A Case of New Murmur and Hepatomegaly in a Child with Respiratory Insufficiency

Quick Takes

  • Acute severe mitral regurgitation will result in hemodynamic instability requiring rapid intervention.
  • It is important to determine the etiology of mitral regurgitation to guide medical management. Identifying the infectious responsible agent, if present, is essential to determine appropriate long-term therapy after surgery.

A previously healthy 13-month-old male presented to the Emergency Department with 7 days of cough, congestion and intermittent fever to a maximum of 104.8F, decreased oral intake and new increased work of breathing. On exam, there was a grade 2-3/6 holosystolic murmur at the left lower sternal border, intermittent S3 gallop and hepatomegaly to 3 cm below the right costal margin. He was initially diagnosed with pneumonia and was given empiric antibiotics and a fluid bolus. He failed to respond to non-invasive respiratory support, became hypotensive and required rapid-sequence intubation with pressor support. Troponin and b-type natriuretic protein levels were elevated at 0.15 ng/mL (reference range for normal < 0.03) and 995.5 pg/mL (reference range <100), respectively. A chest x-ray (Figure 1), electrocardiogram (Figure 2) and transthoracic echocardiogram (Figure 3) are shown below.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

What is the most likely cause of the patient's clinical deterioration?

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