4- RHD IE rhumatic heart disease 222.pdf

RhD

1. Dr.MohammadShafiq,MD,FESC,FSCAI
Associateprofessorofcardiology
Rheumaticfever(RF)
RheumaticFever(RF)&Rheumatic
heartdisease(RHD)
1)Definition:
Rheumaticfeverisasystemicinflammatorydiseaseaffecting
collagenfiberssecondarytopriorstreptococcal-infection
(tonsillo-pharyngitiscausedbygroupAhemolytic
streptococci).
2)Mechanism:Auto-immune

2. 3)Predisposingfactors:
1-Recurrent,severestrept.infection.
2-Lowsocio-economicstatus
3-Age(5-15Y).Notbefore?Immatureimmunesystem.
4-Sex:EqualexceptSydenhamchoreawhichismore
commoninfemaleafterpuberty
4)Latentperiod:betweenstreptococcalinfection,RFis
2-3weeksexceptinchorea(≥3months).
3

3. 5)Pathology:
-Inflammatoryprocessaffecting:Joints(synovialmemb),
heart(otherserousmemb:pleura,peritoneum),CNS(esp.
Basalganglia),skin-Subcutaneoustissue,smallBlood
vessels.
-2typesofinflammatoryreactions:
-Exudativereaction:
-Affectmainlyserousmemb&healingoccurwithout
residualeffect.
-Proliferativereaction(aschoffnodule):
-Affectmainlyskin,heart&healingoccurbyfibrosis.
4

4. DiagnosisofRF
(ModifiedJonescriteria):
2majorcriteriaor(1major+2minor)
+evidenceofrecentupperairway
strept(GrouppAStreptococci
infection).
5

5. -1)Majorcriteria:
a-Carditis(in50%ofcases):Mostserious,most
specific
-Pericarditis:Chestpain,pericardialeffusion.
-Myocarditis:HeartFailureeitheracuteor
chronic.
-Endocarditis:(Leftsidevalvesmoreaffected
thanrightsidedvalvesandmitralvalveismore
thanaorticvalvecausing:MitralStenosis(MS),
MitralRegurgitation(MR),AorticStenosis(AS)
&AorticRegurgitation(AR).
6

6. 7

7. 8

8. b-Arthritis(in80%ofcases):Mostcommon,least
specificcharacterizedby:
-Asymmetricpolyarthritis
-Affectlargejoints(knee,ankle/wrist,elbow).
-Signsofacuteinflammation:red,hot,tender,
swollen.
-Markedlimitationofmovement.
-Healswithoutresiduallocomotiondefect.
-Migratory:butseveraljointsmaybeaffected
simultaneously.
-DramaticresponsetoAspirinwithinfewdaysofttt
-Resolvespontaneouslywithin2-4weeks.
9

9. 10

10. c-Sydenhamchorea(in30%ofcases):
-Purposeless,involuntarymovementofface,limbs,muscle
hypotoniaandhyporeflexia,emotionallability.
-Resolvespontaneouslywithin3months.
d-Subcutaneousnodules(in20%ofcases):
-Small(0.5-2cm)symmetricfirmpainlessfreelymobilenodules
moreoverbonyprominences(Extensorsurfaceofjoints&occiput,
spinousprocessesofvertebrae).
11

11. e-Erythemamarginatum(5%):
-Non-pruriticerythematousmacularorpapularrashwithpale
centre.
-Affecttrunk,inneraspectofproximalpartofextremitiesbut
notface.
12

12. 2)Minorcriteria:
a-Fever,arthralgia.
b-Elevatedacutephasereactantsofacuteinflammation:High
ErythrocyteSedimentationRate(ESR):mostly>100atfirsthour)
orhighpositiveC-ReactiveProtein(C-RP).
c-ProlongedPRinterval(inelectrocardiogram(ECG).
3)Evidenceofrecentstrept(GAS)infection:
-AntiStrptolysin-O-Titre(ASOT):Elevated(titre>250todd
units/mlinadultor>500inchildren)orrisingASOTtitre(>2
foldincreaseafter2weeksoffollowup).
13

13. TreatmentandpreventionofRF
14

14. Treatment(ttt)ofRF:
1)Eradicationofstreptococcalinfection(10daystttwith
antibiotic)by:
-BenzathinePenicillinG:600,000–1,200,000UonceIMafter
doinghypersesetivitytestor:
-Erythromycinorcephalosporinsfor10days(ifpatienthas
penicillinallergy).
2)Arthritis::Bedrest+salicylates(Aspirin75-100mg/Kgbody
weightwithmaximumdose3-4gm/daygiudedby
normalizationofCRPandESR).
3)Carditis:Bedrest+cortisone(prednisoloneoral)+ICU
admissionfortttofheartfailure(diuretics,digoxin,beta
blockersandvasodilators)
4)SyndenhamChorea:Haloperidol+neurologicalconsultaion.
15

15. PreventionofRF
1)1ryprevention:
-Earlydiagnosisandtttofupperrespiratorytract
infections.
-Tonsillectomyinpatientwithrecurrenttonsillitis:if6
attacks/yearormore).
2)2ryprevention:
a-BenzathinePenicillin:1.2millionUIM/2-4wksfor:
-Until5yearspostattackofarthritisoruntilageof18
years:IfRFwithoutcarditis.
-Beyond25Y:IfRF+carditiswithoutValvularheart
disease.
-Atleastuntilage40Y,maylifelong:ifresidualVHD.
b-Erythromycin:250mg/12hoursoral(Ifpenicillin
allergy).
16

16. Infectiveendocarditis
Def:Adisesaecausedbymicrobialinfectionthat:
-Affectsthenativeheartvalvesorprostheticvalve
-Affectsendothelialliningofacardiacchamberorbloodvessel.
Pathophysiology:occursduetobacteremia+endothelial
injurysecondarytopresenceofhighvelocityjeton
predisposedendocardiallininge.g:MR,ARorVSD.
Causativeorganisms:Usuallycausedbybacteriumbutmay
berickettsia,chlamydiaorfungus.
•Itmaybeacute,subacuteorchronic(healed).

17. •Clinicallymaybepresentby:
-Highgradepersistentfevernotrespondingtoausual
antibiotictherapywithoutobviouscause.
-Prominentorchangingheartmurmurandpetichae.
-Acuteheartfailure
-AcuteemboliceventslikeCVSoracutelimbischemia
-Orrenalfailureasacomplicationofembolizationto
kidney,autoimmunereactionordrugsusedfor
treatmente.g:aminogycosides
19

18. 20

19. 21

20. Management
Mustbehospitalizedandlinesoftreatmentare:-
A)Medicaltreatment:
•startwithempiricalantibiotictherapy:Penicillin+gentamycininjections
untilresultsofbloodculturethenculturebasedantibiotictreatment.
•Lastsfor4-6weeksaccordingtotypeoforganismbutmayextendupto
monthsinspecialcaseslikeQfeverorbrucellosistakingcareofantibiotic
sideeffects(e.grenalfailurewithgentamycinorallergywithpenicillin).
B)Surgicalttt:
•Forcardiacvalvesaffection:e.gmitraloraorticvalvereplacementifmitral
oraorticendocarditisorlocalcomplicationslikeaorticrootabscess.
•Treatmentofcomplications:e.gembolectomyifperipheralembolization
occured. 22

21. ThankYou
DrNaderGalal2016 23