever (ARF). ARF is a complication of group A Streptococcus (GAS) infection characterized by a constellation of clinical findings (eg, arthritis, carditis, subcutaneous nodules, erythema marginatum, chorea). Patients with a history of ARF are at high risk for recurrence and progression of RHD with repeated episodes of GAS pharyngitis. Therefore, antibiotic therapy is required to eradicate GAS at the time of diagnosis. In addition, patients should receive prophylaxis with intramuscular benzathine penicillin G every 4 weeks to prevent recurrence. The total duration of antibiotic prophylaxis depends on the severity of heart disease at presentation. This patient has mild mitral regurgitation and should also be monitored every 6-12 months for signs of left ventricular dysfunction, in which case valve replacement may be an option. (Choice A) Methotrexate is a folate antimetabolite typically used for neoplasms and rheumatologic disease. Although it is commonly used for rheumatoid arthritis, it does not treat ARF or RHD. (Choices B and D) Mitral stenosis is a common presentation of RHD decades after the initial episode of ARF, and it can cause atrial fibrillation due to a dilated left atrium. Beta blockers (eg, metoprolol) and warfarin may be required in this situation but are not indicated in this patient, who has no mitral stenosis or atrial fibrillation. (Choice E) Penicillin is needed in patients with a history of ARF to prevent future episodes of GAS pharyngitis. Failure to provide antimicrobial prophylaxis may lead to progression of RHD. Educational objective: Patients with a history of acute rheumatic fever are at risk of progressive rheumatic heart disease from recurrent group A Streptococcus pharyngitis. Treatment with penicillin prophylaxis prevents streptococcal infections and limits the progression of heart disease. References: Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/23546444) Rheumatic heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/22405798)

A 13-Year-Old Girl Is Brought to the Clinic for a Routine