Cardiovascular

Question 1

> 5 years
Male predominance

Dreaded Carditis
Chronic valvulopathy

Answer 1

RF/RHD

Question 2

<5 years

Dreaded vasculitis, coronary aneurysm and thrombosis

Answer 2

Kawasaki disease

Question 3

Systemic vasculitis
Inflammation of small to medium-sized arteries with resulting aneurysm

Febrile mucocutaneous illness of childhood
Fever and rash

Answer 3

Kawasaki disease

Question 4

Leading cause of acquired heart disease in children in developing nations

Answer 4

Rheumatic fever/ RHD

Question 5

Most important manifestation of Kawasaki

Answer 5

Aneurysmal involvement of coronary arteries

Peak mortality 15-45 days after onset of fever with mortality rate ranging 0.08-3.7%

Question 6

Greatest risk of cardiac involvement in Kawasaki occur in

Answer 6

<1 year

Atypical

Question 7

Etiology of Kawasaki

Answer 7

Infection
Superantigen-driven response (genetic predisposition -> oligoclonal conventional antigen vs polyclonal)

Increased production of cytokines and MMP

Question 8

Kawasaki Phases

Answer 8

Early - first day of high fever, swelling of endothelium and edema of media, intact IEL

SubAcute (7-9d) - influx of neutrophils, CD8+, cytotoxic lymphocytes and IgA producing plasma (IEL fragmentation, vascular damage, dilatation, aneurysm)

Convalescent (>10d) increase cytokines, IL, MMP (fibrosis)

Question 9

IV IG in Kawasaki is best given between

Answer 9

6th-10 days of illness because of inflammation

Question 10

Kawasaki Disease criteria

Answer 10

Fever >5 days and
4/5 Main clinical features after exclusion

or

> 4 principal criteria at day 4 of fever

Question 11

Principal features of Kawasaki

Answer 11

Acute: Changes in extremities (erythema of palms, soles; edema of hands)

Subacute: periungal peeling of fingers, toes in weeks 2 and 3

Polymorphous exanthem

Bilateral bulbar conjunctival injection without exudates

Changes in lips and oral cavity: erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosa

Cervical lymphadenopathy 1.5 cm unilateral

Question 12

Patients with fever of at least 5 days and <4 principal criteria can be diagnosed with KD when

Answer 12

coronary artery abnormalities are detected by 2D ECHO or angiography

Question 13

If patients have at least 3/5 but present with this symptom, KD is disgnosed

Answer 13

Coronary artery disease

Question 14

High grade fever with or without other manifestations (arthritis, myocarditis)
Lips and mucocutaneous changes
Cervical adenitis
Normal CBC

Answer 14

Acute phase

first 10 days

Question 15

Thrombocytosis
Desquamation of skin and palms
Beau’s lines 
With or without aneurysm
Coronary thrombosis
Mitral insufficiency

Answer 15

Subacute phase

11-22 days p

Question 16

Cause of death in acute phase of KD

Answer 16

Myocarditis

Question 17

Cause of death in subacute phase of KD

Answer 17

MI
Rupture of aneurysm
Myocarditis

Question 18

May still be with Thrombocytopenia
Arthritis
Coronary and peripheral aneurysm

Answer 18

Convalescent phase

Cause of death: MI, IHD

Question 19

Angina pectoris

MI

Answer 19

Chronic phase

Question 20

Fever responds to this in KD

Answer 20

IVIG

Question 21

Polymorphic exanthem on perineum mistaken for diaper rash

Dry erythematous, fissured, swollen and cracking lips

Strawbery tongue

Painful erythema and edema of extremity

Bilateral non exudative conjunctivitis

Unilateral Non-suppurative Cervical Lymphadenopathy >1.5 cm o

Answer 21

Fever >5 d
4/5

Kawasaki disease

Question 22

Valvular regurgitation because of ischemia of papillary muscles in KD occurs in

Answer 22

Mitral

Aortic

Question 23

Kawasaki disease Tx

Answer 23

IVIG (modulate cytokines, neutralization of bacterial super antigens)
Aspirin

Dipyrimadole if viral infection or hypersensitive (PDE 3 inhibitor antiplatelet)

Question 24

Peaks 11-15 years

Inflammatory process mediated by immunologic reaction initiated by GABHS

Answer 24

Rheumatic fever

Question 25

Most frequent GABHS serotype causing RF

Answer 25

M type 1.3.5.6.18

Question 26

Proves you had a strep infection within the last 2-6 weeks

Answer 26

ASO titer

Question 27

Specific HLA associated with RF/RHD

Answer 27

HLA DR4 | HLA DR2

Question 28

Tropic for throat rather than skin M Protein Hyaluronate capsule Can produce lipoprotein lipase (opacity factor) highly contagious

Answer 28

GABHS M strain | Lancefield A

Question 29

Latent period of RF

Answer 29

1-3 weeks Antibody-induced immunological damage

Question 30

Strep infection affects susceptible host positive for

Answer 30

D8/17

Question 31

Universal heart finding in rheumatic carditis

Answer 31

Endocarditis Carditis is the only manifestation that leaves a sequalae and permanent damage to the organ

Question 32

Girls 15-18 years 6-12 days after attack of RF Clumsiness Deterioration of hand writing Emotional lability of grimacing of face Stress and disappears with sleep + anti neural ab in 90% Latency of 1-6 months

Answer 32

Chorea in RF

Question 33

Transient, serpiginous-looking lesions Pale center, erythematous, non-prurituc, irregular margin Trunk and limbs Worsens with application of heat Disappears with exposure to cold

Answer 33

Erythema marginatum of RF

Question 34

Hard, painless, pea sized, palpable nodules Over extensor surfsces Always associated with severe carditis and higher moratality rate

Answer 34

Subcutaneous nodules of RF

Question 35

Jones Minor criteria of RF

Answer 35

Fever Arthralgia Inc ESR and CRP Leukocytosis Prolonged PR interval

Question 36

Jones Criteria Diagnosis for RF Major

Answer 36

``` Polyarthritis major joints (migratory) Erythema marginatum Carditis Chorea Subcutaneus nodules ```

Question 37

Supportiving evidence of RF

Answer 37

+ Throat culture or elevated rapid streptococcal antigen test Inc or rising streptococcal antibody titer of at least 2 fold from baseline

Question 38

Diagnosis of RF

Answer 38

Two Major 1 Major + 2 minor Evidence of Group A (culture, Rapid antigen, antibody titer)

Question 39

Post strep arthritic condition that doesn’t fulfill Jones criteria Additive vs migratory joint pains Poor response to salicylate and NSAID Inc APR + ASO May develop mitral disease

Answer 39

Poststreptococcal Reactive Arthritis

Question 40

Primary Prevention of RF

Answer 40

Benzanthine Pen G IM once Pen V Oral 10d If allergic Erythromycin estolate PO 10d Ethylsuccinate PO 10d

Question 41

Tx for Arthritis prominent RF

Answer 41

Aspirin

Question 42

Tx for carditis prominent RF

Answer 42

Prednisolone | Aspirin

Question 43

Secondary prophylaxis for RF | Mainstay management to prevent progression to heart djsease

Answer 43

Benzanthine Pen G 1.2 IM Pen V PO Sulfadiazine POV

Question 44

Low risk group (Fever, joint pains and without confirmed carditis) Give medication

Answer 44

Every 28 d until 5 years | Every 28 d until 21 years if with carditis

Question 45

For high risk grouos (Heart involvement, heart failure, multiple valve involvement and recurrence) Give medication

Answer 45

Every 4 weeks up to 25 years if mild (single valve) Every 3 weeks up to 25 years if severe (decrease to every 4 unless recurrence) For life if with cardiac pathology, stop at 40 if surgically managed

Question 46

Most common involved valve in RF Carditis

Answer 46

Mitral (85%) | Aortic (54%)

Question 47

Small joints Symmetrical Unresponsive to anti-inflammatory Leaves a sequela (enlargement of joints after inflammation) - deformity of joints

Answer 47

Juvenile Rheumatic Arthritis