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| CASE REPORT |
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| Year : 2022 | Volume
: 23
| Issue : 4 | Page : 230-234 |
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Tiger stripes in carditis of rheumatic origin
Najeeb Ullah Sofi, Santosh Kumar Sinha, Mohit Sachan, Ramesh Thakur
Department of Cardiology, LPS Institute of Cardiology, GSVM, Kanpur, Uttar Pradesh, India
| Date of Submission | 12-Jan-2022 |
| Date of Acceptance | 02-Oct-2022 |
| Date of Web Publication | 17-Nov-2022 |
Correspondence Address:
Dr. Najeeb Ullah Sofi
Department of Cardiology, LPS Institute of Cardiology, GSVM, Kanpur, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartviews.heartviews_4_22
 Abstract | | |
“Tiger stripes” or “Zebra stripes” are multiple band-like signals noted on Doppler spectral recordings and have been associated with intracardiac oscillating structures. They have been attributed to flail prosthetic valve leaflet, native valve regurgitation without flail leaflet, papillary muscle rupture in acute coronary syndrome, and possibly Lambl's excrescences. To our knowledge, there is only one case report in the English literature that had identified this sign in rheumatic carditis. We present the case of a 14-year-old boy, who was known to have rheumatic heart disease and presented with worsening dyspnea of recent onset. His antistreptolysin O, C-reactive protein, and erythrocyte sedimentation rate titer were raised. Echocardiography revealed severe eccentric mitral regurgitation with multiple high-intensity signals (tiger stripes) on continuous wave (CW) Doppler. The patient was managed as rheumatic carditis with steroids. Repeat echocardiography after 1 month showed the resolution of tiger stripes. Upon tapering, steroids patient's symptoms worsened and echocardiography revealed the reappearance of tiger stripes. We propose that these high-intensity signals in spectral Doppler reflect valvulitis and are the echocardiographic counterpart of musical overtones. We suggest that these signals on CW Doppler in a patient with established rheumatic heart disease be taken as a marker of carditis and the patient should be managed accordingly. We refer to this sign as a “Fingerprint sign” due to its resemblance to it and to differentiate it from Tiger strips because of its dynamic nature. This sign can be used to identify and follow carditis in a rheumatic scenario.
Keywords: Mitral regurgitation, rheumatic fever, rheumatic heart disease, tiger stripes, valvulitis
How to cite this article:
Sofi NU, Sinha SK, Sachan M, Thakur R. Tiger stripes in carditis of rheumatic origin. Heart Views 2022;23:230-4 |
| Introduction | |  |
Occasionally multiple band-like signals are noted on Doppler spectral recordings of valvular regurgitation. These band-like signals appear to be associated with intracardiac oscillating structures. These structures vibrate with a single frequency with several harmonic overtones. These multiple high-intensity signals have been referred to as “Tiger stripes” or “Zebra stripes” and have been attributed to flail prosthetic valve leaflet, native valve regurgitation without flail leaflet, papillary muscle rupture in acute coronary syndrome, and possibly Lambl's excrescences. To our knowledge, there is only one case report in the english literature that had identified this sign in rheumatic carditis.
| Case Presentation | | |
History of present illness
A 14-year-old boy presented with complaints of fever for 10 days and worsening breathlessness for the past 3 days. On examination, the patient had a blood pressure of 110/60 mm Hg, and his heart rate was 98 beats/min. Chest examination revealed bilateral basal crepts, cardiac examination revealed holosystolic murmur at apex radiating to left axilla with musical overtones.
Past medical history
The patient was known to have rheumatic heart disease for the past 2 years and was put on penicillin prophylaxis but he was not compliant with treatment.
Investigations
The patient was evaluated in the emergency room. His antistreptolysin O titer was 368 Todd unit, erythrocyte sedimentation rate was 42 mm/h, and C-reactive protein was 16 mg/dl. Echocardiography revealed grossly dilated left atrium and left ventricle. Mitral valve leaflets were thickened. Color Doppler showed severe eccentric mitral regurgitant jet directed posteriorly. Continuous wave (CW) Doppler through the mitral valve revealed mitral regurgitant jet with high-intensity band-like signals (Tiger stripes) superimposed on Doppler signal [Figure 1], [Figure 2], [Figure 3], [Figure 4]. It looked like fingerprints. | Figure 1: Left atrium and Left ventricular enlargement with thickened mitral leaflet
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 | Figure 4: Continuous wave Doppler through Mitral valve showing mitral regurgitation and high intensity signals (Tiger stripes)
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Management
The patient was managed as a case of rheumatic carditis with steroids. Echocardiography was repeated after 1 month, once the patient became symptomatically better. Spectral Doppler across the mitral valve had lost its hyper-intensity signals [Figure 5] and on auscultation musical overtones had subsided. Subsequently, steroids were tapered. The patient again visited our clinic after 1 month of tapering steroids. Examination revealed the reappearance of a holosystolic murmur with musical overtones and echocardiography revealed the reappearance of Tiger stripes on Doppler imaging [Figure 6]. The steroid dose was increased and the patient is now on follow-up. | Figure 5: Echocardiography after steroid treatment showing Mitral regurgitation with loss of high-intensity signals (Tiger Stripes)
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| Discussion | | |
Although carditis of rheumatic origin has always been thought of to be as pancarditis and may involve all three layers of the heart, valvulitis is by far the most consistent feature of ARF. The valvulitis presents itself as mitral or less often as aortic regurgitation.[1] In 2015, subclinical carditis, identified by pathological mitral or aortic regurgitant lesions in the absence of typical auscultatory findings, was included as the major criteria for the diagnosis of acute rheumatic fever. The echocardiographic features include four criteria, (1) seen in at least 2 views, (2) jet length, (3) peak velocity >3 m/s, and (4) Pansystolic jet in at least 1 envelope.[1]
Occasionally multiple band-like signals are noted on Doppler spectral recordings of valvular regurgitation.[2] These signals have been attributed to intracardiac oscillating structures.[3] These multiple high-intensity signals have been referred to as “Tiger stripes” or “Zebra stripes” and have been attributed to flail prosthetic valve leaflet,[4],[5] native valve regurgitation without flail leaflet,[6] papillary muscle rupture in acute coronary syndrome,[7] and possibly Lambl's excrescences.[3]
We observed similar multiple high-intensity signals in Doppler spectral in a rheumatic heart disease patient who had an episode of carditis. We managed the patient with steroids, he improved clinically, and repeat echocardiography revealed the resolution of those high-intensity signals. Subsequently, steroids were tapered; however, his clinical condition deteriorated again, and repeat echocardiography revealed the reappearance of those high-intensity signals.
We propose that these high-intensity signals in spectral Doppler reflect valvulitis and are an echocardiographic counterpart of musical overtones. Hence, we suggest that these signals on CW Doppler in a patient with established rheumatic heart disease be taken as a marker of carditis and the patient managed accordingly. We saw five patients with rheumatic heart disease who had carditis in the past 6 months; however, only this patient had such spectral Doppler, so if carditis is suspected in an established rheumatic heart disease patient this sign should be carefully looked for, and if present will establish the diagnosis; however, its absence cannot rule out carditis.
We refer to this sign as the “Fingerprint sign” due to its resemblance to it and to differentiate it from Tiger strips because of its dynamic nature. This sign can be used to identify and follow carditis in a rheumatic scenario.
| Conclusion | | |
In carditis of rheumatic origin, regurgitant lesions may show high-intensity band-like signals on spectral Doppler. These signals are the echocardiographic equivalent of musical overtones heard on auscultation and likely suggest valvulitis. These signals are dynamic and subside with the effective treatment of carditis. These signals may be followed to see the response to the treatment. We refer to this sign as the “Fingerprint sign.”
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al. Revision of the jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: A scientific statement from the American Heart Association. Circulation 2015;131:1806-18.  |
| 2. | Kerut EK. Tiger stripes. Echocardiography 2007;24:558-9. |
| 3. | Davogustto G, Fernando RR, Loghin C. Lambl's excrescence, migrainous headaches, and “tiger stripes”: Puzzling findings in one patient. Tex Heart Inst J 2015;42:70-2. |
| 4. | Wilkins GT, Flachskampf FA, Weyman AE. Echo-Doppler assessment of prosthetic heart valves. In: Weyman AE, editor. Principles and Practice of Echocardiography. 2 nd ed. Philadelphia: Lea & Febiger; 1994. p. 1227-8. |
| 5. | Kinney EL, Machado H, Cortada X. Cooing intracardiac sound in a perforated porcine mitral valve detected by pulsed Doppler echocardiography. Am Heart J 1986;112:420-3. |
| 6. | Rakesh J, Krishnan MN. Tiger stripes sign. JICC 2015;5:138-40. |
| 7. | Cervantes-Nieto JA, Rivera-Silverio DA, Gopar-Nieto R, Azar-Manzur F, Ruiz-Esparza ME, Raymundo-Martínez G. “Tiger stripes” sign in acute coronary syndrome. Signo “manchas de tigre” en síndrome coronario agudo. Archivos de cardiologia de Mexico 2020;90:349-50. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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