rheumatic fever, infectious endocarditis & misc. heart disease
TRANSCRIPT
Rheumatic Fever, Infectious Endocarditis & Misc. Heart
Disease
Rheumatic Fever
• Systemic non-suppurative inflammatory disease
• Inflammation of connective tissue
• Edema, fibrinoid degeneration
• Hypersensitivity reaction to beta-hemolytic Group A Streptococci
RF• 2-3 weeks after Group A Strep infection
• Age 5-15 years
• Sex - equal
• Social economic - poor, malnourished, crowded conditions, or rural isolated - Wy, Idaho, Utah
Major Manifestations
• Carditis
• Polyarthritis
• Chorea
• Erythema marginatum
• Subcutaneous nodules
Minor Manifestations
• Clinical findings• Arthralgia• Fever
• Laboratory findings• Elevated acute phase reactants• Erythrocyte sedimentation rate• C-reactive protein
• Prolonged PR Interval
Supporting Evidence of Antecedent Group A
Streptococcal Infections• Positive throat culture or rapid
streptococcal antigen test
• Elevated or rising streptococcal antibody titer
Acute RF• Pancarditis
• pericarditis - fibrinous• myocarditis - Aschoff bodies and edema • endocarditis - foci of inflammation and
fibrinoid degeneration within the cusps or along the tendinous cords with small fibrinous vegetations - verrucae
Extra cardiac Lesions
• Subcutaneous nodules
• Polyarthritis
• CNS - Sydenham’s chorea
Sequelae of RF
• 1% die of acute carditis
• Progressive stenosis of valves
• Atrial fibrillation
• Mural thrombosis
• Congestive heart failure
• Bacterial endocarditis
Acute rheumatic fever–Acute fibrinous Pericarditis- Bread &Butter type
Aschoff body- poorly formed granuloma
Giant Anitschkow cells Fibrinoid degeneration Anitschkow
edema
cells
Aschoff bodies
• Foci of fibrinoid degeneration
• Lymphocytes (T-cells)
• Macrophages-Anitschkow cells• Large elongated nuclei - caterpillar cells• May form giant cells
Acute rheumatic fever – fibrin vegetations along lines of Closure (verrucus endocarditis)
Chronic Rheumatic Disease• Organization of the acute inflammatory
process and subsequent deforming fibrosis
• Mitral stenosis alone: 65 -70%
• Mitral and aortic: 25 %
Normal mitral valve Chronic rheumatic endocarditis
Chronic rheumatic endocarditis – mitral stenosis
Chronic rheumatic stenosis- fibrous thickening & fusion of Chordae tendinae
Infective Endocarditis
• Every form of micro-organism has been implicated
• Acute form - highly virulent organisms (Staph, Strep, fungal - on normal valves
• Sub acute - less virulent organisms (Strep viridans)- damaged valves
•Pathogenesis of IE
• Sterile platelet -fibrin deposits
• Agglutinating antibodies cause clumps of organisms likely to attach to fibrin
• Bacterial adhesion factors
Infective endocarditis with destruction of the aortic valve
Acute infective endocarditis- note perforation (blue area)Acute infective endocarditis- note perforation (blue area)
Pulmonary valvePulmonary valve Aortic valveAortic valve
Roth spotsRoth spots
Osler’s nodes &Osler’s nodes &Janaway spotsJanaway spotsIn SBE, (rare to seeIn SBE, (rare to seeToday)Today)
Destruction of a damaged (rf) stenotic mitral valve by Stept. viridans
•Complications of IE
Cardiac• Valvular disease with CHF• Myocardial abscess• Suppurative pericarditis• Dehiscence of artificial valve
Embolic• To brain, spleen, kidney, etc.
Complications of IE
Metastatic infections• any organ or site
Renal• Focal glomerulonephritis (immune)• Diffuse GN (immune)• Multiple abscesses
Non-infectious Endocarditis• Libman-Sacks (SLE)
• Non-bacterial thrombotic (marantic)(Terminal DIC syndrome)
• Hypercoagulable state - mucinous adenocarcinoma - pancreas
Complications of Artificial Valves
• Paravalvular leak
• Thromboembolism
• Infective endocarditis
• Structural deterioration
• Occlusion by tissue overgrowth
Pericardial Effusion
• Hemopericardium- blood• Dissection• Trauma
• Hydropericardium-- low protein• Heart failure• Nutrition-- low albumin
Pericarditis• Serous pericarditis- SLE, Uremia etc
• Scant inflammatory cells• Slow build up
• Fibrinous & serofibrinous most common• Acute MI, uremia, SLE, RF• Friction rub
• Purulent or suppurative- Pus, PNMs• Bugs- if bloody think TB
• Hemorrhagic- tumor (breast or lung), TB, bleeding diathesis
Chronic Pericarditis
• Adhesive Mediastinopericarditis • Follows supprative pericarditis, staph,
TB, or cardiac surgery or radiation• Leads to cardiac hypertrophy and
dilatation -Mimics DCM
• Constrictive pericarditis- staph, TB• Restricts cardiac output- mimics
restrictive cardiomyopathy
Summary
• Mitral Stenosis : Rheumatic Heart Disease
• Mitral insufficiency: myxomatous degeneration (mitral valve prolapse), damaged papillary muscle due to infarct
• Aortic stenosis: calcification of normal and congenitally bicuspid aortic valves
• Aortic insufficiency: dilation of the ascending aorta, related to hypertension and aging