SUMMARY In patients with valvular heart disease, fever, and cardiomegaly echocardiography is an invaluable noninvasive tool. In this report we describe a young female presenting with cardiac tamponade due to acute rheumatic carditis. Echocardiography showed an exudative pericardial effusion which was haemorrhagic on pericardiocentesis. She responded to steroid therapy with resolution of carditis and pericardial effusion. Case reportA 12-year-old Malay schoolgirl was admitted to another hospital with a 3-week history of fever, sore throat, transient arthritis of the right knee, and progressive exertional dyspnoea. There were no previous major medical illnesses of note.On admission the patient was pale, orthopnoeic, and febrile at 39°C. The respiratory rate was 30 per minute and the heart rate was 120 per minute. Blood pressure was 120/70 mmHg. On sitting, the jugular veins were distended up to the angle of the jaw. She had cardiomegaly, mitral and aortic regurgitation, and a pericardial rub. The liver and spleen were enlarged.Initial investigations revealed a haemoglobin of 6-2 g/dl and a white cell count of 14-4 x 109/l with neutrophilia. The erythrocyte sedimentation rate was 95 mm in the first hour. Repeated urine microscopy showed no haematuria. The electrocardiogram showed sinus tachycardia with electrical alternans in the praecordial leads. The chest x-ray showed a grossly globular heart and bilateral pleural effusions. The antistreptococcal 0 lysin titre (ASOT) was 716 Todd units. Blood and urine cultures were taken, but they grew no pathogenic organisms.Echocardiography showed the presence of a large pericardial effusion with 'strands' extending across the pericardial space (Figs 1, 2). The mitral valve was thickened, but the aortic valve was normal. No vegetations were seen. The left ventricle was 'swinging' in the pericardial space. The patient was treated with salicylates, ampicillin, cloxacillin, penicillin, and gen-

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We report a case of familial sinus node disease with associated conduction abnormalities in the atrioventricular node and distal conduction system Spontaneous atrial pacemaker activity was absent though the atrium could be depolarized. The pacemaker activity of the heart resided in the atrioventricular junction. The AV node showed impaired automaticity and abnormal conduction properties which partially improved after vagal blockage.