A 9-year-old with acute rheumatic fever and carditis is examined during the acute illness. A short, soft, low-pitched mid-diastolic murmur is heard at the apex, changing with position and disappearing as the inflammation resolves. This murmur is best explained by:

• A Fixed mitral stenosis with commissural fusion
• B Left atrial myxoma obstructing the mitral orifice
• C Aortic regurgitation transmitted to the apex
• D Mitral valvulitis causing relative mitral stenosis (Carey Coombs murmur) ✓

Explanation

The Carey Coombs murmur is a soft, short, mid-diastolic apical murmur produced by acute mitral valvulitis and thickening of the leaflets, creating relative mitral stenosis during active rheumatic carditis. Unlike true rheumatic mitral stenosis it lacks presystolic accentuation, an opening snap, and loud S1, and it fades completely as the carditis subsides. Its transience in this vignette excludes fixed structural mitral stenosis and a myxoma.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.