Atrioventricular block complicating acute streptococcal tonsillitis.

Caraco, J. J.; Arnon, Ron; Raz, Itamar

doi:10.1136/hrt.59.3.389

Cited by 11 publications

(8 citation statements)

References 5 publications

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“…Toxin-mediated myocarditis seems to be the most popular explanation for this condition (Gore & Saphir, 1947;Caraco et al, 1988;Karjalainen, 1989;Gill et al, 1995;Talmon et al, 2008) but needs further investigation. As the streptococcal isolate from case 2 was not available for typing, we typed the organism in case 1 and found it to be 'emm101' -not a known rheumatogenic strain.…”

Section: Discussionmentioning

confidence: 99%

Non-rheumatic streptococcal myocarditis – warm hands, warm heart

Chaudhuri

Dooris

Woods

2013

Journal of Medical Microbiology

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Acute myopericarditis in the developed world is ascribed predominantly to viral infections. Enteroviruses and adenoviruses are commonly implicated but are not routinely tested for, as the condition is self-limiting and has a good prognosis. However, we recently encountered two cases of acute myopericarditis associated with concomitant Streptococcus pyogenes [group A Streptococcus (GAS)] pharyngotonsillitis. A microbiological aetiology was pursued because of the severity of the upper respiratory tract infection and associated systemic illness rather than to explain the myopericarditis per se. We report these two cases and review the literature of this potentially under-recognized condition. In the absence of features of rheumatic fever, we hypothesize a toxin-mediated process as opposed to an immune-mediated one. We suggest that perhaps all patients with myopericarditis be assessed for GAS pharyngitis. Case reports Case 1A 29-year-old male was brought to our emergency department with left-sided chest pain and high fevers. He had developed a sore throat 3 days prior to admission which progressed to odynophagia and mild trismus at the time of admission. Urgent ENT consultation confirmed a peritonsillar abscess, which was treated with incision and drainage under local anaesthesia. Simultaneous investigation of his chest symptoms revealed widespread 'saddleshaped' ST elevation and a raised serum cardiac troponin I (cTnI) (peak level 25 ng l 21 ). An echocardiogram revealed mild segmental systolic dysfunction and regional wall motion abnormalities (Table 1). The temporal pattern of cTnI levels was not monophasic and the ECG evolution was not typical of myocardial infarction. Coronary artery disease was a possibility, which prompted additional investigations of cardiac magnetic resonance imaging (MRI) and left heart catheterization. MRI showed moderate systolic dysfunction left ventricular ejection fraction 39 % which was segmental but no obstructive coronary artery disease was found on coronary angiogram. Abnormal MRI was consistent with diffuse myopericarditis, with oedema and late gadolinium enhancement in subepicardial and intramural regions (Fig. 1). Left heart catheterization revealed abnormal haemodynamics of relative hypotension with elevated left ventricular enddiastolic pressure. A diagnosis of myopericarditis was made and the patient was admitted with cardiac monitoring.Intravenous penicillin was commenced for peritonsillar abscess, which shortly grew group A Streptococcus (GAS). Streptococcal serology done soon after admission was negative. The patient remained febrile, appeared flushed with warm bounding peripheries but was haemodynamically robust (heart rate of 90-100 b.p.m.; blood pressure of 130/70 mmHg; mean arterial pressure of 90 mmHg). Minimal improvement of his pharyngeal symptoms prompted a repeat incision and drainage, plus the addition of intravenous lincomycin for presumed anaerobic bacterial infections potentially resistant to penicillin. He made a gradual recovery over 5 days and lincomycin w...

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Section: Discussionmentioning

confidence: 99%

Non-rheumatic streptococcal myocarditis – warm hands, warm heart

Chaudhuri

Dooris

Woods

2013

Journal of Medical Microbiology

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“…This may be due to the higher glycogen content of the conduction system. 7,12,25 A co-existent sub-clinical myocarditis cannot be entirely excluded in our patient, despite the benign clinical course and normal echocardiograms. A cardiac MRI scan was not obtained, which is a limitation of this case report.…”

Section: Discussionmentioning

confidence: 57%

“…The presence of junctional tachycardia and intermittently conducted sinus beats with prolonged P-R interval and right bundle branch aberrancy (Fig 1) may constitute evidence of possible acute inflammation to the atrioventricular conduction system. 7,12 An alternative explanation can be speculated for the conducted beats with prolonged P-R interval and right bundle branch. This may be because of the premature timing of the sinus beats relative to the atrioventricular conduction system that had not fully recovered following its depolarisation from the preceding junctional beat.…”

Section: Discussionmentioning

confidence: 99%

Junctional tachycardia in a child with non-rheumatic fever streptococcal pharyngitis

2016

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Accelerated junctional rhythm has been reported in children in the setting of acute rheumatic fever; however, we describe a hitherto unreported case of isolated junctional tachycardia in a child with streptococcal pharyngitis, not meeting revised Jones criteria for rheumatic fever. A previously healthy, 9-year-old girl presented to the emergency department with complaints of sore throat, low-grade fever, and intermittent chest pain. She was found to have a positive rapid streptococcal antigen test. The initial electrocardiogram showed junctional tachycardia with atrioventricular dissociation in addition to prolonged and aberrant atrioventricular conduction. An echocardiogram revealed normal cardiac anatomy with normal biventricular function. The patient responded to treatment with amoxicillin for streptococcal pharyngitis. The junctional tachycardia and other electrocardiogram abnormalities resolved during follow-up.

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“…Chest pain, either mimicking angina or con sistent with pain of pericardial origin, is usually the presenting symptom. The ECG can be interpreted as demonstrating only acute pericarditis, but enzyme release con firms the myocardial component of the in flammatory process [7][8][9], Involvement of the heart conduction system is also possible, as demonstrated by our recent report of complete atrioventricular block complicat ing acute streptococcal tonsillitis [10], Nev ertheless, the long-term prognosis of overt infectious myocarditis is thought to be good, and the patient can generally be assured of complete recovery [5,8],…”

Section: Discussionmentioning

confidence: 99%

Acute Nonrheumatic Perimyocarditis Complicating Streptococcal Tonsillitis

Putterman¹,

Caraco²,

Shalit³

1991

Cardiology

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Streptococcal infection is a rarely recognized cause of nonrheumatic perimyocarditis. We report a case of a young patient who developed acute perimyocarditis as manifested by diffuse electrocardiogram changes, and markedly elevated cardiac enzymes, concurrently with streptococcal tonsillitis. Despite the dramatic presentation, the patient recovered uneventfully. We conclude that streptococci can involve the heart also directly by a bacterial component or toxin, and not only through a delayed immunologic mechanism as in rheumatic fever. Further studies are necessary to accurately determine the incidence of myocardial involvement during early stages of streptococcal infection.

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Atrioventricular block complicating acute streptococcal tonsillitis.

Cited by 11 publications

References 5 publications

Non-rheumatic streptococcal myocarditis – warm hands, warm heart

Non-rheumatic streptococcal myocarditis – warm hands, warm heart

Junctional tachycardia in a child with non-rheumatic fever streptococcal pharyngitis

Acute Nonrheumatic Perimyocarditis Complicating Streptococcal Tonsillitis

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