Chinese Medical Journal

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RHEUMATIC HEART DISEASE WITH VASCULAR ENDOTHELIOSIS 55

prominent. The heart was enlarged mainly toward the left side. There was a systolic thrill over the sternal notch and the right first intercostal space. A blowing systolic and a diastolic murmur were heard over the right first intercostal space near the sternum. Over the apex there was also a diastolic murmur which was rough and rumbling in character. The pulmonary second sound was accentuated. The heart beat was regular. The blood pressure was 124/80-0 mm Hg. There were positive peripheral vascular signs of aortic insufficiency. The abdomen was slightly full. The liver was enlarged to 4.5 cm below the right costal margin, soft and non-tender. The spleen was enlarged to 7.5 cm below the left costal margin, with definite tenderness on palpation. No ascites or edema of the legs.

Laboratory findings. Hemoglobin 7 gm per cent, RBC 2,450,000 per cu mm. WBC and differential count were as shown in Table 1. Erythrocyte sedimentation rate 107 mm per hour. Hematocrit 29 per cent. Platelet count and reticulocyte count were normal, Blood Kahn and Wassermann tests were negative. Serum albumin 4.08 gm per cent, serum globulin 4.01 gm per cent. Venous pressure 200 mm of water column. Circulation time: arm to lung 10 seconds, arm to tongue 15 seconds. Blood culture negative. Thymol flocculation test 3 plus, cephalin-cholesterol flocculation test 3 plus. Urinalysis: albumin 1 plus, granular cast 0-3 per lower power field, RBC few. Stool examination revealed the presence of ascaris ova. EKG showed left ventricular preponderance. : [

Radiological examination of the chest revealed that the lungs were clear, the heart was enlarged mainly toward the left side, and the aorta was slightly widened with prominent pulsation. The esophagus was pushed backward by the enlarged left auricle as shown by barium meal examination.

After admission, the patient, in addition to the complaint of upper abdominal pain, developed edema of both legs, occasional petechiae over the skin and pain in the finger tips and toes. There were profuse sweating and cough with frothy sputum. He had shortness of breath while lying flat. No chills or fever. He was then diagnosed as a case of rheumatic double valvular disease with heart failure and subacute bacterial endocarditis. Besides the treatment for his heart failure, penicillin intramuscularly was started on February 2, 1954 with a dosage of 200,000 units every four hours for six weeks. The condition of the patient did not improve in the course of penicillin treatment. He still had profuse sweating and frequent attacks of pain over the spleen and the epigastric region as well as the tip of the fingers or toes. The spleen increased in size and reached at one time 12 cm below the costal margin.

On April 14, 1954 the bone marrow culture revealed the growth of streptococcus, D group, whereupon penicillin 200,000 units every four hours intramuscularly together with streptomycin 0.5 gm every twelve hours intramuscularly were given for another six weeks. Following this treatmetnt, the symptoms began to improve: there was better appetite, less sweating, the liver and the spleen decreased in size and the tenderness of the spleen disappeared. But the patient still had occasional epigastric pain and loose bowel movements. The pain in the tip of the fingers or toes occurred less frequently.

The patient was discharged on July 6, 1954 with cardiac findings same as on admission. The liver and the spleen were just palpable and non-tender. He gained 10 pounds of body weight. The blood taken from the ear lobe and the finger tip revealed a normal leukocyte count and differential count. He came back for a follow-up examination on August 30, 1954 and was found in fairly good general condition,