Page 60 - JSOM Summer 2025

Severe Rheumatic Heart Disease
Requiring Mechanical Valve Placement in a
Special Operations Forces Soldier

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Kyler C. Osborne, MD *; Davis Duncan, SOCM-ATP ;
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Angela Curell, MD ; Megan Mahowald, MD ; Rachel E. Bridwell, MD, FS 5

ABSTRACT
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Rheumatic heart disease (RHD) has become exceedingly rare complications. Despite resolution of streptococcal pharyn-
in the United States, but a recent resurgence may place military gitis and ARF, a chronic systemic immune response damages
Servicemembers at increased risk for this diagnosis. Our case valves, leading most commonly to mitral stenosis (MS) or mi-
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describes a 29-year-old U.S.-born Special Operations Forces tral regurgitation (MR). Individuals affected by RHD typi-
(SOF) Soldier who presented for recurrent exertional near-syn- cally present between the ages of 20–30 years after an initial
cope and progressive exercise intolerance with subsequent episode of ARF with symptoms of orthopnea, palpitations, ex-
workup remarkable for RHD. Initial electrocardiogram was ertional dyspnea, syncope, near-syncope, or decreased exercise
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notable for benign early repolarization and intraventricular tolerance. High-intensity exercise can accelerate progression
conduction delay. Cardiology evaluation with transthoracic of valvular disease; those in physically demanding jobs, such
and transesophageal echocardiograms revealed severe mitral as military service or Special Operations, are at increased risk
regurgitation and rheumatic appearing mitral valve leaflets. of exertional syncope, provoking underlying arrhythmias and
The patient underwent a successful mechanical mitral valve potentially sudden cardiac death. While RHD is a rare diag-
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replacement, requiring lifelong anticoagulation with warfarin. nosis in the U.S., it carries significant morbidity and opera-
Depending on severity of valvular disease, treatment modali- tional implications if undiagnosed and untreated. Therefore,
ties range from conservative medical therapies to invasive and military Servicemembers and those within Special Operations
minimally invasive surgical intervention. This case demon- Forces (SOF) who present with palpitations, syncope, or de-
strates the importance for SOF medics and providers to re- creased exercise tolerance should undergo a rigorous and fo-
main vigilant of this resurging disease process. Additionally, it cused evaluation to include these insidious cardiac etiologies.
emphasizes the necessity for a high level of clinical suspicion
in those with exertional complaints and decreased exercise tol- Case Presentation
erance to ensure timely diagnosis and treatment of rare but
potentially life-threatening conditions. A 29-year-old active-duty male SOF Soldier presented to
his Battalion Aid Station (BAS) for recurrent, intermittent
Keywords: rheumatic heart disease; exertional syncope; near-syncope during exertion, increasing in frequency. Three
palpitations; mechanical valve; special operations years prior, the patient first noted exertional near syncope last-
ing 1–2 minutes, with spontaneous resolution and no loss of
consciousness. He sought care at the BAS, though no further
workup was pursued at that time. He returned to the BAS for
Introduction
more frequent episodes of near-syncope, which he described
Rheumatic heart disease (RHD) is a very rare sequela of strep as tunnel vision, dizziness, seeing stars, and feel lightheaded,
pharyngitis and acute rheumatic fever (ARF) that can lead to along with worsening exercise tolerance. Previously, the pa-
valvular damage and potentially the need for cardiac surgery. tient could run seven to eight miles without issue, but now ex-
Though exceedingly rare in the United States, it remains one of perienced dyspnea on exertion at three to four miles with new
the most common acquired heart diseases of children and ad- nocturnal palpitations. The patient had no personal or family
olescents globally with a prevalence of over 40 million cases, history of structural heart disease and has not lived outside
accounting for over 300,000 deaths annually worldwide. In of the U.S. for any extended period with the exception of one
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developed countries, including the U.S., ARF cases remain low four-month deployment to the Middle East. Medical history
with an incidence of <2 cases per 100,000 people and RHD- revealed only a history of pediatric recurrent Streptococcus
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related deaths of 3.1 cases per 100,000 people. However, pyogenes pharyngitis as a child though no previously valvu-
age-adjusted mortality rates have increased in the U.S. over lopathy, autoimmune conditions, or recent streptococcal in-
the past 5 years with a suspected surge in RHD-related health fections. He denied tobacco use or any recreational drugs. His
*Correspondence to Kyler Osborne, 9040A Jackson Ave., Joint Base Lewis-McChord, WA 98431, USA or kyler.c.osborne.mil@health.mil
1 CPT Kyler C. Osborne is a resident physician affiliated with the Department of Emergency Medicine, Madigan Army Medical Center, Joint Base
Lewis-McChord, WA. SFC Davis Duncan is a Special Operations Combat Medic affiliated with the Special Warfare Medical Group, U.S. Army
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John F. Kennedy Special Warfare Center and School, Fort Bragg, NC. Maj Angela Curell is a Physician affiliated with the Center for Sustainment
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of Trauma and Readiness Skills (C-STARS) at the University of Cincinnati, Cincinnati, OH, and the Uniformed Services University of the Health
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Sciences, Bethesda, MD. MAJ Megan Mahowald is a physician affiliated with the 75th Ranger Regiment, Fort Benning, GA, and the Uniformed
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Services University of the Health Sciences, Bethesda, MD. MAJ Rachel E. Bridwell is a physician affiliated with the 1st Special Forces Command,
Fort Bragg, NC, and the Uniformed Services University of the Health Sciences, Bethesda, MD.
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