Rheumatic fever By Dr. Ali Abdel-Wahab

Lecture specs At the end of lecture students should be able to Classify disorders of the heart, especially inflammatory diseases Define endocarditis and enumerate its causes and pathological subtypes Define rheumatic fever and enumerate organs affected by this disorder Describe Aschoff body (rheumatic granuloma) Enumerate possible complications of rheumatic fever

Diseases of heart Heart failure Congenital heart Valve diseases Hypertensive heart diseases Ischemic heart disease Cardiomyopathy Cardiac transplantation

Pericardiac diseases Myocardiac diseases Endocardiac diseases Pancarditis

Endocarditis Usually associated with vegetations (thrombosis on cardiac valve) that may leads to Emboli Fibrosis and valve diseases Non-infective endocarditis Rheumatic fever(part of pancarditis) Rheumatoid disease Infective endocarditis

Rheumatic fever It is an non-infective immune disorder A systemic autoimmune disease affecting mainly the heart, joints, subcutaneous tissue and CNS.

Incidence Children between 5-15 years. Developing countries. Familial Low socioeconomic standards Poor nutrition Overcrowding Poor ventilation Bad habits

Rheumatic fever Pathogenesis Certain susceptible individuals An upper respiratory tract infection by Group A β hemolytic streptococci. After 1-4 weeks start immune reaction Streptococcal antigen stimulates antibody production High anti-streptolysin O (ASO) indicate recent streptococcal infection The antistreptococcal antibody cross-react with host cardiac antigen starting the disease.

Manifestations of rheumatic fever Cardiac; pancarditis Extra cardiac manifestations Skin rash Arthritis Brain

Extra-cardiac manifestations Fever, malaise and increased ESR. Joint: arthralgia and migratory polyarthritis that usually heals without residual effect. Subcutaneous nodules over bony prominences. Sydenham’s chorea (chorea minor); involuntary semi-purposeful movements associated with emotional liability

Rheumatic fever Pancarditis Inflammation of the 3 heart layers= Pancarditis Pericarditis Myocarditis Endocarditis

Rheumatic fever serious lesions During the acute stage, rheumatic myocarditis is more dangerous With chronic disease, endocarditis leads to valve lesions

Rheumatic pericarditis It produces serofibrinous pericarditis. Pericarditis heals by organization (fibrosis)

Rheumatic Myocarditis Aschoff’s nodules (granuloma) developing in the myocardium Rarely acute left ventricular failure

Aschoff’s nodules (granuloma) Site: myocardium, skin nodules Paravascuar collections of monocular cells Caterpillar cells

Rheumatic endocarditis Mural endocardium Valvular endocarditis Inflammation of the cardiac cusps commonly affected The mitral and aortic valves Mitral ˃mitral with aortic˃ aortic ˃ tricuspid Edema of the leaflets of the cusps make the endocardium liable to injury during closure of the valve This leads to small thrombosis on the valve (vegetations)

Rheumatic fever Complications thrombus Mitral stenosis Mitral incompetence Double mitral valve disease Stenosis

Rheumatic fever Complications Aortic stenosis Aortic incompetence Double aortic valve disease

Rheumatic fever Complications Pulmonary and tricuspid valves are rarely affected.

Diagnosis of Rheumatic Fever Jones criteria Major criteria Carditis Polyarthritis Chorea Skin rash Skin nodules. Two major or Two minors +one major Minor criteria Fever Arthralgia increased ESR CRP Previous rheumatic fever. ECG changes