Acute Myocarditis As A Complication Of Acute Rheumatic Fever With Right Atrium

Thrombus: Precision Treatment To Resolve The Complication

M.R.A. Dita1, N. A. Asbarinsyah2

1
General practitioner at Sari Asih Arrahmah Hospital, Tangerang, Indonesia
2
Cardiologist at Sari Asih Karawaci Hospital, Tangerang, Indonesia

Background
Acute rheumatic fever (ARF) is one of the national burdens in developing countries with low-income
population. The annual incidence ranges from <0,5/100.000 in developed countries to >100/100.000 in
developing countries. In Indonesia, the prevalence of ARF is still unclear due to limited research, but in
2017, as many as 10.408 children was inpatient because of ARF. The clinical manifestations of ARF are
quite diverse, one of them is carditis.The predominant manifestation of carditis in ARF is the
involvement of the endocardium presenting as valvulitis, but in rare case myocarditis may occur.
Myocarditis in ARF usually lead to heart failure and it may cause cardiogenic shock. It is important to
find the right diagnosis and treatment to resolve the complication and to do the prevention for the long-
term effect to the patient.
Case Illustration
A 14-year-old child presented to ER with shortness of breath 4 days before admission, accompanied
with dyspneu on effort and orthopneu. She also complained joint pain in both knees in the last 1 month
accompanied by sore throat. She was alert, blood pressure was 120/70, heart rate was 120, regular,
respiratory rate was 48 with oxygen saturation of 96% in room air, there was an increase in jugular
venous pressure, crackles in both lungs, and the widening of heart border. The ASTO value was 800, the
CRP value was 17.1, the electrocardiogram showed sinus tachycardia, the thorax x-ray showed
cardiomegaly, and the echocardiography showed dilatation of all chamber of the heart, global
hypokinetic, ejection fraction was 18 – 23% and a thrombus was found in right ventricular sized
2.2x2.9cm. She was diagnosed with acute decompensated heart failure due to myocarditis related to
ARF complicated with right atrium thrombus. She was treated with heart failure medications, steroids,
benzathine penicillin, and oral anticoagulant. After 1 month, the evaluation of echocardiography showed
the ejection fraction increased to 43.35% and the thrombus was disappeared.
Discussion
In this case, acute myocarditis occurred as a complication of acute rheumatic fever due to infection of
Group A Streptococcus. This patient fulfilled the jones criteria which consist of carditis, polyarthralgia
and the elevation of CRP with evidence of Group A streptococcus infection. Acute myocarditis led to
the acute decompensated heart failure and a thrombus was formed in the right atrium due to blood stasis.
The treatment was given and it resolved the acute myocarditis in this patient. The patient would have
benzathine penicillin injection every month until the next 10 years as a secondary prevention for the
recurrent rheumatic infection.
Summary
The case of an adolescent presenting with symptoms and signs of acute myocarditis due to acute
rheumatic fever was reported. Early diagnosis and appropriate management are determining key factors
which will influence the clinical outcome and prognosis of this patient.
Keywords: Acute Rheumatic Fever, Myocarditis, Right Atrium Thrombus
 Figure 1.ECG taken on presentation showing sinus tachycardia

Figure 2.Thorax x-ray showed the cardio-thorax ration was >50% that indicate the cardiomegaly of the patient
 Figure 3.Thorax x-ray 1 month after inpatient showed normal cardio-thorax ratio

Figure 4.Echocardiography showed dilatation of all chamber of the heart, global hypokinetic, EF 18-24%
Figure 5.Echocardiography 1 month after inpatient showed an increase in EF to 43.35%

Figure 6.Echocardiography 2 month after inpatient showed an increase in EF to 44.9%

Figure 7.Echocardiography 6 month after inpatient showed an increase in EF to 49.8%