Rheumatic fever

ByDr. Ali Abdel-Wahab

Lecture specs

At the end of lecture students should be able toClassify disorders of the heart, especially inflammatory diseasesDefine endocarditis and enumerate its causes and pathological subtypesDefine rheumatic fever and enumerate organs affected by this disorderDescribe 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 feverPathogenesis

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 feverPancarditis

- Inflammation of the 3 heart layers= Pancarditis

1. Pericarditis

2. Myocarditis

3. 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 feverComplications

Mitral stenosis Mitral incompetence Double mitral valve

disease Stenosis

thrombu

s

Rheumatic feverComplications

Aortic stenosis Aortic incompetence Double aortic valve

disease

Rheumatic feverComplications

Pulmonary and tricuspid valves are rarely affected.

Diagnosis of Rheumatic FeverJones criteria

– Major criteria1. Carditis2. Polyarthritis3. Chorea4. Skin rash5. Skin nodules.

Two major or Two minors +one major

– Minor criteria1. Fever2. Arthralgia3. increased ESR 4. CRP5. Previous rheumatic fever.6. ECG changes