1. Anatomy
    2. 1. Mediastinum
    2. The Heart Development
    3. Pericardium
    4. Features of the Heart
    5. Arterial Supply of Heart
    6. Venous Drainage of the Heart
    7. Conducting System of Heart
    8. Nervous System of Heart
    9. Foetal Circulation and Changes at Birth
    10. Microscopic Structure of Heart
    11. Arteries
    12. Arch of Aorta
    13. Descending Thoracic Artery
    14. Abdominal Aorta
    15. Subclavian Artery
    16. Axiallary Artery
    17. Internal Thoracic Artery
    18. Brachial Artery
    19. Radial Artery
    20. Ulnar Artery
    21. Palmar Arches
    22. External Iliac Artery
    23. Internal Iliac Artery
    24. Femoral Artery
    25. Popliteal Artery
    26. Posterior Tibial Artery
    27. Anterior Tibial Artery
    28. Dorsalis Pedia Artery
    29. Common Carotid Artery
    30. External Carotid Artery
    31. Internal Carotid Artery
    32. Veins
    33. Internal Jugular Vein
    34. External Jugular Vein
    35. Superior Venacava
    36. Inferior Venacava
    37. Brachiocephali vein
    38. Subclavian vein
    39. Axillary vein
    40. Cephalic vein
    41. Basilic vein
    42. Azygous vein
    43. Hemiazyous vein
    44. Accessory Hemiazyoug Vein
    45. Internal Hemiazygous Vein
    46. Internal Iliac Vein
    47. Femoral Vein
    48. Popliteal Vein
    49. Long Saphenous Vein
    50. Small or Short Saphenous Vein
    51. Hepato-portal System
    52. Lymphatic System
    53. Spleen
    54. Thymus
    55. Thoracic duct
  2. Pharmacology
    3. 56. Congestive Heart Failure
    57. Therapy of Arrhythmiasis
    58. Angina pectoris
    59. Therapy of Hypertension
    60. Therapy of Shock
    61. Haemostatic Agents
    62. Therapy of Thromboembolic Disorder
    63. Thrombolytic or Fibrinolytics
    64. Antifibrinolytics
    65. Antiplatelet Drugs
    66. Therapy of Iron Deficiency Anemia
    67. Therapy of Megaloblastic Anaemia
    68. Hypolipidemic Drugs and Plasma Expanders
  3. Physiology
    4. 69. Properties of Myocardial Cells
    70. Heart - A Mechanical Pump
    71. Cardiac Cycle
    72. Electrocardiogram (ECG)
    73. Cardiac Output (CO)
    74. Haemodynamics of Circulation
    75. Heart Sounds
    76. Arterial Pulse
    77. Blood pressure
    78. Regional circulation
    79. Cardiovascular chanes during exercise
    80. Edema Dropsy of fluid retention
    81. Shock
    82. Hematology
  4. Pathology
    5. 83. Anaemia
    84. Hypertension
    85. Hypertensive Heart Disease
    86. Ischemic Heart Disease
    87. Angina pectoris
    88. Myocardial infarction
    89. Rheumatic Fever and Rheumatic Heart Disease (RHD)
    90. Acute Pericarditis
    91. Myocarditis
    92. Infective Endocarditis (IE)
    93. Congenital Heart Disease
    94. Cardiomyopathies
    95. Arteriosclerosis
    96. Atherosclerosis
    97. Inflammatory Disease of Blood Vessels
    98. Aneurysms and Dissection
    99. Congestive Heart Failure
    100. Iron Deficiency Anaemia
    101. Megaloblastic anaemia
    102. Pancytopenia
    103. Leucocytosis and Leucopenia
    104. Aplastic anaemia
    105. Haemolytic anaemia
    106. Hereditary Spherocytosis
    107. Haemoglobinipathies
    108. Thalassemia syndrome
    109. Sickle Cell Disease
    110. Leukaemia
    111. Leukemoid reaction
    112. Lymphadenitits
    113. Hodgkin lymphoma
    114. Non-hodgkin lymphoma
    115. Myeloproliferative disorders
    116. Myelofibrosis
    117. Multiple myeloma
    118. Bleeding disorders
    119. Coagulation disorders
    120. any
    121. Blood grouping
  5. Microbiology
    6. 122. Introduction of Blood borne infections
    123. Infective Endocarditis
    124. Brucella
    125. Rickettsiae
    126. Leishmania donovani
    127. Plasmodium
    128. Wuchereria bancrofti
  6. Biochemistry
    7. 129. Metabolism in Blood Cells
    130. Iron metabolism
    131. Haemoglobin
    132. Lipoprotein metabolism
    133. Biochemical aspect of MI
Pathology
89. Rheumatic Fever and Rheumatic Heart Disease (RHD)
RHEUMATIC FEVER
Introduction
Definition
Rheumatic fever (RF) is an acute, immunologically mediated, multisystem inflammatory disease classically occurring a few weeks after an episode of group A streptococcal pharyngitis.
Occurs in children between 5 and 15 years.
Pathogenesis of Rheumatic Fever
graph TD 1["Pharyngitis by group-A, β hemolytic <i>Streptococcus</i>."] 2["M<sub>1</sub> protein of <i> Streptococcus pyogenes</i> released in circulation."] 3["Symptoms of pharyngitis subside in 97%."] 4["In 0.3 to 3% people, after 3-5 weeks development of <br>antibodies against M<sub>1</sub> protein by host immune system."] 5["Molecular similarity between M<sub>1</sub>-protein and human cell membrane,<br> hence antibodies directed against M<sub>1</sub>-protein cross react with <br>glycoprotein antigens in Brain, Heart, Joint, Skins and Subcutaneous nodules."] 6["Rheumatic fever"] 7["On second attack, with same bacteria, reactivation of immune system."] 8["Cross reaction takes place"] 9["Continuous progressive damage to heart result<br> in permanent damage to heart valves and myocardium."] 10["Rheumatic Heart Disease"] 1 --> 2 2 --> 3 3 --> 4 4 --> 5 5 --> 6 6 --> 7 7 --> 8 8 --> 9 9 --> 10
Clinical features
M1-protein in bacterial surface resembles the following proteins of human body and thus affects these organs whose symptoms becomes the diagnostic criteria of John's criteria.
  1. Lyso gangliosides of Brain
  2. Keratin of Skin
  3. Vimentin of Joint
  4. Tropomyosin of Endocardium
  5. Laminin of Heart valves
John's criteria
Evidence of a preceding group A Streptococcus infection + (2 major or (1 major + 2 minor criteria))
Major criteria
Brain
Syndenham's chorea (Saint Vitus dance)
Skin
Erythema marginatum
Joint
Migratory polyarthritis
Subcutaneous nodules
Enlarged
Heart
Pancarditis
Minor criteria
  1. High fever
  2. History of Rheumatic fever
  3. Leukocytosis
  4. Increased ESR/ CRP
  5. Prolonged PR interval
  6. Arthralgia (Joint pain)
RHEUMATIC HEART DISEASE
Definition
Rheumatic Heart Disease is a condition in which permanent damage occurs to heart as a consequence of rheumatic fever.
Classification of Rheumatic Fever
Acute Rheumatic Heart Disease
Morphology
Acute rheumatic carditis is manifested in all three layers of heart so called Pancarditis.
Acute rheumatic pericarditis
Gross
  1. Fibrinous and serofibrinous exudate in pericardial sac, bread butter appearance.
Microscopic
  1. Fibrin on surface
  2. Infiltration by lymphocytes, plasma cells, histiocytes and few neutrophils.
Acute rheumatic myocarditis
Gross
  1. Early stage: Myocardium of especially left ventricle become soft and flabby.
  2. Intermediate stage: Interstitial tissue of the myocardium show small foci of necrosis.
  3. Late stage: Tiny pale foci of Aschoff bodies throughout the myocardium.
Microscopic
    Aschoff bodies, a Distinctive lesion, are found which consists of following
  1. Foci of lymphocytes (primarily T-cells)
  2. Occasional plasma cells
  3. Anitschkow cells
    1. Plump activated macrophages
    2. Abundant cytoplasm
    3. Central round to ovoid nuclei in which the chromatin is disposed in a central, slender, wavy ribbon hence called as Caterpillar cells.
    4. May become multinucleated i.e., Aschoff giant cells.
    5. Anitschkow cell is pathognomonic for Rheumatic fever.
Acute rheumatic endocarditis
Acute rheumatic valvulitis
Gross
  1. Fibrinoid necrosis within the cusps or tendinous cords.
  2. Overlying these necrotic foci and along the lines of closure are small (1 to 2 mm) vegetations, called Verrucae.
Microscopic
    Acute rheumatic submural endocarditis
    Gross
    1. Subendocardial lesions, perhaps exacerbated by regurgitant jets, can induce irregular thickenings called MacCallum plaques, usually in left atrium.
    Microscopic
      Chronic Rheumatic Heart Disease
      Morphology
      1. Valves
        2. ◉ Involved valves:
        Mitral valve is almost always affected.
        1. Mitral valve in isolation in 75%
        2. Mitral valve + Aortic valve in 25%
        3. Tricuspid and pulmonary valve is rarely affected.
        ◉ Changes in Mitral valve:
        ◈ Thickening of leaflet: Due to fibrosis
        ◈ Fusion and shortening of Commissures: The valve orifice becomes reduced to a fixed narrow opening that gives the characteristic appearance of Fish mouth (or Button hole)
        ◈ Thickening and fusion of the chordae tendinae:
      2. Dilation of left atrium with mural thrombi
      3. Long standing stenosis may lead to right ventricular hypertrophy

      Question Answers

      Q.

      Write short notes on: Morphology of Rheumatic Heart Disease

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      Q.

      Describe the microscopic features of rheumatic heart disease.

      (5= 5)

      [2059]

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      Q.

      Describe the gross and microscopic features of rheumatic carditis. List out its complications.

      (4= 4)

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