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 Laboratory 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: %
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. Acute infective endocarditis- note perforation (blue area)
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 Embolic Valvular disease with CHF
Myocardial abscess
Suppurative pericarditis
Dehiscence of artificial valve
Embolic
To brain, spleen, kidney, etc.

26. Complications of IE Metastatic infections Renal any organ or site
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

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

31. 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

32. 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

33. 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