Acute Rheumatic Fever Presenting With Severe Epistaxis in A Child in Sokoto, Nigeria

Background: Rheumatic Heart Disease (RHD) is a preventable cause of cardiovascular death and disability. It is preceded by Acute Rheumatic Fever (ARF), which has some diagnostic criteria. Some cases present with atypical features including epistaxis, which occurs in about 4% of ARF. Objective: To report a case of a child who had febrile illness with epistaxis, then 2 months after developed rheumatic valvular heart disease. Case Report: A 10-year old girl with one-week history of high-grade fever, A day history of bleeding through the nostrils. She did not have sore throat, joint pains nor past history of epistaxis. She was febrile (38.70 C), moderately pale and anicteric. She was transfused within 24 hours, treated for sepsis and malaria. She had features of cardiac decompensation on 4th day of admission despite adequate blood transfusion. Results of complete blood count, peripheral blood film and clotting profile were not suggestive of bleeding abnormalities. Fever resolved after several antibiotics and antimalarials. She defaulted follow up for 2 months then presented with progressive easy fatiguability, cough and fast breathing. No prior fever, joint pains or sore throat. She was in respiratory distress and tachycardic. She had displaced apex beat and apical pansystolic murmur. Echocardiography revealed RHD with mitral and aortic regurgitation. She is presently on follow up in Paediatric cardiac clinic. Conclusion: The patient had febrile illness with epistaxis and heart failure some weeks before diagnosis of RHD supporting the possibility of the initial presentation to be probably ARF with epistaxis. At risk children presenting with fever, epistaxis and cardiac decompensation should be evaluated for ARF.