COMPLETE HEART BLOCK COMPLICATING ACUTE RHEUMATIC FEVER

5 December 2010 Dear Editor, One of the common manifestations included in the Jones Criteria for diagnosis of Acute Rheumatic Fever (ARF) is first-degree heart block. Higher grades of heart block, including complete heart block, are described infrequently in the literature, but have the potential to cause severe symptoms, especially in isolated regions where this disease remains relatively common. An 8-and-a-half year old indigenous boy was referred with complete heart block in the setting of ARF. He had previously been entirely well, with no previous episode of ARF and no previous cardiac symptoms. He presented with a 1-week history of fever and migratory arthritis of his left knee and ankle. Initial examination did not reveal a cardiac murmur. His left knee was mildly swollen with tenderness to palpation and with reduced movement. ECG demonstrated complete heart block with a junctional escape rhythm at 60–70 beats per minute (Fig. 1a). Blood tests revealed elevated acute phase reactants (ESR 56; CRP 154; WCC 15.1; neutrophils 10.08; platelets 421), ASOT 1520 (<200), Anti-Dnase B 1080. Other relevant results included CK 221 (31–152) and cTnI 0.2 (<0.04). (a) Complete Heart block with narrow complex junctional escape rhythm in haemodynamically stable child. (b) Recovery phase demonstrating second-degree AV-block in same child. Echocardiography revealed a structurally normal heart with physiologic mitral regurgitation. There was no evidence of valvular heart disease and cardiac function and chamber size was normal. There was no pericardial effusion. The child commenced aspirin at anti-inflammatory doses and showed rapid improvement in symptoms of arthritis. Prednisone 1 mg/kg daily was also commenced and he was placed on telemetry to observe the progress of his heart block. He received intramuscular benzathine penicillin and commenced a course of monthly penicillin prophylaxis against further episodes of ARF. Blood and throat cultures were negative for Group-A streptococci. Over several days observation, the complete heart block showed complete recovery, progressing through second degree heart block (Fig. 1b) to sinus rhythm and first-degree heart block upon discharge. No active treatment was required for heart block during his admission. Complete heart block is rarely reported in association with acute rheumatic fever.1–3 In 508 patients seen with ARF in Toronto from 1948–1971, 3 had ECG evidence of complete heart block.4 The natural history tending to spontaneous resolution in this case is similar to other reports in the literature. This patient remained haemodynamically stable throughout, and did not require any pharmacologic treatment or pacing. Temporary pacing, via trans-venous electrode may be instituted for complete heart block associated with haemodynamic compromise. Indeed, two case reports exist documenting in-hospital cardiac arrest as a result of complete heart block during admission for ARF in a 12–year-old boy from Hobart and a 13-year-old boy in Pittsburgh.5,6 This instructive case highlights a potential cause of sudden cardiac death in ARF, and encourages wider awareness of this rare but serious complication.

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