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Case Study

Rheumatic Carditis Or.....?? A Case Study
Dr [MS] Meena T Mankani

Understanding Rheumatic Carditis:
Rheumatic fever is a systemic illness nearly always accompanied by arthritis and sometimes by skin rashes, carditis and neurological features [Sydenham's chorea]. The arthritis of rheumatic fever [sometimes called acute rheumatism, but not to be confused with rheumatoid arthritis] is an acute painful inflammation of one or several joints. There is commonly, but not invariably, a history of sore throat 2-4 weeks before the onset of joint symptoms. In adults, joint symptoms tend to be more prominent than carditis, while in children under six years the converse may be true.

Carditis, which usually occurs within a week or two of the onset of the arthritis, is the most important manifestation of rheumatic fever. It presents as palpitation, chest pain or breathlessness. There is usually a tachycardia and often cardiac enlargement. Cardiac failure may result either from impaired function of ventricular muscle or from mitral or aortic incompetence caused by valve damage.

A fever, leukocytosis and raised ESR are usual and non-specific , but useful for following the progress of the disease once diagnosed. The fever, in some cases, runs very high ; however in most cases the temperature is not more than one or two degrees above the normal. Culture of group A beta haemolytic streptococci from a throat swab, is positive in only a minority of cases by the time rheumatic fever is clinically manifest. Antistreptolysin O antibodies [ASO /titre] are useful evidence of recent streptococcal infection; but ASO titres are normal in about a fifth of adult cases of rheumatic fever. Echocardiography is useful for detecting cardiac dilatation and valve abnormalities.

Predisposition to this complaint seems to lie between the years of fifteen and forty. Early childhood and old age are generally exempt.

Case: 2. The Patient
She is our 57 year old dear mother; obese, mild, timid, very God fearing and genuinely philosophical . Has always suffered from eczema and vague aches and pains. She immensely loved sweets [3], eggs[3], fats[3] and icecreams[3], and always had profuse sweats all over, that invariably left indelible yellow stains. She had no problem with her menses but always suffered from early morning hurried diarrhoeas. Very hot and thirsty. Salivated [2] and uncovered her feet during sleep[3]. Generally dreamt of relatives who were dead long past. She had not a single tooth left since all of them had prematurely fallen off 10 years back.

Had faced many hardships in life with courage, but the recent passing away of my father after a prolonged sickness [whom she had devotedly served day and night with great love] and the consequent "not so pleasant" behaviour of some of her sisters-in-law, affected her immensely. She started brooding and weeping most of the time and tried to find some consolation in her religion and its philosophy. She drew her strength from her faith in God and thought it was her duty to be good to one and all, even to the 'not so pleasant' people.

But now gradually she started falling sick.

3] Derangement of the dynamis -OPD
She started losing her appetite. Along with it, gradually, she started having pain in her left knee joint, that increased in intensity with every passing day. Slowly, even her right knee started aching to some extent. No swelling, no heat, no redness. But the pain was excruciating [3] , shooting down to the toes, agg on motion [3] and somewhat amel. by external heat [2]

Around 10-12 days later, she developed symptoms of endocarditis with mitral insufficiency and she seemed to be going into CCF. Following were the symptoms:

Decreased urine output with oedematous swelling all over. Orthoponoea due to pulmonary congestion. P-120/m, feeble. T-100 * F, continuous B.P 130/80 mm of hg. Face cyanotic. Limbs cold. General pulsations. She felt whole left side of the body was very weak. Could not tolerate pressure of clothing around her chest. The condition seemed grave and something had to be done immediately.

4] Diagnosis and the subsequent management of the case:
Now I had a choice. Either I could call in my family pathologist and the cardiologist, get the case thoroughly investigated and get her rushed to the hospital, or stand up courageously with my unshaken faith in my science and give myself some time to wait and watch over carefully before I ridiculed my science with my failure. I opted for the latter.

As far as the diagnosis was concerned, though unusual at this age [but not impossible] , the typical presentation of the disease picture pointed strongly towards Rheumatic Carditis. So I first took the following totality:
a] Ailments from, grief [Sys3. p.4]
b] Delusions, wrong, suffered wrong; he has [sys p 82]
c] Delusions, neglected: duty; he has neglected his [Sys p 67]
d] Brooding [Sys p 24]
e] Heart, endocarditis, sepsis [Ph 4 , p 177]
f] Extremities, pain, rheumatic, left to right [Sys p 1218]
g] Chest, clothing agg [Sys p 1003]
h] Heart, mitral valve [Boger 5, p 254]

On 22/9/97, she was put on complete bed rest and was given Naja 1M in water, frequent doses by plussing. Exactly 2 hours after giving the first dose, she felt hungry for the first time after so many days and ate well. Gradually her urine output increased, relieving her of the oedema and the breathlessness. By 30/9/97 her pulse settled down to 100/m and T to 99.2 * F. Her limbs got warmer and her face was no longer cyanotic. Also, the clothing around her chest did not distress her anymore. There was no pain in the right knee, and that of the left knee was better.

But now she started getting worse again. There was no oedema, no breathlessness, no cyanosis. But she started getting excruciating pains on the left side of her head and chest and so also the whole of her left lower limbs. The pains were very severe, paroxysmal and of shooting type. Her whole of left side got very sore and painful, but now there seemed to be strong pericardial mischief. Also, she felt strong pulsations all over.

Now Spigelia was selected due to following reasons: 
a] Chest, pain , heart, rheumatic [Sys p 1029]
b] chest, pain, heart, extending to head [Sys p 1029]
c] HERING 'S GUIDING SYMPTOMS gave these symptoms:
Acute inflammatory rheumatism
Rheumatism attacking heart.
Endocaridtis with insufficiency of mitral valve after acute articular rheumatism.
Neuralgia amel. by warm applications.

Heart affections and neuralgia
Rheumatic carditis, trembling pulse, whole left side sore.

She was now put on Spigelia 1M in water, frequent doses by plussing. Soon all her discomfort disappeared completely, except the general pulsations. Her left knee joint pain was much better, but yet++ on movement. Now gradually the pulsations would localise in all odd places like ankles, elbow, stomach etc. besides, since 11/11/97, as soon as the clock struck 4 p m she would get violent palpitations, which would gradually taper off after 8 or 9 p.m. Her pulse now was 110/m strong, T -99*F, continuous and B.P 120/80 mm of Hg.

The totality now considered was:
a] Generals, afternoon, 16h [Sys p 1545]
b] heart, palpitation, metastasis from [Ph R. P 180]
c] Pulsation, throbbing , odd places in [Ph R. p 280]
d] Chest, inflammation, heart, endocardium, mitral insufficiency and violent, rapid action, with [Sys p 1014]
e] Chest , inflammation, heart, endocardium, rheumatic [Sys p 1014]
f] Extremities, pain, rheumatic, acute [Sys p 1218]
So, on 15/11/97 she was given Cactus-g 1M in water, frequent doses by plussing. She got well completely except for some pain in her left knee which yet persisted.
On 27/11/97, she developed a cough which was particularly in 2 bouts in quick succession. The temperature now remained normal and the Pulse -84/m . Now going back to the generals and the peculiar cough at the moment, the remedy now selected was Merc-sulph [rubric: cough, paroxysmal, consisting of two coughs, quick succession, in -Sys p 978]

She was now given Merc-sulph 1M in water, frequent doses by plussing. Soon her cough disappeared and the knee pain lessened further. She is now absolutely alright, performing her regular chores without any problem. However , a negligible amount of knee pain only on motion is yet persisting. She continues to be onMerc-sulph 1M in plussing doses.

5] The investigations:
Some investigations were performed on 14/11/97 . The ASO titre showed negative, so also all her other blood tests. The 2 D Echocardiogram also showed no abnormalities.

6] Some points to ponder:
Due to over- anxiety, my failure to perform the necessary investigations during the active phase of the disease process will always make one wonder about the real nature of the disease, more so when we consider the age factor. The ASO titre being negative also cannot satisfy our doubt since as per Davidson's Principles and Practice of Medicine, it can be so in one -fifth of the adult patients of rheumatic fever. However, the classic symptomatology of rheumatic carditis being there , the question by and large still remains.

Rheumatic carditis or....???

Anyway, all is well that ends well.

References :
1] Davidson's Principles and Practices of Medicine
2] Special pathology and diagnostics with Therapeutic Hints - Dr C G Raue.
3] Synthesis
4] Phatak's Repertory
5] Boger's Synoptic key.