An 11-year-old girl from a village in Odisha has had pain in both knees, ankles and wrists for 6 days, with no joint swelling. She had a sore throat 3 weeks ago. Temperature 38.6°C, ESR 64 mm/h, ASO titre raised, PR interval 0.22 s. Echocardiography is normal, and other causes of joint pain have been excluded. By the revised (2015) Jones criteria, what is the conclusion?

Acute rheumatic fever, as polyarthralgia is a major criterion here

Not rheumatic fever, as two major criteria are always needed

Post-streptococcal reactive arthritis

Not rheumatic fever, as polyarthralgia is only a minor criterion

A 46-year-old man is on day 6 of IV antibiotics for Staphylococcus aureus endocarditis of a native aortic valve in a Hyderabad hospital, and his fever persists. Today's ECG shows a PR interval of 0.30 s; on admission it was 0.16 s. BP 118/62 mmHg, no signs of heart failure. What is the most likely explanation, and what should be done?

Aortic root abscess: urgent TEE and surgery

Drug-induced AV block: change the antibiotic

Vagal effect of fever: observe and continue

Septic coronary embolism: start thrombolysis

A 71-year-old retired teacher in Pune has had two fainting spells while climbing stairs and chest tightness on exertion. He has a slow-rising carotid pulse, a soft single second sound and a harsh ejection systolic murmur at the right second intercostal space radiating to the neck. Echocardiography: aortic valve area 0.7 cm², mean gradient 52 mmHg, ejection fraction 60%. What is the next best step?

Valve replacement, surgical or transcatheter

Balloon aortic valvotomy as definitive care

Nitrates and a beta-blocker for symptom control

Repeat echocardiography after 6 months

A 62-year-old man with a mechanical aortic valve placed 4 years ago has had fever for 2 weeks. Two of three blood culture sets grow Staphylococcus aureus. Transthoracic echocardiography shows no vegetation, but the views of the prosthesis are limited by acoustic shadowing. What is the next best investigation?

Transoesophageal echocardiography

Cardiac magnetic resonance imaging

Repeat transthoracic echo after 4 weeks

Valvular, rheumatic and infective endocarditis

22 NEET-PG practice questions on Valvular, rheumatic and infective endocarditis, part of General Medicine. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
An 11-year-old girl from a village in Odisha has had pain in both knees, ankles and wrists for 6 days, with no joint swelling. She had a sore throat 3 weeks ago. Temperature 38.6°C, ESR 64 mm/h, ASO titre raised, PR interval 0.22 s. Echocardiography is normal, and other causes of joint pain have been excluded. By the revised (2015) Jones criteria, what is the conclusion?
1. ANot rheumatic fever, as two major criteria are always needed
2. BPost-streptococcal reactive arthritis
3. CAcute rheumatic fever, as polyarthralgia is a major criterion here
4. DNot rheumatic fever, as polyarthralgia is only a minor criterion
Show answerHide answer
Answer: C · Acute rheumatic fever, as polyarthralgia is a major criterion here
The 2015 Jones revision uses separate criteria for low-risk and moderate-to-high-risk populations, and India is high-risk. In high-risk groups polyarthralgia counts as a major criterion once other causes are excluded; her fever of 38°C or more, ESR of 30 mm/h or more and prolonged PR interval are minor criteria. With evidence of recent streptococcal infection, one major plus two minor criteria makes the diagnosis. She needs treatment and long-term secondary prophylaxis with benzathine penicillin.
- A: One major plus two minor criteria also satisfies Jones for a first episode.
- B: Reactive arthritis involves true arthritis and is diagnosed only when Jones criteria are not met.
- D: Polyarthralgia is a minor criterion only in low-risk populations, not in India.
Question 2 · Hard
A 46-year-old man is on day 6 of IV antibiotics for Staphylococcus aureus endocarditis of a native aortic valve in a Hyderabad hospital, and his fever persists. Today's ECG shows a PR interval of 0.30 s; on admission it was 0.16 s. BP 118/62 mmHg, no signs of heart failure. What is the most likely explanation, and what should be done?
1. ADrug-induced AV block: change the antibiotic
2. BVagal effect of fever: observe and continue
3. CSeptic coronary embolism: start thrombolysis
4. DAortic root abscess: urgent TEE and surgery
Show answerHide answer
Answer: D · Aortic root abscess: urgent TEE and surgery
New or lengthening AV block in aortic valve endocarditis means the infection has spread into the perivalvular tissue, usually as an aortic root abscess close to the AV node and His bundle in the membranous septum. Persistent fever despite appropriate antibiotics points the same way, and S. aureus is the organism most likely to do this. TEE confirms the abscess, which antibiotics alone rarely cure, so early surgery is indicated. Meanwhile he needs cardiac monitoring because complete heart block can follow suddenly.
- A: Antistaphylococcal antibiotics do not usually lengthen the PR; the rising PR with fever points to the valve.
- B: Fever causes tachycardia, not progressive AV block, and watching risks complete heart block.
- C: Thrombolysis is contraindicated in endocarditis because of bleeding from septic emboli and mycotic aneurysms.
Question 3 · Medium
A 71-year-old retired teacher in Pune has had two fainting spells while climbing stairs and chest tightness on exertion. He has a slow-rising carotid pulse, a soft single second sound and a harsh ejection systolic murmur at the right second intercostal space radiating to the neck. Echocardiography: aortic valve area 0.7 cm², mean gradient 52 mmHg, ejection fraction 60%. What is the next best step?
1. ABalloon aortic valvotomy as definitive care
2. BNitrates and a beta-blocker for symptom control
3. CRepeat echocardiography after 6 months
4. DValve replacement, surgical or transcatheter
Show answerHide answer
Answer: D · Valve replacement, surgical or transcatheter
A valve area below 1.0 cm² with a mean gradient of 40 mmHg or more is severe aortic stenosis. Once angina, syncope or heart failure appears, survival without valve replacement is poor, so replacement is indicated. A heart team chooses surgical replacement or TAVI by age, surgical risk and anatomy. Vasodilators such as nitrates can cause dangerous hypotension because the output across the valve is fixed.
- A: Balloon dilatation of a calcified adult valve restenoses within months and is only a bridge.
- B: Nitrates can drop BP sharply across a fixed obstruction and do not change the outcome.
- C: Surveillance suits asymptomatic disease; symptoms make severe stenosis an indication for replacement.
Question 4 · Easy
A 28-year-old woman from a tea estate in Assam has had breathlessness on exertion for a year and recently coughed up blood-streaked sputum. At the apex, heard best with the bell in the left lateral position, there is a loud first heart sound, an opening snap and a low-pitched rumbling mid-diastolic murmur with presystolic accentuation. Her pulse is regular. What is the most likely valve lesion?
1. AMitral stenosis
2. BTricuspid stenosis
3. CAortic regurgitation
4. DMitral regurgitation
Show answerHide answer
Answer: A · Mitral stenosis
A loud S1, an opening snap and a low-pitched apical mid-diastolic rumble with presystolic accentuation are the signs of mitral stenosis, which in India is almost always rheumatic. The presystolic accentuation comes from atrial contraction and is lost when atrial fibrillation sets in. The shorter the gap between S2 and the opening snap, the more severe the stenosis, because left atrial pressure is higher. Haemoptysis reflects raised pulmonary venous pressure, and echocardiography confirms the valve area and morphology.
- B: Tricuspid stenosis is heard at the lower left sternal edge and becomes louder on inspiration.
- C: Aortic regurgitation gives a high-pitched early diastolic murmur along the left sternal edge.
- D: Mitral regurgitation gives a pansystolic apical murmur radiating to the axilla, usually with a soft S1.
Question 5 · Medium
A 62-year-old man with a mechanical aortic valve placed 4 years ago has had fever for 2 weeks. Two of three blood culture sets grow Staphylococcus aureus. Transthoracic echocardiography shows no vegetation, but the views of the prosthesis are limited by acoustic shadowing. What is the next best investigation?
1. ACoronary angiography
2. BCardiac magnetic resonance imaging
3. CTransoesophageal echocardiography
4. DRepeat transthoracic echo after 4 weeks
Show answerHide answer
Answer: C · Transoesophageal echocardiography
Transoesophageal echocardiography is far more sensitive than transthoracic echo for vegetations, abscesses and dehiscence of a prosthetic valve, because the probe sits just behind the heart and avoids shadowing from the prosthesis. It is indicated in every suspected prosthetic valve endocarditis and in S. aureus bacteraemia with a negative TTE. If the first TEE is negative but suspicion stays high, it is repeated after about a week, and FDG PET-CT can help with prosthetic valves.
- A: Coronary angiography does not image the valve and risks dislodging aortic vegetations.
- B: Cardiac MRI images prosthetic valve vegetations poorly and is not the next step.
- D: Waiting weeks delays treatment and can miss an abscess forming.
Question 6 · Medium
A 25-year-old primigravida at 30 weeks, whose rheumatic mitral stenosis (valve area 1.1 cm²) was not known before pregnancy, is admitted to the labour ward in Patna with breathlessness at rest and basal crackles. Pulse 124/min, regular. Why has her condition worsened during pregnancy?
1. AA fall in blood volume reduces atrial filling
2. BPregnancy hormones thicken the mitral leaflets
3. CA faster heart rate shortens diastolic filling
4. DPeripheral vasodilatation raises the afterload
Answer and explanation in LearnFree account
Question 7 · Medium
A 24-year-old slim woman in Bengaluru has occasional palpitations and atypical chest pain. At the apex there is a mid-systolic click followed by a late systolic murmur. When she stands, the click moves earlier towards S1 and the murmur lengthens; when she squats, the click moves later. What is the most likely diagnosis?
1. ABicuspid aortic valve
2. BAtrial septal defect
3. CMitral valve prolapse
4. DRheumatic mitral regurgitation
Answer and explanation in LearnFree account
Question 8 · Medium
A paediatric resident in Lucknow writes four statements about the 2015 revised Jones criteria as applied to Indian children, a moderate-to-high-risk population. 1. Subclinical carditis seen only on echocardiography counts as a major criterion. 2. Sydenham chorea can establish the diagnosis even without evidence of recent streptococcal infection. 3. Monoarthralgia counts as a major criterion. 4. A recurrence can be diagnosed with three minor criteria plus evidence of recent streptococcal infection. Which statements are correct?
1. A2, 3 and 4 only
2. B1, 2, 3 and 4
3. C1 and 3 only
4. D1, 2 and 4 only
Answer and explanation in LearnFree account
Question 9 · Medium
A 26-year-old woman from Malappuram has breathlessness on mild exertion (NYHA class III). Echocardiography shows rheumatic mitral stenosis with a valve area of 0.9 cm², pliable non-calcified leaflets (Wilkins score 7) and trivial mitral regurgitation; transoesophageal echo shows no left atrial clot. She is in sinus rhythm. What is the treatment of choice?
1. ADiuretics and a beta-blocker alone
2. BMitral valve replacement
3. CWarfarin and review after a year
4. DBalloon mitral valvotomy
Answer and explanation in LearnFree account
Question 10 · Medium
A 9-year-old boy from a crowded urban slum in Mumbai develops fever, migratory polyarthritis and a new apical pansystolic murmur 3 weeks after an untreated sore throat. A throat swab culture is now negative, but anti-streptolysin O and anti-DNase B titres are high. What is the mechanism of his valve inflammation?
1. ADeposition of streptolysin O immune complexes on valves
2. BCross-reacting antibodies to streptococcal M protein
3. CDirect invasion of the valve by streptococci
4. DSuperantigen effect of pyrogenic exotoxin
Answer and explanation in LearnFree account
Question 11 · Medium
A 19-year-old college footballer in Kozhikode collapsed briefly during a match. He has a harsh systolic murmur at the left sternal edge that becomes louder when he stands up from squatting and during the strain phase of the Valsalva manoeuvre, and softer when he squats. His carotid upstroke is brisk. What is the most likely diagnosis?
1. AHypertrophic cardiomyopathy
2. BValvular aortic stenosis
3. CMitral regurgitation
4. DVentricular septal defect
Answer and explanation in LearnFree account
Question 12 · Medium
A 67-year-old man in Ludhiana is being treated for infective endocarditis of the aortic valve; three sets of blood cultures grew Streptococcus gallolyticus (formerly S. bovis biotype I). He has mild iron-deficiency anaemia but no bowel symptoms. Besides completing his antibiotics, which investigation should be arranged?
1. AUpper GI endoscopy
2. BContrast CT of the brain
3. CColonoscopy
4. DBone marrow examination
Answer and explanation in LearnFree account
Question 13 · Medium
A 34-year-old man is seen in the cardiology OPD in Kolkata for palpitations. BP is 164/48 mmHg, the pulse rises sharply and collapses quickly, his head nods with each heartbeat, and capillary pulsation is visible in the nail beds. A high-pitched, blowing early diastolic murmur is heard at the left third intercostal space, loudest when he sits forward with breath held in expiration. What is the most likely lesion?
1. AChronic aortic regurgitation
2. BPatent ductus arteriosus
3. CPulmonary regurgitation
4. DAortic stenosis
Answer and explanation in LearnFree account
Question 14 · Medium
Four patients are booked for tooth extraction at a district hospital dental clinic in Thrissur. 1. A 50-year-old man with a bioprosthetic aortic valve. 2. A 34-year-old woman who had infective endocarditis two years ago. 3. A 16-year-old boy with unrepaired tetralogy of Fallot. 4. A 40-year-old woman with an isolated secundum atrial septal defect. By current AHA guidance, which of them should receive antibiotic prophylaxis against infective endocarditis?
1. A1, 2 and 3 only
2. B1, 3 and 4 only
3. C2 and 3 only
4. D1 and 2 only
Answer and explanation in LearnFree account
Question 15 · Easy
A 45-year-old man with a mechanical mitral valve, placed for rheumatic disease, needs a molar extraction at a dental college in Chennai. He has no drug allergy. Which antibiotic regimen is recommended to prevent infective endocarditis?
1. ACiprofloxacin 500 mg orally 1 hour before
2. BAmoxicillin 2 g orally 30-60 minutes before
3. CMetronidazole 400 mg orally 1 hour before
4. DAmoxicillin 500 mg thrice daily for 5 days after
Answer and explanation in LearnFree account
Question 16 · Medium
A 38-year-old woman with known rheumatic mitral regurgitation has had low-grade fever, fatigue and weight loss for 5 weeks since a tooth extraction at a local clinic. Temperature 38.4°C; the MR murmur is unchanged. Two blood culture sets drawn 12 hours apart both grow viridans group streptococci, and transthoracic echo shows a 9 mm oscillating mass on the anterior mitral leaflet. How is this case classified by the modified Duke criteria?
1. APossible endocarditis, until TEE is done
2. BPossible endocarditis, with one major criterion
3. CRejected, as the organism is a commensal
4. DDefinite endocarditis, with two major criteria
Answer and explanation in LearnFree account
Question 17 · Easy
A 13-year-old boy in Jharkhand recovers from his first attack of acute rheumatic fever, which caused arthritis and mild mitral regurgitation. Before discharge, the paediatrician plans secondary prophylaxis to prevent recurrences. Which regimen is preferred?
1. AOral prednisolone tapered over 12 weeks
2. BOral amoxicillin only when he has a sore throat
3. COral aspirin until the ESR returns to normal
4. DIM benzathine penicillin G every 3-4 weeks
Answer and explanation in LearnFree account
Question 18 · Hard
A 12-year-old girl in Bhubaneswar is admitted with fever, flitting polyarthritis and a raised ASO titre. She has an apical pansystolic murmur radiating to the axilla and a short, soft mid-diastolic murmur at the apex, with no opening snap and a normal first heart sound. Echocardiography shows thickened, inflamed mitral leaflets with moderate mitral regurgitation and a normal mitral valve area. What does the mid-diastolic murmur most likely represent?
1. AEstablished rheumatic mitral stenosis
2. BTricuspid stenosis from right-sided carditis
3. CAustin Flint murmur of aortic regurgitation
4. DIncreased flow across an inflamed mitral valve
Answer and explanation in LearnFree account
Question 19 · Medium
A 40-year-old man with infective endocarditis of the aortic valve is examined on the ward. He has 1. painful, tender nodules on the pads of two fingers, 2. painless flat haemorrhagic macules on the soles, 3. oval retinal haemorrhages with pale centres, 4. a positive rheumatoid factor. Which of these count as immunological phenomena in the modified Duke criteria?
1. A1 and 3 only
2. B1, 2, 3 and 4
3. C2, 3 and 4 only
4. D1, 3 and 4 only
Answer and explanation in LearnFree account
Question 20 · Easy
A 26-year-old man who injects heroin is admitted in Imphal with fever and rigors for 10 days. He has a pansystolic murmur at the left lower sternal edge that becomes louder on inspiration, and chest X-ray shows multiple small cavitating nodules in both lungs. Which organism is most likely?
1. AEnterococcus faecalis
2. BViridans group streptococci
3. CCandida albicans
4. DStaphylococcus aureus
Answer and explanation in LearnFree account
Question 21 · Medium
A 30-year-old man with rheumatic mitral regurgitation, from a village near Nagpur, has had fever for 4 weeks; a local practitioner gave him oral cefixime for 10 days before referral. He has splenomegaly, microscopic haematuria and a mitral vegetation on echocardiography. Three blood culture sets show no growth after 5 days. What is the most likely reason the cultures are negative?
1. AAntibiotics given before cultures were drawn
2. BFungal endocarditis caused by Aspergillus
3. CInfection with a slow-growing HACEK group organism
4. DNon-infective marantic endocarditis
Answer and explanation in LearnFree account
Question 22 · Hard
A 35-year-old woman with rheumatic mitral stenosis (valve area 1.2 cm²) develops atrial fibrillation; she has no other illness, and her CHA2DS2-VASc score is 1. Her rate is controlled with metoprolol. She asks for a tablet that needs no blood tests. Which anticoagulant is most appropriate for her?
1. ANone, as her CHA2DS2-VASc score is low
2. BAspirin 75 mg once daily
3. CWarfarin with a target INR of 2-3
4. DRivaroxaban 20 mg once daily
Answer and explanation in LearnFree account

Valvular, rheumatic and infective endocarditis

A 25-year-old primigravida at 30 weeks, whose rheumatic mitral stenosis (valve area 1.1 cm²) was not known before pregnancy, is admitted to the labour ward in Patna with breathlessness at rest and basal crackles. Pulse 124/min, regular. Why has her condition worsened during pregnancy?

A 45-year-old man with a mechanical mitral valve, placed for rheumatic disease, needs a molar extraction at a dental college in Chennai. He has no drug allergy. Which antibiotic regimen is recommended to prevent infective endocarditis?

A 13-year-old boy in Jharkhand recovers from his first attack of acute rheumatic fever, which caused arthritis and mild mitral regurgitation. Before discharge, the paediatrician plans secondary prophylaxis to prevent recurrences. Which regimen is preferred?

A 26-year-old man who injects heroin is admitted in Imphal with fever and rigors for 10 days. He has a pansystolic murmur at the left lower sternal edge that becomes louder on inspiration, and chest X-ray shows multiple small cavitating nodules in both lungs. Which organism is most likely?

A 35-year-old woman with rheumatic mitral stenosis (valve area 1.2 cm²) develops atrial fibrillation; she has no other illness, and her CHA2DS2-VASc score is 1. Her rate is controlled with metoprolol. She asks for a tablet that needs no blood tests. Which anticoagulant is most appropriate for her?