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Ventricular Septal Defect (VSD) in a Pediatric Patient in Sub-Saharan Africa.

Ventricular Septal Defect (VSD) in a Pediatric Patient in Sub-Saharan Africa.

Patient details
Patient details.
A, a 6-month-old female infant from a rural community in northern Kenya.
Patient case fields
Presenting Complaint

 A's mother brought her to the local health clinic due to concerns about poor feeding, frequent respiratory infections, and difficulty breathing, especially during feeding and crying. A also seemed to sweat more than usual during breastfeeding.

History

A was born at home after an uneventful pregnancy. She has not gained weight adequately since birth and has been described as smaller than other infants of her age. Over the past two months, she has experienced several episodes of chest infections, treated with antibiotics from the local pharmacy. However, her symptoms persist, with bouts of coughing and shortness of breath. There is no known family history of congenital heart disease.

Examination

Vitals: Heart rate 150 bpm, respiratory rate 50 breaths per minute, mild subcostal retractions.

Growth: Weight below the 3rd percentile for age.

Cardiac Exam: A pansystolic murmur is heard at the left lower sternal border. A palpable thrill is felt in the same region.

Respiratory Exam: Mild crackles heard bilaterally. Increased work of breathing noted.

Other Systems: No cyanosis, hepatomegaly noted.

Investigations

A chest X-ray showed cardiomegaly with increased pulmonary vascular markings.

An echocardiogram performed at the referral hospital confirmed a large perimembranous ventricular septal defect (VSD) with left-to-right shunting.

Diagnosis

A was diagnosed with a large VSD, leading to heart failure and recurrent respiratory infections.

Management Plan
  1. Medical Management: A was started on diuretics (furosemide) and an angiotensin-converting enzyme (ACE) inhibitor to manage heart failure symptoms. Nutritional support was initiated to improve weight gain.
  2. Surgical Referral: Given the size of the VSD and signs of heart failure, she was referred to a paediatric cardiac center in Nairobi for surgical evaluation. However, due to limited resources and long waiting times for surgery, her family was counselled on the need for close follow-up and managing complications while awaiting surgery.
  3. Social and Educational Support: The family was provided with counselling on infection prevention and advised on maintaining A’s caloric intake despite her feeding difficulties.
Prognosis

With timely surgery, A's prognosis would likely improve significantly. However, challenges such as delayed access to specialized care in sub-Saharan Africa could complicate her long-term outcomes.

Discussion
No data was found
Questions
1. What is the most likely cause of A’s symptoms, including poor feeding, respiratory infections, and difficulty breathing?

 a). Asthma

b). Pneumonia

c). Ventricular Septal Defect (VSD)

d). Gastroesophageal reflux disease (GERD)

2. Which of the following findings from the physical exam supports the diagnosis of a ventricular septal defect? 

a). Hepatomegaly

b). Crackles in the lungs

c). A pansystolic murmur at the left lower sternal border

d). Cyanosis

3. What is the primary long-term management option for A’s large VSD? 

a). Long-term antibiotic therapy

b). Surgical closure of the VSD

c). Diuretics and ACE inhibitors as lifelong treatment

d). Oxygen therapy

4. What is one of the primary complications A faces due to delayed access to specialized care in sub-Saharan Africa? 

a). Progression to cyanotic heart disease

b). Risk of infection

c). Weight loss despite nutritional support

d). Worsening heart failure

Reveal answers

Answers

  1. c) Ventricular Septal Defect (VSD)
  2. c) A pansystolic murmur at the left lower sternal border
  3. b) Surgical closure of the VSD
  4. d) Worsening heart failure