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A case of acute rheumatic fever presenting with syncope due to complete atrioventricular block/Tam atriyoventrikuler blok nedeni ile senkopla basvuran akut romatizmal ates vakasi.

Cases with acute rheumatic fever (ARF) are usually admitted to cardiology clinics withsigns and symptoms of poliartritis, pericarditis or heart failure. In these cases, the mostly observed electrocardiographic finding is the prolongation of PR interval (1). Rarely, second degree, third degree atrioventricular (AV) block and bundle branch blocks can also happen. In these cases with ARF; syncope, due to complete AV block is very rare and not frequently described. In the present study, we report a case with ARF admitted to our clinic with a history of syncope.

A 17 years old female patient was admitted to our emergency clinic with a history of syncope two or three hours before. She had an upper respiratory tract infection two weeks ago. She complained of bilateral ankle pain aggravated with motion. The electrocardiogram analysis revealed complete AV block (37 beat/min) and width of QRS complex was not more than 0.1 second (Fig. 1). Cardiac auscultation revealed the systolo-diastolic murmurs at the left sternal border and apex. Both bilateral ankles were tender but no redness or swelling were noted. Initial laboratory examination revealed a white blood cell count of 13,000/ml, sedimentation rate of 85 mm/h, C-reactive protein: 132 mg/dl, Antistreptolisin O (ASO): 870 Todd units (normal<200). Other biochemical parameters were normal. Echocardiographic examination was normal except minimal mitral regurgitation.

A diagnosis of ARF was made on the basis of carditis, arthralgia, high erythrocyte count, sedimentation rate, high ASO and a history of upper respiratory tract infection A temporary pacemaker was implanted on the day of admittance. Penicillin G procaine 800000 twice a day and aspirin 100 mg/kg/day were ordered. Type 1 second degree AV block and then first-degree AV block (PR: 0,28 sec, rate72 beat/min) were observed on the second and third days of the admittance respectively. On the fifth day, there was a normal sinus rhythm with a normal PR interval (PR 0.20 sec, rate 88 beat/ min). Ankle pain and chest pain subsided after the first and second day of the therapy, respectively. Pericardial friction rub resolved completely on the third day. The temporary pacemaker was removed on the fourth day. She was discharged on the 12th day.

The most common manifestation of ARF is polyarthritis. A pain of pericarditis, new onset murmur, pericardial friction rub and heart failure symptoms can be observed as initial ARF symptoms. Cases with a complete AV block are rarely observed (2-4). Reasons of the conduction disturbance are not well known but are attributed, in part, to an increased vagal tone (5). It has been suggested that the site of vagal hypertonia may be in the vagal center of the medulla, but there is evidence that this excessive nerve endings of heart. Besides this, inflammation of the atrioventricular node and the His bundle may be cause of AV block.

This data showed that syncope could be the first or the most dominant clinical manifestation of ARF. Other clinical signs may be indistinct. The ARF should be remembered in young patients presenting with syncope and AV block.


Nilufer Eksi Duran, Kenan Sonmez, Murat Biteker, Mehmet Ozkan

Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey


(1.) Clarke M, Keith JD. Atrioventricular conduction in acute rheumatic fever. Br Heart J 1971; 33: 12-5.

(2.) Reddy DV, Chun LT, Yamamoto LG. Acute rheumatic fever with advanced degree AV block. Clin Pediatr 1989; 28: 326-8.

(3.) Syncope in a middle aged male due to acute rheumatic fever. Indian Heart J 2004; 56: 668-9.

(4.) Keith JD. Overstimulation of the vagus nerve in rheumatic fever. Q J Med 1938; 7: 29.

Address for Correspondence/Yazisma Adresi: Nilufer Eksi Duran, MD.

Beyazkaranfil Sok. No: 4 D: 10, 34178, Acibadem, Istanbul, Turkey

Phone: +90 216 459 07 94 Fax: +90 216 456 63 21

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Article Details
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Duran, Nilufer Eksi; Sonmez, Kenan; Biteker, Murat; Ozkan, Mehmet
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Feb 1, 2009
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