Clinical Improvement in an Adolescent with Severe Multivalvular Rheumatic Heart Disease During Conservative Management: A Case Report

Abstract

Rheumatic heart disease (RHD) remains an important cause of cardiovascular morbidity in children and adolescents, particularly in developing countries. Severe multivalvular involvement, especially severe mitral regurgitation (MR) accompanied by severe aortic regurgitation (AR), may result in substantial hemodynamic burden and frequently requires evaluation for definitive valve intervention. However, the clinical course of selected adolescents with severe multivalvular RHD managed conservatively remains insufficiently described. Case Report: A 14-year-old boy presented with fever, progressive dyspnea, chest pain, palpitations, and migratory joint pain with swelling, preceded by recurrent sore throat and episodes of migratory arthralgia. Laboratory investigations demonstrated elevated C-reactive protein, erythrocyte sedimentation rate, and antistreptolysin O titer. The clinical presentation was consistent with acute rheumatic fever, with carditis and polyarthritis fulfilling major Jones criteria and fever fulfilling a minor criterion, supported by evidence of preceding streptococcal infection. Echocardiography demonstrated severe MR, severe AR, and mild tricuspid regurgitation, with preserved left ventricular systolic function and low probability of pulmonary hypertension. The patient received medical treatment consisting of benzathine penicillin G, prednisone, aspirin, furosemide, and captopril, followed by regular secondary prophylaxis with benzathine penicillin G and clinical follow-up. During follow-up, the patient's fever, dyspnea, chest pain, palpitations, and migratory joint symptoms resolved, and he was able to perform light physical activities without symptoms. Serial echocardiography showed improvement of AR from severe to moderate, while severe MR persisted. At the latest follow-up, left ventricular ejection fraction remained preserved at 71%. Conclusion: This case demonstrates sustained clinical and functional improvement in an adolescent with severe multivalvular RHD during individualized conservative management and secondary antibiotic prophylaxis. However, clinical improvement did not indicate resolution of structural valvular disease, as severe MR persisted despite improvement of AR and preservation of left ventricular systolic function. Conservative management should therefore not be considered a substitute for definitive valve intervention but may provide clinical stability in selected patients while the indication and timing of intervention are reassessed through close clinical and echocardiographic follow-up.