Rheumatic heart disease is an irreversible sequela of rheumatic fever which is a major cause of cardiovascular morbidity and mortality in developing countries. We report a case of a 22-year-old lady with underlying chronic rheumatic heart disease, underwent mitral valve repair, presented with a recurrence of acute rheumatic fever with new aortic regurgitation confirmed by echocardiography, upon defaulting oral penicillin prophylaxis. She was treated symptomatically and started on IV Penicillin 2.4MU for 14 days based on clinical suspicion of possible infective endocarditis although laboratory values were not suggestive. With the resolution of clinical symptoms and treatment completion, she was discharged with oral penicillin despite non-compliance and a referral to the tertiary cardiac centre for continuation of care. Medical management was continued without surgical intervention to date. There is no specific guideline available in Malaysia to manage rheumatic heart disease, therefore treatment relies on the physician’s experience. Majority still prefer prescribing oral penicillin prophylaxis in Malaysia but the recommended choice of prophylaxis worldwide is IM penicillin. In my opinion, this patient should have been discharged with IM penicillin or, even better, initiated at the point of initial diagnosis. In this case report, we not only highlight the importance of secondary prophylaxis but also focus on the route of prophylaxis to halt the progression of the disease.