Presentation
Acute on chronic cough and shortness of breath. Remote history of atrial fibrillation and cardiac valve replacement.
Patient Data
Cardiomegaly; double density sign, carinal angle widening.
Metallic mitral and aortic valves.
Sternotomy wires.
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Apart from cardiomegaly and the metallic mitral and aortic valves, there are curvilinear calcifications at the posteroinferior left atrial wall. No pericardial or septal calcifications.
Case Discussion
This patient has rheumatic heart disease.
Acute rheumatic endocarditis commonly involves the mitral and aortic valves, manifested as mitral insufficiency and/or aortic stenosis, which may require valvular replacement, as in this case. Left untreated, mitral stenosis develops later.
Sequelae of mitral insufficiency include left atrial enlargement, and in longstanding and severe disease, the regurgitant jet of blood is traumatic to the posterior left atrial endocardium and may subsequently result in subendocardial fibrosis and calcifications. These changes are referred to as MacCallum's triangle or patch.
It has also been proposed that rheumatic endocarditis also plays a role in the pathogenesis of MacCallum's patch.
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