RHEUMATIC HEART DISEASE D. HANA OMER

OBJECTIVES

• To know definition, symptoms, signs, diagnosis of Rheumatic fever.

• To know the treatment of Rheumatic fever.

• Rheumatic fever is an acute, multisystem inflammatory disease that follows a group A (β-hemolytic) streptococcal (GAS) throat infection.

• It is a disease of school-aged children. • The incidence between 5 and 15 years of age.

• The most serious aspect of rheumatic fever is :-1. chronic valvular disorders .2. heart failure .

PATHOPHYSIOLOGY

Acute stage

• The acute stage of rheumatic fever includes a history of an initiating streptococcal infection and subsequent involvement of the connective tissue of the heart, blood vessels, joints, and subcutaneous tissues.

• It is characterized by present of lesion called the Aschoff body ( which is a localized area of tissue necrosis surrounded by immune cells in the heart valve) .

the Aschoff body

the Aschoff body

recurrent phase

• The recurrent phase usually involves extension of the cardiac effects of the disease.

chronic phase

• The chronic phase of rheumatic fever is characterized by permanent deformity of the heart valves and is a common cause of mitral valve stenosis .

• Chronic rheumatic heart disease usually does not appear until at least 10 years after the initial attack .

Clinical features

• Symptoms before the onset of rheumatic fever :-• Sore throat .• headache. • Fever .• abdominal pain .• nausea.• vomiting .• swollen glands (usually at the angle of the jaw).

Clinical features

• Clinical features associated with an acute episode of rheumatic fever :-

• Carditis .• Migratory polyarthritis of the large joints .• Erythema marginatum .• Subcutaneous nodules .• Sydenham’s chorea.

Carditis.

• The carditis can affect the pericardium, myocardium, or endocardium, and all of these layers of the heart usually are involved.

• The involvement of the endocardium and valvular structures produces the permanent and disabling effects of rheumatic fever.

• Although any of the four valves can be involved, the mitral and aortic valves are affected most often.

• During the acute inflammatory stage of the disease, the valvular structures become red and swollen; small vegetative lesions develop on the valve leaflets .

• small vegetative lesions develop on the valve leaflets .

• development of fibrous scar tissue .

• deformity of the valve leaflets and shortening of the chordae tendineae.

• The manifestations of acute rheumatic carditis include :- 1. heart murmur .2. Cardiomegaly .3. friction rub .4. congestive heart failure .

Carditis .

Arthritis

• The arthritis involves the larger joints, particularly the knees, ankles, elbows, and wrists .

• It is almost always is migratory, affecting one joint and then moving to another.

• It is usually response (usually within 48 hours) to salicylates.

migratory polyarthritis of the large joints

Erythema marginatum

• lesions are maplike, macular areas most commonly seen on the trunk or inner aspects of the upper arm and thigh.

• they are transitory and disappear during the course of the disease.

erythema marginatum

subcutaneous nodules

• The subcutaneous nodules are 1 to 4 cm in diameter.• They are hard, painless, and freely movable and usually

overlie the extensor muscles of the wrist, elbow, ankle, and knee joints.

subcutaneous nodules .

Sydenham’s chorea

• Is the major central nervous system manifestation.• It is seen most frequently in girls.• The choreic movements are spontaneous, rapid, purposeless,

jerking movements that interfere with voluntary activities.• The chorea is self-limited, usually running its course within a

matter of weeks or months.

Sydenham’s chorea.

Diagnosis

Treament

• The treatment is based on :-1. Antibiotics . 2. Anti-inflammatory drugs .3. selective restriction of physical activities are prescribed.

• Penicillin also is the antibiotic of choice for treating the acute illness.

• Salicylates and corticosteroids are used as apain killer and disease control .

• Penicillin is the treatment of choice for secondary prophylaxis, but sulfadiazine or erythromycin may be used in penicillin-allergic individuals .

• The duration of prophylaxis could extend to 10 years .

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