Infantile multicystic encephalomalacia after maternal bee sting anaphylaxis during pregnancy.

Our case illustrates the persistence of severe rheumatic carditis and emphasises a number of points in the diagnosis and management of a febrile child with valvulitis and significant haemodynamic disturbance. The differential diagnosis between the two most likely aetiological factors was made difficult by the previous administration of antibiotics and by the absence of laboratory evidence of a recent streptococcal infection. Although our patient had one major and two minor criteria for the diagnosis of acute rheumatic fever, there was no evidence of a preceding streptococcal infection as required in the 1965 revision of the Jones's criteria,' until 8 weeks after the onset of symptoms. It was clear that cardiac surgery was required but our dilemma was that we were unable to exclude subacute bacterial endocarditis and indeed, in view of the comparative rarity of acute rheumatic carditis of this severity, we felt that an infective endocarditis was the more probable cause. We therefore considered it advisable to delay surgery until we could ensure that sufficient antibiotic treatment had been administered to render this intervention less hazardous. Although our preoperative_diagnosis was shown to be wrong, we believe that faced with the same situation we would still pursue the same course of management. In accordance with previous reports,2-4 this case shows that surgical intervention in the acute phase of rheumatic fever is safe and beneficial; in the critically ill patient it may even be life-saving.