Rheumatic Fever

Front 1

Is Rheumatic Fever suppurative or non-suppurative

Back 1

Non-suppurative (no pus production is observed in it)

Front 2

Rheumatic fever affects which organs

Back 2

• Heart (pancarditis)

• Joints (polyarthritis)

• Skin (Erythema marginasum)

• Subcutaneous tissue (nodules)

• CNS (Syndeham chorea)

Front 3

Is Rheumatic Fever post or pre streptococcal

Back 3

It is post streptococcal. It happens after strep infection (streps pharyngitis)

Front 4

Effect of Chronic stage of Rheumatic fever on the heart

Back 4

Pancarditis (affects all layers of the heart)

Front 5

Rheumatic fever is very common in what people?

Back 5

In Children (5-15 years)

Front 6

Which sex is more affected by Rheumatic fever?

Back 6

Both sexes are affected equally

Front 7

Rheumatic fever is caused by direct infection by Group A strep. T/F

Back 7

False, it is not direct infection. It is by hypersensitivity and autoimmunity (body's own defence).

Front 8

Rheumatic fever is caused by direct infection by Group A strep. T/F

Back 8

False, it is not direct infection. It is by hypersensitivity and autoimmunity (body's own defence).

Front 9

What 2 evidences support that Rheumatic fever is not a direct infection

Back 9

a) Epidermiological evidence

b) Immunological evidence

Front 10

Incidence of Rheumatic fever is more common in which regions

Back 10

Subtropical and tropical regions with cold and damp climate

Front 11

What percentage of people with Strep pharyngitis develop rheumatic fever

Back 11

Less than 3% (<3%)

Front 12

Epidemiological evidence that RF is caused by Group A strep

Back 12

a) Survey shows that people with RF symptoms develop it 2-3 weeks after strep pharyngitis and Upper respiratory tract infection

b) Antibiotics against strep reduces the symptoms

c) Subsequent infection with group A strep worsens the RF

d) Patients with RF have elevated antibodies against group A strep

e) Climate (seen more in cold climate)

f) Geographical location

g) Socioeconomic factors

Front 13

Based on immunological evidence, was Group A strep grown from samples obtained in lesions of affected organs

Back 13

No it wasn't grown. This is because it wasn't actually the organism directly affecting the organs, it operated by mimicry, imitating self antigens found on the affected organs.

Front 14

What makes group A Strep able to cause RF

Back 14

1) Cell wall polysaccharide of group A strep form Antibodies that are reactive to Cardiac valves

2) Hyaluronic acid capsule of the Strep is identical to the hyaluronate in the joints hence the joints are attacked

3) Membrane antigens of group A streps react with membrane/sarcolemma of smooth and cardiac muscles, dermal (skin) fibroblast and neurons of caudate nucleus.

Front 15

Pathological changes in RF are broadly divided into 2

Back 15

• Cardiac lesions

• Extracardiac lesions

Front 16

What is the broad pathological change in Heart (cardiac lesions) in RF

Back 16

There is Pancarditis.

Front 17

What are Aschoff bodies

Back 17

•They are tiny spherical or fusiform structures about 1-2 mm found in the interstitium of the heart

• They are due to inflammation in the myocardium of the heart

• They are found in the vicinity of small blood vessels in the myocardium (majorly), endocardium, and sometimes the pericardium and proximal part of aorta.

• They are granulomatous structures

Front 18

Can Aschoff bodies be seen with the naked eyes?

Back 18

Yes, they actually can

Front 19

Aschoff bodies contain

Back 19

• Lymphocytes

• Plasma cells

• Few neutrophils

• Anitschkow cells [cardiac histiocytes/macrophages]

• Aschoff cells (Multinucleated cardiac histiocytes)

Front 20

Multinucleated Aschoff cells contain how many cells

Back 20

Between 1-4 cells

Front 21

The pathognomonic of Rheumatic Heart Disease is

Back 21

Aschoff bodies/cells

Front 22

Rheumatic Pancarditis is divided into

Back 22

• Rheumatic Endocarditis

• Rheumatic Myocarditis

• Rheumatic Pericarditis

Front 23

Rheumatic endocarditis is divided into

Back 23

a) Rheumatic valvulitis (has more conspicuous features)

b) Mural endocarditis

Front 24

Majority of the clinical features presented by the heart in Rheumatic heart disease is due to

Back 24

Rheumatic valvulitis

Front 25

Features of Rheumatic valvulitis

Back 25

Due to continuous inflammation of the valve, the heart valves endothelium damage exposing underlying collagen causing multiple small warty vegetations(like thrombotic masses) form along the margin (line of closure) of the valves. The vegetations are continuous such that they make the edges of the valve irregular.

Front 26

Do the vegetations on the valves in Rheumatic valvulitis detach

Back 26

No. They are firmly attached to the valve. (It is those of Infective endocarditis that detach and form emboli)

Front 27

Which valve is most affected in Rheumatic valvulitis

Back 27

Mitral valve (98% of cases)

Front 28

Mention the distribution of affected valve in rheumatoid valvulitis

Back 28

Mitral alone= 37%

Mitral+ Aortic= 27%

Mitral+ Aortic + Tricuspid = 22%

Mitral + Tricuspid = 11%

Aortic alone= 2%

All 4 valves= 1%

Front 29

Appearance of mitral valve following rheumatic valvulitis is

Back 29

Fish-mouth stenosis or button-hole stenosis (due to scar tissue from repeated inflammation and damage of valve endothelium)

Front 30

Is calcific aortic stenosis seen in Rheumatic valvulitis

Back 30

Yes (affects the aortic valve)

Front 31

Which has more conspicuous features; Rheumatic valvulitis or Mural endocarditis

Back 31

Rheumatic valvulitis (the vegetations on the valves are very easy to identify)

Front 32

Grossly, Mural endocarditis is called ?? What chamber is it mainly located and eat is its precise location

Back 32

MacCallum's patch

Located in the Left Atrium above the posterior leaflet of mitral valve.

Front 33

Are Aschoff bodies seen in Mural Endocarditis?

Back 33

Yes, sometimes. (Aschoff bodies are seen majorly in myocardium but can also be in endocardium and pericardium)

Front 34

In Rheumatic Myocarditis, what changes occur to the myocardium in acute, intermediate and chronic stage

Back 34

Acute stage: the myocardium is soft and Flabby

Intermediate stage: some foci of necrosis in interstitium

Later stage: Presence of Aschoff bodies throughout the myocardium

Front 35

Which chambers of the heart are majorly affected by Rheumatic Myocarditis and Aschoff bodies

Back 35

Left atrium, Left ventricle and Interventricular septum.

Front 36

What is common in all layers of the heart in Rheumatic Pancarditis

Back 36

Depositions of fibrin

Front 37

What is morphology of Rheumatic Pericarditis

Back 37

Due to damage of cells in the pericardium, exposure of layer underneath causes thrombosis and deposition of fibrin on the pericardium. So you see a FIBRINOID PERICARDITIS and loss of shiny surface of pericardium.

Front 38

When the fibrinoid pericardium is pulled apart, what is observed

Back 38

Bread and Butter appearance.

Front 39

The Extracardiac lesions in Rheumatic Fever include

Back 39

• Polyarthritis (common in adults)

• Subcutaneous nodules (common in children, bcos children eat noodles)

• Chorea minor (Syndeham)

• Erythema marginasum

• Rheumatic Arteritis

• Rheumatic Pleuritis and Pneumonitis

Front 40

In polyarthritis, which joints are inflamed more, larger or smaller joints

Back 40

Larger joints (maybe because of larger amount of hyaluronate). Eg Ankle, Elbow, wrist, knee

Front 41

Rheumatic polyarthritis is observed in which age group

Back 41

Adults (about 90%). Less common in children

Front 42

Gross Observations in polyarthritis

Back 42

The features are typical features of inflammatory response just that it's in the joint:

• Hyperemia (due to vasodilation)

• Edema

• Infiltration of neutrophils

• Anitschkow cells (macrophages) that form Aschoff bodies

• Fibrinoid change

Front 43

Are the subcutaneous nodules painless

Back 43

Yes, they are painless

Front 44

What are the subcutaneous nodules composed of

Back 44

Large Aschoff bodies of the heart.

Front 45

Subcutaneous nodules are often unnoticed because?

Back 45

They attach to deep structures like tendons, fascia, etc.

Front 46

Where are the subcutaneous nodules usually located

Back 46

Extensor surface of wrist, knee, ankle, elbow (like at the back of the hand in that picture)

Front 47

Erythema marginatum features

Back 47

• Non-pruritic (not itchy), transient, migratory rash

• Found in the trunk and proximal extremities

Front 48

Chorea minor is observed in what age group

Back 48

Children particularly girls

Front 49

Rheumatic Arteritis occurs in what vessels

Back 49

Coronary, aortic and other vessels. Aschoff bodies are also found in them

Front 50

Which Extracardiac lesion is very rare

Back 50

Rheumatic Pleuritis and Pneumonitis

Front 51

Aschoff bodies are found in which Extracardiac lesions

Back 51

1) Polyarthritis

2) Subcutaneous nodules

3) Rheumatic Arteritis

Front 52

Chorea minor is also called

Back 52

Syndeham chorea or Saint Vitus dance

Front 53

A patient with rheumatic fever may recover completely only if

Back 53

The heart was unaffected by the RF. If the heart is involved, there is a high probability of reactivation.

Front 54

What are the major causes of death in RF and RHD

Back 54

Mnemonic: E.H.I.S

1) Heart failure (due to valvular damage and stenosis)

2) Infective/bacteria endocarditis (due to bacteria settlement on vegetations)

3) Embolism from mural thrombi, mitral thrombi (rare though) to the brain, kidney

4) Sudden death