Case History/ Examination

A 36-year-old female, with a known history of mitral valve stenosis secondary to rheumatic heart disease, underwent thrombolysis with streptokinase three months ago and presented with the primary complaints of shortness of breath on exertion for four days, orthopnea and paroxysmal nocturnal dyspnea (PND). She had a significant past medical history of mitral valve stenosis for which mitral valvotomy, double valve repair and redo mitral valve repair was done. Patients had recurring symptoms for which thrombolysis by streptokinase started 2 weeks ago. Following streptokinase treatment, the patient now presents with shortness of breath, fever, and bilateral knee pain for the past three days, with no history of photosensitivity, skin rashes, myalgia, malaise and lymphadenopathy. (Figure 1) Her bowel and bladder habits were normal. On examination, the patient was afebrile, pulse was 70/minute regular, respiratory rate was 20/minute, blood pressure was 100/70 mmHg. General examination revealed no pallor, icterus, cyanosis, edema and increased jugular venous pressure. Dermatological, cardiovascular and respiratory system examination was done and found to be normal. On the joint examination, there was no swelling, redness, or warmth on the knee joint.