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Rheumatic Fever, Infectious Endocarditis & Misc. Heart Disease

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.

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Rheumatic Fever, Infectious Endocarditis & Misc. Heart Disease

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  1. Rheumatic Fever, Infectious Endocarditis & Misc. Heart Disease

  2. Rheumatic Fever • Systemic non-suppurative inflammatory disease • Inflammation of connective tissue • Edema, fibrinoid degeneration • Hypersensitivity reaction to beta-hemolytic Group A Streptococci

  3. 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

  4. Major Manifestations • Carditis • Polyarthritis • Chorea • Erythema marginatum • Subcutaneous nodules

  5. Minor Manifestations • Clinical findings • Arthralgia • Fever • Laboratory findings • Elevated acute phase reactants • Erythrocyte sedimentation rate • C-reactive protein • Prolonged PR Interval

  6. Supporting Evidence of Antecedent Group A Streptococcal Infections • Positive throat culture or rapid streptococcal antigen test • Elevated or rising streptococcal antibody titer

  7. 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

  8. Extra cardiac Lesions • Subcutaneous nodules • Polyarthritis • CNS - Sydenham’s chorea

  9. Sequelae of RF • 1% die of acute carditis • Progressive stenosis of valves • Atrial fibrillation • Mural thrombosis • Congestive heart failure • Bacterial endocarditis

  10. Acute rheumatic fever– Acute fibrinous Pericarditis- Bread & Butter type

  11. edema Giant Anitschkow cells Fibrinoid degeneration Anitschkow cells Aschoff body- poorly formed granuloma

  12. Aschoff bodies • Foci of fibrinoid degeneration • Lymphocytes (T-cells) • Macrophages-Anitschkow cells • Large elongated nuclei - caterpillar cells • May form giant cells

  13. Acute rheumatic fever – fibrin vegetations along lines of Closure (verrucus endocarditis)

  14. Chronic Rheumatic Disease • Organization of the acute inflammatory process and subsequent deforming fibrosis • Mitral stenosis alone: 65 -70% • Mitral and aortic: 25 %

  15. Normal mitral valve Chronic rheumatic endocarditis

  16. Chronic rheumatic endocarditis – mitral stenosis

  17. Chronic rheumatic stenosis- fibrous thickening & fusion of Chordae tendinae

  18. 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

  19. Pathogenesis of IE • Sterile platelet -fibrin deposits • Agglutinating antibodies cause clumps of organisms likely to attach to fibrin • Bacterial adhesion factors

  20. Infective endocarditis with destruction of the aortic valve

  21. Pulmonary valve Aortic valve Acute infective endocarditis- note perforation (blue area)

  22. Roth spots

  23. Osler’s nodes & Janaway spots In SBE, (rare to see Today)

  24. Destruction of a damaged (rf) stenotic mitral valve by Stept. viridans

  25. Complications of IE Cardiac • Valvular disease with CHF • Myocardial abscess • Suppurative pericarditis • Dehiscence of artificial valve Embolic • To brain, spleen, kidney, etc.

  26. Complications of IE Metastatic infections • any organ or site Renal • Focal glomerulonephritis (immune) • Diffuse GN (immune) • Multiple abscesses

  27. Non-infectious Endocarditis • Libman-Sacks (SLE) • Non-bacterial thrombotic (marantic) (Terminal DIC syndrome) • Hypercoagulable state - mucinous adenocarcinoma - pancreas

  28. Complications of Artificial Valves • Paravalvular leak • Thromboembolism • Infective endocarditis • Structural deterioration • Occlusion by tissue overgrowth

  29. Pericardial Effusion • Hemopericardium- blood • Dissection • Trauma • Hydropericardium-- low protein • Heart failure • Nutrition-- low albumin

  30. 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

  31. 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

  32. 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

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