A 27-year-old young adult Ethiopian female patient who is known to have chronic rheumatic valvular heart disease for the past 8 years started to experience repetitive uncontrollable movements of her extremities and trunk since 3 years ago and which were occurring once to three times per month. The abnormal body movements usually lasted up to a week duration and got worse while she tried to sit or walk and improved with rest. She was consistently taking intramuscular injection of benzathine penicillin G 1.2 million units every month for the past 8 years. She did not have previous history of behavioral and emotional lability. She does not remember childhood history of rheumatic fever or movement disorder. She did not use oral or injectable hormonal agents. There was no family history of rheumatic fever, social stress, psychiatric disease, or tic disorders. Upon physical examination, temperature was 36.7 C, heartbeat was 90 beats per minute, and blood pressure was 100/70 mmHg. There was holosystolic murmur at the apical area radiating to the left axilla. Choreiform movements were apparent on all limbs and trunk.
Laboratory investigations revealed moderate leukopenia (but with a normal repeat complete blood count after 3 days), normal liver enzymes, normal renal function tests, erythrocyte sedimentation rate of 37 mm/hour, negative qualitative C-reactive protein, weakly positive anti-streptolysin O antibody, negative qualitative antinuclear antibody, negative urine human chorionic gonadotrophin and normal level of thyroid stimulating hormone. Magnetic resonance imaging of the brain showed left parietal periventricular tiny white matter non-specific lesion. Rheumatic heart involvement was confirmed by echocardiography which showed thickening of mitral valve leaflets with severe mitral regurgitation (Figure 1). 
The present case was diagnosed as recurrent Sydenham chorea based on clinical evidence and she was prescribed valproic acid 500 mg PO/day for 2 weeks and benzathine penicillin G injection was made every 3 weeks. She was re-evaluated after 2 weeks and she had significant improvement with good control of motor activity and reduced involuntary movements of her extremities and trunk. She was then followed every 3 weeks for the subsequent 3 months and she did not have any abnormal body movement. She was finally referred to an advanced cardiac center for possible mitral valve replacement.