Rheumatic Heart Disease Flashcards by Iseoluwa Ojo

Rheumatic Fever (RF) is a (local or systemic?) , post-__________ , (suppurative or non-suppurative?) inflammatory disease, principally affecting the _____,____,____,____,______

Systemic

streptococcal

non-suppurative

heart, joints, CNS, skin , subcut.tissues

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The (acute or chronic?) stage of RF involves _____ layers of the heart ( _______ ) causing major cardiac sequelae referred to as Rheumatic Heart Disease (RHD).

Chronic

all three

pancarditis

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RHD

Most commonly seen in (children or adults?) _____ years

When ________ infection is most frequent and intense

Children; 5-15

streptococcal

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Streptococcus pharyngitis is seen (more or less?) commonly in poor socioeconomic strata of people living in damp and crowded places which promotes interpersonal spread of strep.infection
•Its incidence has declined in _______ countries.

developed

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Both sexes are nearly equally affected in RHD

T/F

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AETIOPATHOGENESIS of RHD

• It is generally accepted that there is a preceding _______ with ________ streptococcus of group ____ in RF

throat infection

beta- haemolytic

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AETIOPATHOGENESIS of RHD

• the mechanism of lesions in the heart, joints and other tissues is by direct infection

T/F

If T , why
If F, then by how?

not by direct infection but by induction of hypersensitivity or autoimmunity

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AETIOPATHOGENESIS of RHD

• However, the mechanism of lesions in the heart, joints and other tissues is not by ____ but by ___________________________
• 2 evidences support this concept.

_________ and _________

direct infection

induction of hypersensitivity or autoimmunity

EPIDEMIOLOGIC EVIDENCE

IMMUNOLOGICAL EVIDENCE

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AETIOPATHOGENESIS of RHD

A. EPIDEMIOLOGIC EVIDENCE
• 1. a preceeding history of _____infection & _____ infection with this micro-organism, ___________ prior to the attack of RF.

pharyngeal ; URT

2 or 3 weeks

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AETIOPATHOGENESIS • A. EPIDEMIOLOGIC EVIDENCE

• 2. Subsequent attack is generally associated with ________ of ______

• 3. administration of antibiotics leads to ____________ as well as _____ of RF and its _______

exacerbation of RF

lowering of the incidence

severity; recurrence

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the latent period required for sensitization to the bacteria( streptococcus pyogenes) is??

2-3 weeks

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AETIOPATHOGENESIS of A. EPIDEMIOLOGIC EVIDENCE

• 4) Patients with RF have elevated titres of _____ to the ______ of ______-haemolytic strep of group ____ such as ___________ O (ASO) & S, _______, ________ and ___________

Abs to the Ags

beta; A

antistreptolysin; antistreptokinase

antistreptohyaluronidase

anti-DNAase B.

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AETIOPATHOGENESIS of RHD• A. EPIDEMIOLOGIC EVIDENCE

• 5.________ factors
• 6. _________ distribution

Socioeconomic

Geographic

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AETIOPATHOGENESIS of RHD
A. EPIDEMIOLOGIC EVIDENCE

• 7. Climate: its role has been desribed by some workers. Incidence of the dx is higher in _____ and _____ regions with (cold or hot?) , damp climate near the rivers and water ways which favour the spread of the infection

subtropical and tropical

Cold

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AETIOPATHOGENESIS of RHD A. EPIDEMIOLOGIC EVIDENCE

• Despite all these evidences, only a (small or large?) proportion of patients of ________ infection develop RF- the attack rate is _____%.

Small

strep. pharyngeal

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AETIOPATHOGENESIS of RHD: B. IMMUNOLOGIC EVIDENCE

RF appears ____ weeks after throat infection

2-3

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AETIOPATHOGENESIS of RHD B. IMMUNOLOGIC EVIDENCE

• The org can not be ______ from _____ in the target tissues

• This has led to the concept that lesions are produced as a result of ______ by formation of ______ against ______

grown from lesions

immune response

autoAntibodies

bacteria

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A number of components of streptococcus identify or cross- react with target human tissues in RHD

T/F

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AETIOPATHOGENESIS of RHD: immunological evidence

• One such important component is _____ identified as ______ of streptococcus which has various antigenic types, and hence corresponding antibodies in humans which target different tissues.

M-protein; surface protein

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AETIOPATHOGENESIS of RHD: immunological evidence

• 1._________ of grp A strep forms antibodies which are reactive against ______

Cell wall polysaccharide

cardiac valves

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AETIOPATHOGENESIS of RHD: immunological evidence

• 2._________ capsule of grp. A streptococcus is identical to _______ present in _____ tissues and thus these tissues are target of attack.

hyaluronate

human hyaluronate

joint

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AETIOPATHOGENESIS of RHD: immunological evidence

• 3. ____ Antigens of group. A streptococcus react with ______ of _________ muscle , dermal _____ and neurons of _______

Membrane

sarcolemma

smooth and cardiac

fibroblasts; caudate nucleus.

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PATHOLOGIC CHANGES of RHD

• A.______ LESIONS
• B. _______ LESIONS

CARDIAC

EXTRACARDIAC

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PATHOLOGIC CHANGES • A. CARDIAC LESIONS

• The cardiac manifestations of RF are in the form of (focal or diffuse?) inflammatory involvement of the ______ tissues of the ____ layers of the heart, the so called (_______).

Focal

interstitial

3; Pancarditis

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• The pathognomonic features of pancarditis in RF is the presence of distinctive __________ or ________

Aschoff nodules or Aschoff bodies.

PATHOLOGIC CHANGES :A. CARDIAC LESIONS • Aschoff bodies are _______ or ________ shaped distinct (tiny or large?) structures 1-2mm in size occuring in the interstitium of the heart in RF

spheroidal or fusiform Tiny

PATHOLOGIC CHANGES • A. CARDIAC LESIONS •Aschoff bodies : They are especially found in the vicinity of __________ in the _________ and __________ and occasionally in the _______ and the ________ of the (proximal or distal?) part of the _______.

small blood vessels myocardium and endocardium pericardium & the adventitia Proximal ; aorta

Aschoff bodies may be visible to naked eye. T/F

cardiac histiocytes (__________ cells) modified multinucleate cardiac histiocytes ( _______ cells)

Anitschkow Aschoff

PATHOLOGIC CHANGES • A. CARDIAC LESIONS • It consists of ________, plasma cells, few ________, cardiac _______ and modified ______________

lymphocytes neutrophils histiocytes

• Aschoff contain ___-___ cells.

1 to 4

RHEUMATIC PANCARDITIS • all the 3 layers of the heart are affected in RF, with equal intensity in terms of their involvement T/F

F Although all the 3 layers of the heart are affected in RF, the intensity of their involvement is variable

RHEUMATIC ENDOCARDITIS •______ lesions of RF may involve the ______ and _______ endocardium causing _________ and _______, respectively

Endocardial valvular and mural rheumatic valvulitis and mural endocarditis

__________ is chiefly responsible for the major cardiac manifestations in chronic RHD

Rheumatic valvulitis

Rheumatic valvulitis • There is formation of characteristic, (small or large?) (1- 3mm), (single or multiple?) , ______ vegetations or verrucae, chiefly along ______ of the leaflets and cusps

Small Multiple; warty the line of closure

Rheumatic valvulitis • The vegetations are (continuous or discontinuous?) so that the free margin of the cusps appear as _________________________

continuous a rough and irregular ridge

Rheumatic valvulitis They are (weakly or firmly?) attached so that they are not likely to ____________, unlike the friable vegetations of ________

Firmly get detached to form emboli infective endocarditis

Rheumatic valvulitis The chronic stage of RHD is xterized by (temporary or permanent?) deformity of _________, especially the _____ (98%)

Permanent 1 or more valves mitral

_______ valve is almost always invoved in RHD

Mitral

• Gross appearance of chronic healed mitral valve in RHD is characteristically ‘_______’ or ‘ ________ ’ stenosis

fish-mouth button hole

Mitral stenosis and insufficiency are commonly combined in chronic RHD T/F

_________ stenosis may also be found in chronic RHD

Calcific aortic

Which is more conspicuous, rheumatic mural endocarditis or rheumatic valvulitus

rheumatic valvulitis are more conspicuous compared to rheumatic mural endocarditis

RHEUMATIC MURAL ENDOCARDITIS • Grossly, seen commonly as _________

MacCallum’s patch

RHEUMATIC MURAL ENDOCARDITIS • This is the region of the endocardial surface in the (anterior or posterior ?) wall of the _______ just above the (anterior or posterior?) leaflet of the _____ valve • It appears as a _____-like area of ________,_______, and ________ part of the endocardium

Posterior ; left atrium Posterior ; mitral map; thickened, roughened and wrinkeled

Microscopically, Rheumatic mural endocarditis is similar to rheumatic valvulitis T/F

Rheumatic mural endocarditis • Affected area shows ____, ______ change in the ____ and cellular infiltrate of lymphocytes, plasma cells and macrophages with many _______ cells

oedema; fibrinoid; collagen Anitschkow

Typical Aschkoff bodies are never found in Rheumatic mural endocarditis T/F

F Typical Aschkoff bodies may sometimes be found

RHEUMATIC MYOCARDITIS • In the acute stage the myocardium is ___________, in the intermediate stage, the interstitial tissue of the myocardium show __________. Later tiny ______________ may be visible throughout the myocardium

soft and flabby small foci of necrosis foci of Aschoff bodies

RHEUMATIC MYOCARDITIS • the diagnostic nodules found eventually in the chronic stage are scattered thruout the interstitial tissue of the myocardium and are most frequent in the __________,________, and _______

interventricular septum, LV and LA

In RHEUMATIC MYOCARDITIS Derrangement of the conduction system may be present. T/F

RHEUMATIC PERICARDITIS • Usual finding is ______ pericarditis in which there is loss of normal ____ pericardial surface due to ________ and accumulation of ________________ in pericardial sac

fibrinous shiny; deposition of fibrin slight amount of fibrinous exudate

RHEUMATIC PERICARDITIS When the pericardium is pulled apart, it gives a shaggy appearance of ‘__________’

bread and butter

RHEUMATIC PERICARDITIS Can eventually lead to chronic ___________ pericarditis

chronic adhesive

EXTRACARDIAC LESIONS: POLYARTHRITIS • (Acute or chronic?) & (painless or painful?) inflammation of the _______ of some of the joints. Especially the (smaller or larger?) joints of the limbs • In about 90% of RF in (adults or children?) & less often in (adults or children?)

Acute; painful; synovial membranes Larger Adults; children

EXTRACARDIAC LESIONS: POLYARTHRITIS • Hyperemia, fibrinoid changr, oedema, neutrophil infiltration & _______ are observed •___________ into the joint cavity is commonly present

Aschoff bodies Serous effusion

POLYARTHRITIS • involves ______ polyarthritis involving _______ joints at a time

Migratory 2 or more

EXTRACARDIAC LESIONS: SUBCUTANEOUS NODULES • Occurs more often in (adults or children?) than in (adults or children?) • (Small or Large?) 0.5-2.0cm • Spherical, ovoid or (painful or painless?)

children; adults Small Painless

EXTRACARDIAC LESIONS: SUBCUTANEOUS NODULES • Often remain un-noticed because they are attached to ______ structures such as ____,______,_______, or ______ • characteristically located in the _____ surfaces of the ______,______,______ and _____

deeper tendon, ligament, fascia or periosteum extensor wrist , elbows, ankles and knees

EXTRACARDIAC LESIONS: SUBCUTANEOUS NODULES • The subcutaneous nodules are (small or giant ?) ________ of the heart with ________ zones

Giant Aschoff bodies ; 3 distinct

EXTRACARDIAC LESIONS: SUBCUTANEOUS NODULES histogically similar but clinically different from _______ of ________

subcutaneous lesions of RA

ERYTHEMA MARGINATUM • (Prurituc or Non pruritic?) erythematous rash xteristic of RF • Occurs mainly on the _____ & prox.part of the ______

Non pruritic trunk; extremities

ERYTHEMA MARGINATUM • The erythema is (transient or rapid?) and (static or migratory?)

Transient Migratory

RHEUMATIC ARTERITIS • Involves _____,_______ & aa of various organs such as renal, mesenteric & cerebral • Lesion is like those of ______________ or resemble _____

coronary, aorta hypersensitivity angiitis PAN

RHEUMATIC ARTERITIS • Occasionally, foci of __________ and ill- formed _______ may be seen close to the vessel wall

fibrinoid necrosis Aschoff bodies

CHOREA MINOR Or _________ or ________ is a delayed manifestation of RF as a result of the involvement of the _____

Syndenham’s chorea; Saint Vitus’ dance CNS

CHOREA MINOR Characterised by _________ movements of the trunk and extremities accompanied by some degree of __________ • Occurs more often in (younger or older ?) age, particularly (boys or girls?)

involuntary jerky emotional instability Younger; girls

CHOREA MINOR • Lesions located in the ________,_________, _______________ • Consist of small haemorrhages, oedema and perivascular infiltration by lymphocytes

cerebral hemispheres, brainstem and basal ganglia

Involvement of the lungs and pleura occurs often in RF T/F

F rarely

RHEUMATIC PNEUMONITIS AND PLEURITIS • Pleuritis is often accompanied with ________________________ but definite • Aschoff bodies are (present or absent?)

serofibrinous pleural effusion Absent

RHEUMATIC PNEUMONITIS AND PLEURITIS • In rheumatic pneumonitis, the lungs are (small or large?) , (loose or firm ?) and _______

Large Firm Rubbery

When RF is suspected, ______ specific test is done

RF has wide systemic involvement & no specific lab.test is available

CLINICAL FEATURES of RHD • First attack of RF occurs 2-3 wks after ________ • Subsequent ______ leads to reactivation of disease •Generally presents with _______ and _____

strep.pharyngitis pharyngitis migratory polyarthritis & fever

revised jones criteria Clinical diagnosis of RF is made in a case with antecedent lab.evidence of __________ in the presence of: • -any ________ criteria, or • -occurrence of ______ and ______ criteria

strep.throat infection 2 major 1 major and 2 minor

If the heart is spared in acute RF, the patient may have _____ without ________ However once the heart is involved it is often associated with _____________

complete recovery any sequelae reactivation & re

MAJOR CAUSES OF DEATH IN RF & RHD • 1) _______ Failure due to chronic _________ (young patients), ________________ in older pts • 2)_________________, both acute & subacute may supervene due to inadequate use of antibiotics

Cardiac; valvular deformity superimposed coronary heart disease Bacterial Endocarditis

MAJOR CAUSES OF DEATH IN RF & RHD 3)Embolism in RHD originates from ________,______, or _______ to the brain, kidney, spleen and lungs • 4) Sudden Death as a result of ________ in the Left Atrium or due to _________ in association with ________

mural thrombi, atrial appendage or mitral stenosis ball thrombus acute coronary insufficiency; aortic stenosis

Acute Rheumatic fever is caused by molecular mimicry T/F

________ is the most common cause of death during the acute phase

Myocarditis

Acute rheumatic fever Uses types of hypersensitivity reactions __________ reactions (type ___ hypersensitivity reaction) ___________ reactions (type ___ hypersensitivity reaction):

Antibody-mediated ; II T cell–mediated; IV

Acute rheumatic fever Antibody-mediated reactions: ______ in acute rheumatic fever. T cell–mediated reactions :______ of rheumatic fever.

pancarditis lesions

Anitschkow or ———- cells

Caterpillar

Aschoff and anitschkow cells are found in (acute or chronic?) rheumatic carditis

Acute

Fish mouth valvular stenosis Acute or chronic rheumatic heart disease?

Chronic

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Rheumatic Heart Disease Flashcards

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