Description

A previously healthy 29-year-old Mexican woman presented to an emergency department with transient hemiparaesthesias and dysarthria. There was no evidence of stroke on cross-sectional imaging of the head, and she was discharged without a clear diagnosis. Two days later, she returned with acute abdominal pain. Abdominal imaging revealed complete occlusion of the right renal artery, prompting emergency embolectomy. Following the procedure, she developed acute haemoptysis, dyspnoea and hypoxaemia. Chest imaging demonstrated evidence of pulmonary venous hypertension. Cardiac auscultation revealed an opening snap followed by a diastolic murmur with presystolic accentuation. These sounds were better appreciated in combination with phonocardiography, a technique supplanted by echocardiography in the 1970s1 that visualised heart sounds (video 1). An echocardiogram confirmed the presence of mitral stenosis (MS), unifying the syndrome of embolic phenomena, haemoptysis and pulmonary hypertension. She underwent successful mitral valve replacement and has since returned to normal activities.

Despite the advances in developed countries, rheumatic heart disease remains the most common cause of MS worldwide. Early manifestations include dyspnoea and fatigue, but occasionally embolic phenomena are part of the initial presentation. Definitive diagnosis can be made with echocardiography, but careful cardiac auscultation remains an important step in the diagnostic pathway when any of the following four signs are present: (1) pronounced S1, (2) early diastolic opening snap, (3) rumbling diastolic murmur at the apex using the bell and (4) presystolic accentuation of the murmur.2 In this case, phonocardiography was used to facilitate recognition of these signs.