Etiology and Diagnostics – Rheumatic Heart Disease

Name: Etiology and Diagnostics – Rheumatic Heart Disease
Uploaded: 2022-03-15
Duration: 3 min 56 s
Description: The lecture Etiology and Diagnostics – Rheumatic Heart Disease by Richard Mitchell, MD, PhD is from the course Valvular and Hypertensive Heart Disease.

by Richard Mitchell, MD, PhD

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00:01 Let's talk about another etiology for valvular disease. This is rheumatic fever. A rheumatic fever, as you are probably abundantly aware, is an acute immunologically mediated multisystem inflammatory disease that typically begins, classically, a few weeks after a group A streptococcal pharyngitis. So, we're looking into the pharynx of this person, and we have some angry read mucosa, and we have some enlarged nodes and, in this case, would be due to streptococcus pharyngitis. The immune response to the strep bacteria as we will see in the next couple of slides gives rise to auto - to antibodies that, for good or for ill in some patients, recognize or cross-recognize heart antigens, and that will be the cause of the valvular disease. You can also have those same antibodies and some of the inflammatory T cells can also cause myocarditis or a pericarditis. So, the systemic manifestations, when you are developing immune response to the streptococcal bacteria that caused the pharyngitis, you can have other manifestations that are part of acute rheumatic fever. Okay? It's not just the valvular disease or the carditis that affects the heart, you - classically, there are five kind of Jones criteria, five major manifestations that you need to be thinking about. The first one there is subcutaneous nodules typically on extensor surfaces of the elbows and the knees. Erythema marginatum which is an irregular kind of somewhat circular rash that can be on any body surface. Sydenham's chorea, this is due to immune complex deposition or antibodies binding to particular antigens in various parts of the basal ganglia and you get patients with kind of uncontrollable choreoathetoid movements. There's a polyarthritis. Again, probably immune complex and/or direct antibody binding. So, you get a polyarthritis. And the Jones criteria means that we have evidence of a preceding group A streptococcal infection, and then a certain number of the major or minor criteria. So, on the previous slide were the major criteria. And then, we have minor criteria that include things like fever, arthralgia, elevated blood levels of acute phase reactants. So, already mentioned this several times, but now you've heard it probably for the third time, so it's maybe important. It does show up on the boards. About 85% of the time, Rheumatic heart disease is the cause of mitral stenosis. And here, you see the valve is thickened, it is somewhat stenotic, and the atrium behind it is quite dilated as a result of the increased pressure having to go through that tight valve. The epidemiology of this. So, in developed countries, this is not a major problem. That's because we improved sanitation, less streptococcal distribution within the population, and also because we have very rapid diagnosis in treatment of strep pharyngitis so that we treat with antibiotics before patients develop any significant antibody titer. So, overall, in the US, many places in Europe, there's a declining incidence in mortality from rheumatic fever and rheumatic heart disease. On the other hand, in developing countries, it's still an important public health problem estimated at 15 million people a year who have some degree of rheumatic heart disease.

About the Lecture

The lecture Etiology and Diagnostics – Rheumatic Heart Disease by Richard Mitchell, MD, PhD is from the course Valvular and Hypertensive Heart Disease.

Included Quiz Questions

What pathogen is likely responsible for mitral regurgitation in a patient who develops symptoms four weeks after an upper respiratory infection with pharyngitis?

Group A streptococcus
Staph aureus
Staph epidermidis
Group B streptococcus
Coxsackievirus

Which of the following is NOT a systemic manifestation of acute rheumatic fever?

Splinter hemorrhages
Circular rash (erythema marginatum)
Uncontrollable movements (Sydenham chorea)
Subcutaneous nodules on extensor surfaces
Polyarthritis

What is the correct definition of the Jones criteria for the initial diagnosis of rheumatic fever, in addition to evidence of prior group A streptococcal infection?

2 major manifestations OR 1 major + 2 minor manifestations
2 major manifestations only
1 major + 2 minor manifestations only
3 major + 1 minor manifestations
1 major OR 2 minor manifestations

Author of lecture Etiology and Diagnostics – Rheumatic Heart Disease

Richard Mitchell, MD, PhD

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