A case report of isolated rheumatic tricuspid regurgitation and pericarditis

Rheumatic fever (RF) is a complex syndrome in which the human body develops antibodies against β-haemolytic streptococcus, and triggers inflammation in various organs. RF valvulitis mostly affects the mitral valve (MV) and, to a lesser extent, the aortic valve (AV). Isolated rheumatic tricuspid valve (TV) disease and pericarditis is extremely rare and is not well described in the RF guidelines. The current case demonstrates the echocardiographic findings of TV valvulitis of RF and describes the presentation and electrocardiogram (ECG) changes in pericarditis. We present the case of a 16-year-old male patient who developed upper respiratory tract infection followed by typical pericarditis chest pain. The patient had no history of joint pain or swelling, but was found to have a tricuspid regurgitation (TR) murmur upon examination. Laboratory investigations revealed an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and antistreptolysin O titres. ECG showed a wide-spread 1.5 mm upward concave ST-segment elevation. In echocardiography, the TV opened well with markedly thickened leaflets and severe TR, while the MV and AV were normal in both structure and function. The diagnosis of RF was established and treatment with high-dose aspirin and antibiotics was initiated. The treatment led to resolution of the chest pain. Our case highlights that the physical and lab findings of rheumatic TR are similar to those of rheumatic mitral regurgitation, with the exception of a high-velocity jet. Similarly, the presentations of rheumatic pericarditis are similar to other types and may also respond to high-dose aspirin. Finally, physicians should be familiar with both the common and rare complications of RF because the guidelines have placed Middle East region among the high-risk countries.