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Dr Nadjib.A.SpA(k)
ETIOLOGY
1. Immunologic
Streptococcus Beta hemolytic group A
2. Predisposing factors
- Family history
- Socio economic status
- Age 5 -15 years ( peak 8 years)
PATHOLOGY
Inflammatory lesion : heart, brain, joints,
skin
1. Arthritis
* Affects 70 % of cases
* Large joints : knee, ankle, elbow, wrist
* Often > 1 joints, simultaneously or
in succession, migratory
* Swelling, heat, redness, severe pain,
tenderness, motion <
* Dramatic response to salicylate
2. Carditis
50 % of cases, usu within first 3 wks
Diagnosis requires presence of 1 of 4:
- organic heart murmur
- pericarditis (friction rub, pericard effusion,
chest pain, ECG changes)
- cardiomegaly on chest X ray
- congestive heart failure
3. Erythema marginatum
- <10 % of cases
- Non pruritic erythematous rashes,
never on face
- Most prominent on trunk and inner
proximal portions
- Disappear on exposure to cold,
seldom detected on AC hospitals
4. Subcutaneous nodules
- 2-10 % of cases, esp in recurrences
- Hard, painless, non pruritic, freely
moveable, swelling 0.2-2 cm
- Usually symmetric on extensor surfaces
of joints, scalp, along spine, lasts for
weeks
5. Sydenhams chorea
- 15 % of patients, more often in prepubertal
girls.
- begin with emotional lability and personal
ity changes
- spontaneous, purposeless movement
followed by motor weakness, slurred speech
- Dysfunction of basal ganglia and cortical
neuronal components
Minor criteria
- Arthralgia
- Fever
- Elevated acute phase reactants: CRP,
ESR
- ECG : PR interval > : not specific
Evidence of antecedent Group
A Streptococcal infection
Positive throat culture or rapid
streptococcal antigen tests for group A :
less reliable
Streptococcal antibody tests : most
reliable
- ASTO : 80%
- Anti-DNA se B
- Anti hyaluronidase
Diagnosis of rheumatic
fever
Based on
2 major criteria
or + ASTO
1 major + 2 minor
Exeptions
Affects
Mitral valve 75 %
Aortic valve 25 %
Tricuspid valve rare
Pulmonary valve never
Prevalence
Most common valvular involvement in
adult
Requires 5-10 years from the initial
attack
Pathology
- Thickening of the leaflets and fusion of the
commisure
- Calcification results overtime
- Dilated and hypertrophied LA and right sided
heart
- Pulmonary venous hypertension pulmonary
congestion and edema and fibrosis of the
alveolar walls, hypertrophy of the pulmonary
arterioles, loss of lung compliance
Clinical manifestations
Mild MS : asymptomatic
More severe : dyspnea with/out
exertion : orthopnea, nocturnal
dyspnea or palpitation
Physical Examinations
Increased RV impulse along the LSB
Weak peripheral pulse with narrow pulse
pressure
Pulmonary hypertension : loud S1 at
apex and narrow split S2, accentuated
P2
Mid diastolic/presystolic murmur
ECG : RAD, LAH, RVH (due to PH)
CXR :
Enlarged LA and RV, MPA segment
prominent
Pulmonary venous congestion
Treatment of MS
Prophylactic antibiotic
Restriction of activity depends on
severity
Symptomatic patients (dyspnea on
exertion, pulmonary edema,
paroxysmal dyspnea) : baloon or
surgery
MITRAL REGURGITATION
CXR
LA and LV enlarged
Pulmonary congestion pattern in CHF
Treatment
Prophylactic antibiotic
No restriction of activity in mild cases
Surgical : intractable CHF,
progressive
cardiomegaly, pulmonary
hypertension
AORTIC REGURGITATION
Pathology
* Semilunar cusps are deformed and
shortened.
* Valve ring is dilated
* Commisures usually are fused
Clinical Manifestations
Copy by tigor00
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