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Y3 IWB > PATHOLOGY- Heart disorders 2 > Flashcards

PATHOLOGY- Heart disorders 2 Flashcards

1
Q

What is acute rheumatic fever?

A

Acute immunologically mediated multi system inflammatory disease following group A beta haemolytic streptococcal infection

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2
Q

What is rheumatic heart disease

A

VALVULAR disease resulting from chronic valve damage as a result of acute rheumatic fever (AKA rheumatic valve disease)

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3
Q

What is the difference acute rheumatic fever and rheumatic heart disease?

A

acute rheumatic fever is inflammatory disease whereas rheumatic heart disease is a valvular disease

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4
Q

What causes acute rheumatic fever?

A

An immunologically mediated inflammatory disease usually following group A streptococcal pharyngitis

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5
Q

In which groups of people is acute rheumatic fever common in?

A

Commonly in children between the ages of 5-15

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6
Q

What is acute rheumatic fever characterised by?

A

Delayed, chronic inflammatory changed in primarily the heart, blood vessels, joints subcutaneous tissue and CNS

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7
Q

When do symptoms and signs of acute rheumatic fever start showing?

A

10 days to 6 weeks post infection

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8
Q

What type of reaction does acute rheumatic fever cause?

A

A hypersensitivity reaction
a combined antibody and T cell response

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9
Q

To what pathogen is the immune response targeting in a patient with acute rheumatic fever?

A

group A strep (pharyngitis)

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10
Q

How can the immune response fighting acute rheumatic fever harm the host?

A
  1. Antibodies that are directed against the M proteins of streptococci end up cross reacting with self antigens in the heart
  2. CD4+ T cells specific for streptococcal peptides react with self proteins in the heart
  3. CD4+ T cells produce cytokines that activate macrophages
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11
Q

Immunological damage in patients with acute rheumatic fever can affect…

A
  1. Joints
  2. Subcutaneous tissues
  3. Basal ganglia of the brain
  4. Heart valves/ heart tissue
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12
Q

What is acute rheumatic fever in the heart called?

A

Acute rheumatic carditis

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13
Q

Carditis of the pericardium is called what?

A

Pericarditis

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14
Q

Carditis of the Myocardium is called what?

A

Myocarditis (aschoff body)

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15
Q

Carditis of the Endocardium is called what?

A

Valvulitis

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16
Q

What is another name for myocarditis?

A

Aschoff body

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17
Q

What is chronic valve damage due to acute rheumatic fever called?

A

Rheumatic heart (valve) disease

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18
Q

Do pericarditis or myocarditis lead to chronic disease?

A

No they are only vascular manifestations

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19
Q

What is Aschoff body

A

A sign of myocarditis

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20
Q

Describe the histology of Aschoff body

A
  1. Distinctive cardiac lesions can be seen
  2. Foci of T cells, plasma cells and macrophages can be seen (anitschkow cells)
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21
Q

Where can Aschoff body be found?

A

In all three cardiac layers (known as pancarditis)

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22
Q

What is acute rheumatic fever characterised by?

A

Its systemic symptoms and signs

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23
Q

List some of the systemic signs and symptoms of acute rheumatic fever

A
  1. Migratory polyarthritis of the large joints
  2. Pancarditis
  3. Subcutaneous nodules
  4. Skin lesions
  5. Sydenham chorea
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24
Q

What is Sydenham chorea?

A

Involuntary purposeless movements

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25
Q

Name the criteria we use to diagnose acute rheumatic fever ?

A

Jones criteria

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26
Q

Describe jones criteria

A

Jones criteria requires evidence of a preceding group of A streptococcal infection
Alongside either:
2 major manifestations
OR
1 major and 2 minor manifestations

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27
Q

What does pancardititis refer to?

A

Inflammation across all three layers of the heart

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28
Q

Name the 3 cardiac layers

A
  1. Pericardium
  2. Myocardium
  3. Endocardium
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29
Q

What is the first thing you need to identify when using Jones criteria

A

Evidence of preceding GROUP A STREPTOCOCCAL infection

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30
Q

List the major diagnostic criteria (using jones criteria) to diagnose acute rheumatic fever

A
  1. Carditis
  2. Polyarthritis
  3. Chorea
  4. Erythema marginatum
  5. Subcutaneous nodules
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31
Q

List the minor diagnostic criteria (using jones criteria) to diagnose acute rheumatic fever

A
  1. Fever
  2. Arthralgia
  3. Previous rheumatic heart disease or fever
  4. Acute phase reactions
  5. Prolonged PR intervals
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32
Q

Why does it take 10 days - 6 weeks for clinical features to become apparent in patients with acute rheumatic fever?

A

As it takes time to accumulate an immune response

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33
Q

Name the main manifestations of acute rheumatic fever

A
  1. Acute (pan)carditis
  2. Migratory Polyarthritis
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34
Q

What is migratory polyarthritis

A

When one large joint after another becomes painful and swollen for a period of days and then subsides spontaneously leaving no residual disability

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35
Q

What is acute pancarditis

A

Pericaridal friction rubs, tachycardia and arrhythmias

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36
Q

What can myocarditis cause

A

Myocarditis can cause cardiac dilation that may culminate in function mitral valve insufficiency or even heart failure

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37
Q

Which part of the heart is affected by rheumatic heart disease

A

Valves are damaged in a cumulative and permanent manner

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38
Q

What can patients with rheumatic heart disease develop?

A

Can develop:

  1. Cardiac hypertrophy
  2. Dilation
  3. Heart failure
  4. Arrhythmias
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39
Q

Give some complications associated with rheumatic heart disease

A
  1. Thromboembolic complications due to atrial dilation/ fibrillation
  2. Infective endocarditis
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40
Q

How can we treat rheumatic heart disease

A

Can try and surgically repair or carry out a prosthetic replacement of the diseased valves

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41
Q

Describe the pathology of rheumatic heart disease

A
  1. Veruccae form in the heart
  2. Mitral valve changes
  3. Fibrous bridging of valvular commissures and calcification
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42
Q

What are Veruccae?

A

Vegetations in the heart

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43
Q

What does we mean when we say Veruccae form in the valves

A

Nodules of fibrous tissue form in areas where the valves close

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44
Q

Why do Veruccae form

A

Due to the autoimmune response of self reacting T cells and antibodies occurring along the areas where the valves open and close
This autoimmune reaction results in a nodular fibrosis response in the long term

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45
Q

What can mitral valve changes cause?

A

Mitral stenosis

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46
Q

What is mitral stenosis?

A

Narrowing of the heart’s mitral valve

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47
Q

what is virtually the only cause of mitral stenosis

A

virtually the only cause of mitral stenosis is rheumatic heart disease as a result of acute rheumatic fever

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48
Q

What secondary problems can arise due to mitral stenosis?

A
  1. Right ventricular hypertrophy
  2. Atrial fibrillation
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49
Q

Name the main valve involved in chronic heart diseases

A

Mitral valve (aortic valve can be involved in up 25% of cases)

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50
Q

Where is the mitral valve located?

A

Between the left atrium and the left ventricle of the heart

51
Q

what is a charcteristic lesion of mitral valve stenosis

A

Fibrous bridging of valvular commissures & calcification

52
Q

What is another term for fibrous bridging of valvular commissaries?

A

Fish mouth or button hole stenoses

53
Q

What is endocarditis

A

Inflammation of the endocardium of the heart

54
Q

Name the prototypical lesion in endocarditis

A

Vegetation on the valves

55
Q

Name the 2 main forms of endocarditis?

A
  1. Infective endocarditis
  2. Non infective endocarditis
56
Q

What is infective endocarditis due to?

A

Colonisation/ invasion of heart valves or heart chamber endocardium by a microbe

57
Q

Describe the vegetations you can see in a patient with infective endocarditis

A

It is a mixture of thrombotic debris and organisms that has destroyed underlying cardiac tissue

58
Q

Alongside the endocardium what else can be infected in a patient with infective endocarditis?

A
  1. Aorta
  2. Aneurysmal sacs
  3. Blood vessels
  4. Prosthetic valves
59
Q

What causes most cases of infective endocarditis

A

Bacterial infection

fungi/ other classes can also cause

60
Q

Name the 2 subtypes of infective endocarditis

A
  1. Acute infective endocarditis
  2. Subacute infective endocarditis
61
Q

When can acute infective endocarditis occur?

A

Can occur with infection of a previously normal heart valve

62
Q

What is acute infective endocarditis caused by?

A

Highly virulent organisms

63
Q

What is acute infective endocarditis characterised by?

A

Necrotising, ulcerative, destructive lesions that may perforate through the valve spontaneously

64
Q

What can happen if a valve perforates

A

It is no longer competent in stopping the backflow of blood which can lead to death

65
Q

How do we treat acute infective endocarditis

A

Difficult to treat with antibiotics and usually requires urgent surgery

death frequent days to weeks despite treatment

66
Q

What is subacute infective endocarditis caused by?

A

An organism of lower virulence

67
Q

Name virtually the only cause of mitral stenosis

A

Mitral valve changes due to rheumatic heart disease (which is caused by acute rheumatic fever)

68
Q

How are the symptoms of subacute infective endocarditis described as?

A

Described as a protracted wax and wane course of symptoms that last over weeks to months

69
Q

what does subacute infective endocarditis tend to occur in

A

previously deformed valves

70
Q

How do we treat sub acute infective endocarditis?

A

Cured with antibiotics

71
Q

List the 2 factors that contribute to the development of infective endocarditis

A
  1. Organism must be present in the blood stream to cause the infection
  2. Cardiac vascular abnormality needs to be present that results in abnormal blood flow promotion adherence and growth of infection
72
Q

Can infective endocarditis occur in a normal heart

A

Yes

73
Q

List some risk factors for infective endocarditis

A
  1. Cardiac/ valvular abnormalities leading to abnormal blood flow
  2. Rheumatic heart disease
  3. Mitral valve prolapse
  4. Valvular stenosis
  5. Artificial (prosthetic) valves
  6. Congenital defect (bicuspid AV)
74
Q

What is a major cause of infective endocarditis

A

Rheumatic heart disease

75
Q

Why is rheumatic heart disease a major cause of infective endocarditis

A

As it can lead to mitral stenosis which in turn leads to abnormal blood flow which can can promote adherence and growth of infection

76
Q

Name the type of infective endocarditis intravenous drug users can develop

A

Polymicrobial infective endocarditis

77
Q

What is polymicrobial infective endocarditis

A

It is an infection due to multiple different organisms

78
Q

Who is most affected by polymicrobial infective endocarditis

A

Younger aged male patients

79
Q

Which side of the heart is more affected by polymicrobial infective endocarditis

A

Right hand side involvement in more than 60%

80
Q

polymicrobial infective endocarditis in which side of the heart is more deadly?

A

Mortality rate is 4 times higher for pure left hand sided polymicrobial infective endocarditis vs pure RHS

81
Q

How many patients with polymicrobial infective endocarditis die

A

1/3

82
Q

List the high risk factors for developing infective endocarditis

A

1 Prosthetic cardiac valve
2. Prior episodes of endocarditis
3. Complex congenital cardiac defects
4. Surgically constructed systemic pulmonary shunts of conducts

83
Q

List the moderate risk factors for developing infective endocarditis

A
  1. Patient ductus arteriosus
  2. Septal defects
  3. Coarction of the aorta
  4. Bicuspid aortic valve
  5. Hypertrophic cardiomyopathy
  6. Acquired valvular dysfunction
  7. MVP with mitral regurgitation
84
Q

How can bacteria get into the blood stream?

A
  1. Dental abnormalities
  2. Intra venous drug use (IVDU)
  3. Wounds
  4. Bowel cancer
85
Q

Name some common micro organisms that can cause infective endocarditis

A
  1. Streptococcus viridans
  2. S. aureus
  3. Coagulase negative staphylococci
  4. HACEK group
86
Q

Where are Streptococcus viridans found?

A

In the mouth

87
Q

How many cases of infective endocarditis are caused by Streptococcus viridans

A

50-60%

88
Q

Patients with prosthetic heart valves are at greater risk of developing what?

A

Infective endocarditis

89
Q

Name the predominant risk factor for polymicrobial infective endocarditis

A

Intravenous drug use (IVDU)

90
Q

Where is S aureus found

A

On the skin

91
Q

How many cases of infective endocarditis are caused by S aureus

A

10-20% of cases

92
Q

Which patients are most likely to be affected by s aureus

A

Intravenous drug use

93
Q

Which patients are most likely to be affected by Coagulase negative staphylococci

A

Prosthetic heart valve patients

94
Q

Name the micro organisms found the HACEK group

A
  1. Haemophilus
  2. Aggregetibacter
  3. Cardiobacterium
  4. Eikenella
  5. Kingella
95
Q

Give an example coagulase negative staphylococci

A

S epidermidis

96
Q

Where are HACEK groups usually find?

A

Commensals in oral cavity

97
Q

How many cases of infective endocarditis are thought to be caused by HACEK group organisms

A

3%

98
Q

What is culture negative endocarditis

A

Where you suspect the patient has endocarditis but you can’t isolate the causative agent

99
Q

How many cases of infective endocarditis are culture negative

A

5-10%

100
Q

What is the cause of culture negative infective endocarditis?

A
  1. Prior antibody treatment can suppress the infection that is detected in the blood
  2. Organisms may be deeply embedded within enlarging vegetation so aren’t detected
  3. We may be unable to grow the causative organism in normal blood cultures
101
Q

Give examples of organisms we can’t grow in normal blood cultures

A
  1. Coxiella burnetiid
  2. Chlamydia spp
  3. Bartonella spp
  4. Legionella
102
Q

Describe the vegetations that may form on a patient with infective endocarditis

A

Friable (soft and falling apart), bulky and potentially destructive

103
Q

Where are on the heart do vegetations tend to grow in a patient with infective endocarditis

A

Aortic valve
Mitral valve
Mainly the RHS (especially in intravenous drug users)

104
Q

Describe the pathological features of infective endocarditis

A
  1. Friable, bulky and potentially destructive vegetation
  2. Often more than one valve affected
  3. Vegetation can erode into the myocardium and lead to abscess formation
  4. Emboli con form that contains large number of virulent organisms
105
Q

What complications can arise due to emboli formation in a patient with infective endocarditis

A

This emboli contains a large number of virulent organism that will form an abscess at the site the emboli lodges
This can lead to septic infarcts or mycotic aneurysms

106
Q

Give some clinical features of infective endocarditis

A
  1. Fever (most consistent sign)
  2. Non specific symptoms like loss of weight
  3. Murmurs
107
Q

Describe the fever pattens with infective endocarditis tend to have

A

A rapidly developing fever, chills and weakness

108
Q

How many patients with infective endocarditis had murmurs? What kind of murmur did they have?

A

90% of patients with left sided infective endocarditis experienced sudden onset murmurs

109
Q

Which combination of clinical features would lead you to a diagnosis of infective endocarditis?

A

If a patient has a new heart murmur and low grade fever

110
Q

Name the criteria we use to diagnose infective endocarditis

A

Duke criteria

111
Q

What complications can be seen in a patient with infective endocarditis

A
  1. Immunologically mediated conditions like glomerulonephritis
  2. Micro-thromboemboli
112
Q

What complications can micro- thromboemboli cause

A
  1. Splinter/ sublingual haemorrhages
  2. Janeway lesions
  3. Oslers nodes
  4. Roth spots
113
Q

Describe laneways lesions

A

Erythematous or haemorrhage non tender lesions on the palms or soles

114
Q

Describe oilers nodes

A

Subcutaneous nodules in the pulp of the digits

115
Q

Describe Roth spots

A

They are retinal haemorrhages in the eyes

116
Q

How can we remember the clinical signs and symptoms of infective endocarditis

A

By using the mnemonic:
FROM JANE

117
Q

What do the letters in FROM JANE stand for?

A

Fever
Roth spots
Osler’s nodes
Murmur

Janeway lesions
Anaemia
Nail (splinter) haemorrhage
Emboli

118
Q

Why is it hard to treat infective endocarditis?

A

As organism are protected within vegetations making them harder to treat

119
Q

How do we treat infective endocarditis

A

High concentrations of intravenous (IV) antibiotics for 4-6 weeks (usually adjusted according to the cultural results)
Most common is penicillin

120
Q

What is the association between risk of infective endocarditis and dental procedures

A

As of now there is no clear association with dental procedures and risk of infective endocarditis

121
Q

If you have a patient with infective endocarditis what is not recommended you do?

A

Not recommended you prescribe them antibacterial prophylaxis and chlorohexidine mouthwash for the prevention of infective endocarditis

122
Q

If you have a patient with infective endocarditis what is recommended you do?

A

Reduction of oral bacteraemia - high standard oral hygiene
- Reduce need for dental extractions / surgery;
- Reduce chances of severe bacteraemia if dental surgery is needed

123
Q

what are the NICE guidlines for infective endocarditis

A
  • Patients at risk of endocarditis e.g. valve replacement (see risk factors) should be warned to report to the doctor or dentist any unexplained illness after dental treatment.
  • Any infection in patients at risk of endocarditis should be investigated promptly and treated appropriately to reduce the risk of endocarditis.

Y3 IWB (31 decks)

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