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Summary:The early onset of rheumatic fever and rapid progression to severe and incapacitating chronic valve disease, as in other developing tropical countries, has been repeatedly highlighted in Nigeria. Of interest is the fact that the peak frequency of age distribution is in the early child-bearing age. This study was undertaken to evaluate the clinical course of 44 pregnancies in 32 Nigerian women between 16 and 38 years of age (mean 27), with rheumatic heart disease. The patients received careful clinical assessment on follow-up at 1 to 4 week intervals depending on grade of symptoms and stage of gestation. All deliveries were conducted in the hospital and patients were clinically reassessed 6 months after delivery. The key to grading of symptoms was the New York Heart Association functional classification, coordinated with findings on detailed clinical examination. The majority of the cases were gravida 3 but closely followed by primigravidae. Mitral valve disease with dominant incompetence was the commonest valve lesion. Nevertheless, acute pulmonary edema (1 I cases), the cause in 2 of the 3 maternal deaths, was the most frequent complication. Congestive heart failure occurred in 7 cases, and infective endocarditis in 4 cases. The only patient with mitral valve prosthesis was on warfarin prophylaxis and had 2 of the 3 stillbirths in the series. On clinical reassessment 6 months later. there was evidence of progression of functional state in 8, and interestingly, more maternal deaths occurred in less than a year. These findings are no doubt related to the presently limited medical facilities, inadequate socioeconomic and public health standards, and the need for health education in the country, and not excluding the seemingly rapid progression of rheumatic heart disease itself. In light of such circumstances, the relevant aspects of the accepted program of management in the more developed temperate countries would need to be meaningfully adjusted and suggestions have been made to this effect.

Following electrocardiographic analysis, isolated or combined blocks in the intraventricular trifascicular system including predivisional left bundle branch block with left posterior hemiblock in Nigerians are presented and the underlying causes reviewed. The rarity of complete heart block, despite the not uncommon fascicular blocks, is of interest and may be related to the population age structure considering the invariably slow rate of degeneration of conduction fibres in the system.

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This case report describes a 12-year-old boy with cardiac involvement by Burkitt's lymphoma producing complete atrioventricular block which at one stage showed phenomene d'accrochage. Electrocardiographic findings are discussed and the importance of routine electrocardiogram in Burkitt's lymphoma stressed. Burkitt's lymphoma is the commonest childhood malignancy in most of the endemic areas in tropical and subtropical Africa (Burkitt and Wright, I97oa) including Ibadan, Nigeria (Edington and Maclean, I964). The disease is invariably extensive and multifocal and has a wide tissue and organ distribution. Cardiac involvement is not infrequent (Burkitt and Wright, I970b). Often this consists of nodular deposits on the epicardium, most commonly the right atrium. The myocardium may be involved directly or by extension of the epicardial deposits. Tumour deposits also occasionally appear in the endocardium with consequent polypoid masses in the cardiac chambers. Despite the relative frequency and wide distribution in the heart, Burkitt's lymphoma, to our knowledge, has not been previously described as a cause of intracardiac conduction defects. We report a case of Burkitt's lymphoma to record a rare presentation, heart block, and to discuss the probable significance of electrocardiographic changes in the diagnosis and assessment of patients with this rapidly fatal malignancy.