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Describe the echocardiographic evolution of valvular regurgitation in patients with rheumatic carditis (RC) and to establish which features may predict long-term outcome, in the absence of acute rheumatic fever (ARF) relapse. Retrospective cohort study. 123 patients with confirmed RC, diagnosed at Turin Children's Hospital between 2010 and 2019. We reviewed the echocardiographic images recorded at diagnosis, after 6-8 weeks, after 6 months, then yearly, to assess which predictors at diagnosis are associated with the degree of improvement at 6 months. Secondly, we tested which variables predict the regression of pathological regurgitation of mitral (MV) or aortic valve (AV) during follow-up. At onset, 90.2% patients had MV regurgitation while 42.3% had AV involvement. 115 (93.5%) patients were treated with steroids and 70.8% experienced a downgrading of RC after 6 months. Steroids were associated with better outcomes at six months (p = 0.01). During follow-up (median 56.1 months), MV improved in 58.6% patients, AV in 46.2%. At multivariate analysis, erythrocyte sedimentation rate (ESR) was positively associated with regression of MV regurgitation (OR 1.02, p = 0.02), while higher degree of carditis at onset was negatively associated (OR 0.04, p < 0.01). Conversely, regression of AV regurgitation was more frequent in patients with bi-valvular involvement (OR 20.5, p = 0.03) and in absence of murmur at onset (OR 0.04, p = 0.01). This study indicates that valvular regurgitation improves overtime if there are no ARF recurrences during follow-up, especially when the MV is involved and in patients treated with steroids.

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Lyme disease is a tick-borne illness known for its ability to cause multi-systemic manifestations. It can affect several different systems, including neurological, musculoskeletal, and dermatological systems. However, one of the most concerning biological systems affected is the cardiac system. Lyme carditis typically presents with varying degrees of atrioventricular (AV) block. Additionally, current literature also endorses atypical manifestations, including but not limited to atrial fibrillation and bundle branch blocks. These atypical manifestations are important as they can be the first presenting symptoms in patients with Lyme disease. Therefore, educating clinicians on various signs, symptoms, and manifestations of Lyme carditis remains paramount in reducing morbidity and mortality. We conducted a literature review using PubMed, MEDLINE, and CINAHL, collecting a total of 13 articles to gather information on atypical manifestations of Lyme carditis. This literature review serves to summarize the current research and studies describing these cardiac manifestations and the cardiac pathophysiology associated with Lyme disease. These findings aim to contribute to the expanding understanding of Lyme carditis, subsequently preventing long-term effects through prompt diagnosis and treatment.

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Key Clinical Message: Rheumatic heart disease is a preventable disease. Patients may not present with a typical history of sore throat and polyarthritis but may present with Sydenham's chorea. We should not rely completely on clinical findings to rule out carditis. Echocardiography should be done to rule out subclinical carditis. Abstract: Sydenham's chorea is a major manifestation of rheumatic fever. It occurs primarily in children and is seen rarely after the age of 20 years. We describe a 16-year-old girl who presented with purposeless involuntary movements of her upper and lower limbs. Laboratory blood reports showed raised erythrocyte sedimentation rate and anti-streptolysin O. 2D Doppler Echocardiography confirmed subclinical carditis, thickened mitral and aortic valve with mild mitral regurgitation. She was managed as Acute Rheumatic Fever with oral Phenoxymethyl penicillin and Carbamazepine. At the latest follow-up interviewing the caregiver, the patient had no sequelae. Early diagnosis is key to preventing late consequences of acute rheumatic fever and rheumatic heart disease. Sydenham's chorea is a rare presentation of acute rheumatic fever. The absence of clinical carditis does not rule out carditis.

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Infective endocarditis (IE) is a severe yet rare condition in pediatric patients, often presenting with nonspecific symptoms, which can complicate diagnosis. Chordae tendinea rupture and pulmonary valve involvement are uncommon complications of IE, warranting timely recognition and management to prevent further morbidity and mortality. We present a case of a nine-year-old male child with a rare presentation of endocarditis complicated by chordae tendinea rupture and pulmonary valve vegetation. The child presented with a one-month history of abdominal pain, dyspnea, edema, and cough. Initial investigations revealed severe mitral regurgitation (MR) and tricuspid regurgitation (TR), chordae tendinea rupture, and vegetation on the pulmonary valve. Despite antibiotic therapy, the child's symptoms persisted, necessitating transfer to a tertiary care center for advanced cardiac management. Chordae tendinea rupture is a rare but critical complication of endocarditis, leading to significant valvular dysfunction. Pulmonary valve involvement in endocarditis is relatively uncommon, with most cases involving the mitral and aortic valves. Identifying vegetation on the pulmonary valve underscores the importance of comprehensive echocardiographic evaluation in patients with suspected endocarditis, regardless of valve involvement. Management of pediatric endocarditis involves a multidisciplinary approach, including antibiotic therapy and potential surgical intervention. Despite antibiotic therapy, the child continued to experience fever spikes in this case, indicating a potential need for surgical intervention. In conclusion, this case report highlights the rare presentation of chordae tendinea rupture and pulmonary valve vegetation in pediatric endocarditis. Timely diagnosis and appropriate management, including antibiotic therapy and potential surgical intervention, are essential for optimizing outcomes in affected children.

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Background: In Iran, there is a lack of information and studies on acute rheumatic fever (ARF), a global health issue. The limited understanding of ARF's prevalence and primary clinical symptoms has led to confusion. This research investigates the characteristics of children aged 3-17 years who experience ARF with monoarthritis as their initial symptom. Methods: A retrospective evaluation of medical records of children diagnosed with ARF was conducted. The study aimed to determine the prevalence of monoarthritis as the first manifestation of ARF and its association with age, gender, family history, and cardiac involvement. Categorical variables were analyzed using the chi-square test with a significance level of < 0.05 and a confidence interval of 95%, using SPSS software (Version 23). Results: The study included 62 patients with ARF, comprising 41 (66.1%) boys with an average age of 8.48±3.27 years. Among these patients, 12 exhibited cardiac involvement according to the revised Jones criteria, with 5 clinical carditis and 7 cases of subclinical carditis. Monoarthritis was the initial symptom in seven patients (11.29%); five (71.4%) also had carditis. There was a significant association (p<0.001) between monoarthritis and carditis. Conclusion: The study concludes that monoarthritis may be an early sign of ARF in children and correlates significantly with cardiac involvement. However, more extensive research with more significant participant numbers is necessary to understand ARF in Iran comprehensively. A thorough cardiac examination is also crucial for patients with ARF and monoarthritis.

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Lyme disease is a progressive infectious disease caused by the Borrelia species that affects multiple organ systems, including the brain, heart, skin, and musculoskeletal systems. The cardiac manifestations of Lyme disease typically present with atrioventricular nodal conduction abnormalities and, more rarely, myocarditis. We report a case of an immunocompromised 57-year-old woman who presented with acute onset shortness of breath, hypervolemia, injective conjunctiva, and global vision loss of the left eye in the setting of a recent tick bite. Serologic testing confirmed borreliosis, and cardiac testing demonstrated acute isolated systolic heart failure without any cardiac conduction system abnormalities on the electrocardiogram. The diagnosis of Lyme carditis was made, and the patient was started on doxycycline with complete recovery of cardiac systolic function. This case demonstrates atypical cardiac manifestations of Lyme disease and highlights the difficulty in workup and understanding of Lyme carditis particularly in immunocompromised patients.

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Lyme disease often leads to cardiac injury and electrophysiological abnormalities. This study aimed to explore links between atrioventricular blocks and additional arrhythmias in Lyme carditis patients. This systematic review and meta-analysis of existing literature was performed from 1990 to 2023, and aimed to identify cases of Lyme carditis through serology or clinical diagnosis with concomitant arrhythmias. Pubmed and Web of Science were searched using appropriate MESH terms. Patients were divided into groups with atrioventricular blocks and other arrhythmias for cardiovascular (CV) outcome assessment. A total of 110 cases were analyzed. The majority (77.3%) were male, with mean age = 39.65 ± 14.80 years. Most patients presented within one week of symptom onset (30.9%). Men were more likely to have first-degree atrioventricular blocks (OR = 1.36 [95% CI 1.12-3.96], p = 0.01); these blocks tended to be reversible in nature (OR = 1.51 [95% CI 1.39-3.92], p = 0.01). Men exhibited a higher likelihood of experiencing variable arrhythmias (OR = 1.31 [95% CI 1.08-2.16], p < 0.001). Ventricular and supraventricular arrhythmias were more likely to exhibit instability (OR = 0.96 [95% CI 0.81-1.16] p = 0.01) and variability (OR = 1.99 [95% CI 0.47-8.31], p < 0.001). Men with Lyme carditis are likely to present with various atrioventricular blocks. These atrioventricular blocks are benign, and follow a predictable and stable clinical course. Further large-scale studies are warranted to confirm these associations.

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Introduction and importance: Sydenham's chorea (SC), a major neurological manifestation of acute rheumatic fever (ARF), is commonly seen in young children and adolescents. It is characterized by rapid, unpredictable, involuntary, and nonpatterned contractions affecting mostly distal limbs. It can also be associated with clinical or subclinical carditis. SC has been reported as a major manifestation in only 3.87% cases of acute rheumatic fever in Nepal. Case presentation: The authors report a case of a 12-year-old boy with abnormal movement of his right hand and unsteady gait for 12 days. On examination, he had an abnormal hand grip with difficulty maintaining a tetanic contraction (Milkmaid's grip). Laboratory investigations revealed increased anti-Streptolysin O titre and erythrocyte sedimentation rate. Echocardiography revealed subclinical carditis. After thorough clinical examination and pertinent investigations, the final diagnosis of ARF with SC was made. Clinical discussion: SC is a major clinical feature of rheumatic fever according to the revised Jones criteria. It is related to a previous Group A ß-haemolytic Streptococcus pyogenes (GABHS) infection. Approximately 50-65% of the patients with rheumatic fever later develop clinically detectable carditis. Although a self-limiting condition, it might need treatment with antiepileptics, neuroleptics, and phenothiazines. Conclusion: Any child presenting with a movement disorder should also be considered for SC, necessitating additional testing, including a cardiovascular assessment. It needs to be distinguished from other causes of movement disorders as well as psychiatric conditions. Treatment is necessary for moderate to severe chorea that interfere with daily activities. Compliance with subsequent antibiotic prophylaxis is essential for avoiding future cardiac complications.

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Lyme disease, caused by Borrelia burgdorferi and transmitted via Ixodes ticks, is a common vector-borne illness in the United States, with an estimated 476,000 annual cases. While primarily known for its neurological and rheumatological manifestations, Lyme disease can also involve the cardiac system, known as Lyme carditis, which occurs in about 4% to 10% of cases. This case report details a rare instance of Lyme carditis presenting as ST-segment elevation myocardial infarction (STEMI) in a 31-year-old female with no significant medical history. The patient exhibited symptoms of chest pressure and shortness of breath, with laboratory results showing significantly elevated troponin levels and other indicative markers. Notably, cardiac catheterization revealed no coronary occlusion, suggesting an alternative diagnosis to acute coronary syndrome (ACS). Further testing confirmed Lyme carditis through positive serological tests for Lyme-specific IgM antibodies. The case underscores the importance of considering Lyme myopericarditis in differential diagnoses for STEMI in Lyme-endemic areas and in patients without typical risk factors for coronary artery disease. This report aims to increase clinical awareness of this condition, highlighting the need for thorough investigation in atypical cardiac presentations.

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Lyme carditis, a well-established manifestation of Lyme disease, has been studied in animal models to improve understanding of its pathogenesis. This review synthesizes existing literature on these models and associated disease mechanisms. Searches in MEDLINE, Embase, BIOSIS, and Web of Science yielded 53 articles (47 mice models and 6 other animal models). Key findings include: 1) Onset of carditis correlates with spirochete localization in the heart; 2) Carditis occurs within 10 days of infection, progressing to peak inflammation within 30 days; 3) Infiltrates were predominantly composed of Mac-1+ macrophages and were associated with increases in TNF-α, IL-1 and IL-12 cytokines; 4) Resolution of inflammation was primarily mediated by lymphocytes; 5) Immune system is a double-edged sword: it can play a role in the progression and severity of carditis, but can also have a protective effect. Animal models offer valuable insights into the evolution and pathophysiologic mechanisms of Lyme carditis.

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Background: Lyme borreliosis (LB) of the heart is called Lyme carditis (LC), which often manifests with high-grade atrioventricular block (AVB) requiring pacemaker implantation. LC is treated with antibiotics, and most patients recover fully after treatment. The overall incidence of LC, and of LC as a cause of pacemaker implantation, has not previously been systematically studied. Methods: This was a case-control study based on data from Swedish national registers. The study was divided into two parts; part 1 including all patients diagnosed with AVB between 2001 and 2018, and part 2 including all patients who had received a pacemaker due to AVB between 2010 and 2018. Patients diagnosed with LB 90 days before and 180 days after the AVB diagnosis were identified among the patients and compared to matched control groups generated from the general population. Results: Of 81 063 patients with AVB, 102 were diagnosed with LB. In the control group, 27 were diagnosed with LB. The yearly incidence of LC was 0.056 per 100 000 adults and year. Of 25 241 patients who had received a pacemaker for AVB, 31 were diagnosed with LB. In the control group, 8 were diagnosed with LB. The yearly incidence of LC as a cause of pacemaker implantation was 0.033 per 100 000 adults and year. The estimated risk for patients with LC to receive a permanent pacemaker was 59%. Conclusions: LC is a rare cause of AVB. Nevertheless, more than half of patients with LC receive a permanent pacemaker for a condition that is easily cured with antibiotics.

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Background: Acute rheumatic fever (ARF) with carditis can lead to the development of rheumatic heart disease in children and young adults. Objective: This study aimed to investigate the manifestations of rheumatic carditis, clinically significant regression of valvular regurgitation as assessed by echocardiography, and the independent predictors of mitral regurgitation (MR) improvement after rheumatic carditis in Thai children. Method: Children diagnosed with rheumatic carditis during 2005-2020 at Siriraj Hospital (Bangkok, Thailand) were retrospectively enrolled. Trivial, and mild regurgitation were grouped as non-clinically significant (NCS) regurgitation. Valvular regression was defined moderate-severe regurgitation improving to NCS regurgitation. Results: Eighty-one patients (mean age: 10 years, range: 8-12 years) were included. At presentation, 59 (72.8%) patients had combined mitral regurgitation (MR) and aortic regurgitation (AR), 20 (24.6%) patients had MR alone, and 2 (2.4%) patients had AR alone. Concerning severity, 28 (34.6%) and 30 (37%) patients presented with severe and moderate MR, respectively. Severe and moderate AR was found in 9 (11.1%) and 16 (19.8%) patients, respectively. At the one-year follow-up, 43.4% of moderate-severe MR, and 41.7% of moderate-severe AR improved to NCS regurgitation. Multivariate analysis revealed high erythrocyte sedimentation rate (ESR) (p = 0.01) and severe carditis (p = 0.05) at presentation to be independent predictors of MR improvement. Conclusion: Thai children with rheumatic carditis had a high incidence of valvular regurgitation; however, the valvular damage was improved in most patients. High ESR and severe carditis independently predict MR improvement.

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Understanding of immune-related adverse events (irAEs) has evolved rapidly, and management guidelines are continually updated. We explored temporal changes in checkpoint inhibitor-induced irAE management at a tertiary cancer care center to identify areas for improvement. We conducted a single-center retrospective study of patients who developed a gastrointestinal, pulmonary, renal, or cardiac irAE between July and 1 October in 2019 or 2021. We collected patient demographic and clinical information up to 1 year after toxicity. Endoscopic evaluation and specialty follow-up after discharge for patients with gastrointestinal irAEs declined between the 2019 and 2021 periods. Symptom duration and steroid taper attempts also declined. For pulmonary irAEs, rates of specialty consultation, hospital admission and readmission, and mortality improved in 2021 compared with 2019. Follow-up rates after hospital discharge were consistently low (<50%) in both periods. For cardiac irAEs, consultation with a cardiologist was frequent and prompt in both periods. Outpatient treatment and earlier specialty consultation improved outcomes with gastrointestinal irAEs. Our study exploring irAE practice changes over time identified areas to improve management; specifically, timely specialty consultation was associated with better outcomes for gastrointestinal irAEs. These findings can help improve the quality of management algorithms at our institution and may inform policies in other institutions.

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Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

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In patients with Chronic Rheumatic Carditis, active carditis is an often underdiagnosed condition. Rheumatic attacks promote the aggravation of existing lesions, leading to a deterioration of the patient's clinical condition. Thus, reducing the morbidity and mortality of the disease depends, in part, on controlling relapses through secondary prophylaxis. Underdiagnosis is due in part to the occurrence of subclinical rheumatic attacks. This study was carried out with data from patients who were diagnosed with Chronic Rheumatic Carditis and who underwent cardiac surgery for valve replacement or repair, without clinical or laboratory evidence of rheumatic outbreak. A fragment of myocardium was sent for histopathological analysis. Data on the frequency of histopathological alterations compatible with a rheumatic outbreak were analyzed. After analysis, 80% of patients showed changes compatible with inflammatory activity. Of these, 87.5% had lymphocytic infiltrate; 25% had Aschoff's nodules. The most frequent histopathological findings of chronic disease were myocardial hypertrophy in 56.7% of patients and fibrosis in 53.3% (AU).

Nos pacientes com Cardite Reumática Crônica, a cardite em atividade é uma condição frequentemente subdiagnos-ticada. Os surtos reumáticos promovem o agravamento das lesões já existentes, levando a uma deterioração da condição clínica do paciente. Dessa forma a redução da morbimortalidade da doença depende, em parte, do contro-le de recidivas a partir da profilaxia secundária. O subdiagnóstico deve-se em parte a ocorrência de surtos reumáti-cos subclínicos. Este estudo foi realizado com dados dos pacientes que tiveram o diagnóstico de Cardite Reumática Crônica e foram submetidos à cirurgia cardíaca para troca ou plastia valvar, sem evidência clínica ou laboratorial de surto reumático. Um fragmento de miocárdio foi enviado para análise histopatológica. Foram analisados os dados de frequência de alterações histopatológicas compatíveis com surto reumático. Após análises, 80% dos pacientes apresentaram alterações compatíveis com atividade inflamatória. Desses, 87,5% apresentavam infiltrado linfocitá-rio; 25% apresentavam nódulos de Aschoff. Os achados histopatológicos de doença crônica mais frequentes foram hipertrofia miocárdica em 56,7% pacientes e fibrose em 53,3% (AU).

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The outbreak of COVID-19 was seen first in Wuhan, China, on December 31, 2019. Following this, the virus has emerged, mutated, and spread to all parts of the world, taking many lives. Scientists and healthcare workers all over the world have been involved in developing vaccines and drugs to prevent the deadly virus from spreading. In this review article, we focus on how the human body responds to immune responses by producing antibodies against our immune system and serum levels in different age groups. Few studies are being considered, which include data collected from adults in the UK community, health workers from Oxfordshire, studies from the UK, healthcare workers at a university healthcare center in Turkey, and lastly, non-seropositive and seronegative healthcare workers in the USA children's hospital, respectively, and their responses to the goal. In addition to focusing on this study and its results, we also discuss the role of different vaccines and their development and antibody responses in the body due to natural and post-vaccine infections that include both doses in humans. We focus mainly on immunoglobulin M (IgM) and immunoglobulin G (IgG) levels in the serum produced by plasma cells, as they are involved in the first line of defense against the disease. With the development of effective vaccines and their production, trial, and market distribution to needy people, there are certain prospects for slowing down the progression of the virus, reducing mortality, and preventing re-infection in humans. However impactful and beneficial these vaccines have proven, they also carry a certain amount of danger to the people taking them. We also discuss in this article certain infrequent hematological and cardiovascular complications of the vaccine and their effect on the population.

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Acute rheumatic fever (ARF) is a multi-system inflammatory autoimmune disease. It is a significant cause of heart disease and early death worldwide, especially in children in developing countries. We present a case of acute fulminant rheumatic carditis in a child with no obvious predisposing factors, who resided in a developed country where this disease is not endemic. After pathological examination, a diagnosis of ARF with pancarditis was confirmed. This disease was not suspected before the pathological examination because of its low prevalence in Belgium.

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Lyme's carditis and neuroborreliosis are common manifestation of disseminated Lyme disease. However, third-degree atrioventricular blocks with Lyme's carditis requiring permanent pacemaker with neuroborreliosis and Lyme's disease-associated immunodeficiency are uncommon. Here we present a case of 64-year-old female presenting with neurological symptoms and electrocardiogram changes suggestive of complete heart block with no improvement in the degree of heart block with intravenous antibiotics, requiring permanent pacemaker implantation and course complicated by fungemia.

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