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DT3- EXAM 1 > Rheumatic Disease/ Valvular Disease- Leah (6) * > Flashcards

Rheumatic Disease/ Valvular Disease- Leah (6) * Flashcards

1
Q

Describe the conditions under which rheumatic disease occurs (cause? time of onset?)
How common is it?
How often is it fatal?

A 
-GAS strep pharyngeal infection 
(NOT other locations only strep throat) 
-onset: 10 days --> 6 weeks AFTER pharyngitis 
-occurs in 3% of GAS pharyngitis cases
-1 % of cases are fatal
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2
Q

How is rheumatic disease treated?

A
  • PREVENTED by treating pharyngitis with Abx

* Unlike post strep glomerulonephritis *

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3
Q

What are Aschoff bodies?
What three cell types do they contain?
Where are they found?

A
  • Pathonogmonic histo finding for acute rheumatic disease
  • T lymphs, Plasma cells, Plump MQs/ Antischow cells
  • NOTE: macs/anitschows may fuse to become Giants/aschoffs
  • Also note: a bunch of fragmented collagen may also be in these bodies.
  • Often located on the MYOCARDIUM of an acutely rheumatic heart (but can be found in all layers)
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4
Q

Describe the anitschow cell (cell type + 2 characteristics):

What can they become?

A
  • Caterpillar like MQ (long and thin)
  • Lots of cytoplasm
  • wavy slender nucleus (ribbon-like)
  • May become giant cell
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5
Q

Describe histologic findings in the 4 layers of the heart during acute rheumatic disease:

A
  • pericardium: fibrin exudate –> friction rub
  • myocardium: perivascular Aschoff bodies
  • Subendocardium: fibrosis, especially in left atrium
  • Endocardium: fibrinoid necrosis + valve vegetations
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6
Q

What is the name for fibrosis of the left atrial Subendocardium in acute rheumatic disease?

A

MacCallum plaques

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7
Q

Describe the immunopathology of rheumatic disease

A

CD4+ cells for GAS “M protein” cross react with host tissue

  • Makes patient vulnerable to current AND future pharyngitis infections + second acute rheumatic disease
  • Effects will be cumulative.
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8
Q

How is rheumatic fever symptomatically diagnosed (major + minor criteria)?

A

Must have:

  1. Evidence of preceding GAS pharyngitis
  2. Two major OR two minor + 1 major criteria.

Major: JONES

  • large Joint arthritis (migratory)
  • carditis (the “O looks like a heart?) (listen for friction rub)
  • Nodules (SubQ)
  • Erythema marginatum (trunk, limbs)
  • Sydenham’s chorea

Minor:

  • fever
  • acute phase reactant proteins
  • general arthralgias
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9
Q

Labs that may help with the diagnosis of rheumatic fever (2):

A
  • Streptolysin O
  • DNAaseB Abs
  • verify recent strep infection
  • ^^^Acute phase reactants is a minor criteria for diagnosis
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10
Q

Three possible cardiac outcomes of chronic rheumatic disease?
Which is most common?

A

1 mitral stenosis

Also:
-fibrotic heart disease
-fatal dysfunction

(Disease course is highly variable)

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11
Q

What contributes to mitral stenosis in rheumatic fever? (3)

A
  • leaflet thickening
  • commisural fusion
  • thickening/fusion of chordae tendinae
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12
Q

What percentage of rheumatic disease cases cause mitral stenosis?

A

65-70% of cases cause ONLY mitral stenosis
25% cause mitral AND aortic stenosis

Total ~ 95% of cases will involve the mitral valve

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13
Q

Six effects of mitral stenosis (and therefore the sequelae of most rheumatic disease cases) on the heart

A
  1. Left atrial dilation (due to backup of blood)
  2. Mural thrombus in left atrium (due to stasis in atrium)
  3. Pulm congestion –> Right ventricular hypertrophy (backward effects)
  4. Arrythmia due to left atrial dilation (can cause AFIB)
  5. Murmurs
  6. Hypertrophic heart failure long term
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14
Q

General definition of rheumatic disease:

A
  • IMMUNE mediate disease of multiple systems
  • Post group A strep infection
  • Can be acute or chronically effecting heart valves
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15
Q

In general, what are the physiologic effects of stenosis (2)?

A
  • pressure overload

- impedes forward flow

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16
Q

In general, what are the physiologic effects of regurgitation (2)?

A
  • volume overload

- allows backward flow

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17
Q

What is “functional” valve insufficiency?

A
  • regurgitation due to malfunction of structures supporting valves
    (i. e. dilated chamber or annulus)
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18
Q

What are the most common causes of?

  1. mitral stenosis-
  2. mitral regurgitation-
  3. aortic stenosis-
  4. aortic regurgitation-
A
  1. mitral stenosis- rheumatic disease
  2. mitral regurgitation- mitral valve prolapse
  3. aortic stenosis- calcification
  4. aortic regurgitation- aortic dilation (ascending)
19
Q

What is the most common valve disease in the world?

In the industrialized world?

A

worldwide- aortic stenosis

industrialized world- mitral valve prolapse

20
Q

Causes of aortic stenosis? Which is most common?

A

1- calcification (presents at 60-80 yoa)

  1. congenital bicuspid valve (calcifies @ 50-70 yoa)
  2. rhuematic disease (acquired bicuspid valve possible)
21
Q

How is a bicuspid aortic valve acquired?

A

commisural fusion in rheumatic disease (fish mouth)

22
Q

How to differentiate senile aortic stenosis from rheumatic aortic stenosis? (2)

A

If rheumatic:

  1. mitral valve involvement
  2. commisural fusion
23
Q

Sequelae of aortic stenosis

A
  • increased pressure –> LVH
  • Syncope, Angina, and/ or CHF (Dyspnea)

“Aortic Stenosis makes you “SAD”

24
Q

Death rates for aortic stenosis

A

50% within 5 years of angina onset

50% within 2 years of CHF onset

25
Q

How common is mitral valve prolapse?
What population has the highest MVP rate?
Which populations have the highest RISK associated with MVP?

A

3% of overall population
-most common in young women
-*** higher risk in older patients + male patients
(or, obviously, in patients with arrythmias/ regurgitation)

26
Q

What occurs during systole in a patient with MVP (2)?

A
  • mitral valve leaflets balloon back into the atrium (click!)
  • may see annular dilation
27
Q

Gross appearance of mitral valve in prolapse? (2)

A

-large/ floppy/ rubbery leaflets
- thin/ long cords
(also see ballooning during systole)

28
Q

Histo assc with MVP (2)

A
  • mucoid deposition/ myxomatous degeneration of CT
  • thickening of spongiosa
  • thinning of collagenous fibrosa layers
29
Q

Most common findings assc with MVP? (2)

A
  • mid-systolic click

- may also hear holosystolic murmur

30
Q

How common are serious complications of MVP?

How are they treated?

A

3% of MVP patients have life threatening complcations

Can be treated with valve replacement or repair

31
Q

What areas of the heart are most often effected by endocarditis?

A

valves

mitral and aortic most common, tricuspid in IV drugs users

32
Q

What do vegetations contain in endocarditis? (3)

A
  • the bugs (bacteria)
  • the things to kill the bugs (inflammatory cells)
  • the glue to hold the war bubble together (fibrin)
33
Q 
#1 organism in endocarditis (general)? 
#1 organism in IV drug use endocarditis? 
#1 organism in prosthetic valve endocarditis? 
#1 organism in colorectal carcinoma?
Others (2)?
A

general- strep viridians (gram + optochin resistant)
(This was an Rx question)

IV- staph aureus from skin

prosthetic- staph epidermidis

Colorectal carcinoma- strep bovis

others: HACEK, enterococci

34
Q

Staph Aureus, Strep viridans

Which effects normal valves? Which effects abnormal?

A

Staph Aureus- ACUTE: usually IV drug users, not those with pre-existing heart conditions. Effects NORMAL valves.

Strep viridans- SUBACUTE: endocarditis in those with prosthetic valves most commonly. (ABNORMAL)

35
Q

Risk factors for endocarditis? (4)

A

1- any sort of immunodeficiency
2- IV drug use
3- alcoholism
4- abnormal or prosthetic valves

36
Q

Compare subacute and acute endocarditis

A

acute- 50% mortality, usually involves normal valves + high virulence organisms

subacute- low mortality rate, usually involves prosthetic valves and low virulence organisms

37
Q

Four morphologies/ pathological findings assc with endocarditis?

A

1- friable vegetations
2-valve erosion/ desctruction (moreso in acute)
3-septic emboli
4- myocardial ring (annulus fibrosis) abscess

38
Q

Neuro consequences of septic emboli (2)

A

stroke, brain abscess

39
Q

Two most common symptoms of endocarditis?

A
  • fever w/ rigors

- murmur (90% patients)

40
Q

Acronym for endocarditis symptoms:

A

“Endocarditis is FROM JANE, jesse pinkmann’s IV drug user girlfriend on Breaking Bad:

  1. Fever
  2. Roth Spots
  3. Oslers Nodes
  4. Murmur
  5. Janeway lesions
  6. Anemia
  7. Nailbed hemorrhages
  8. Emboli”

Greatway to remember what’s associated with this acronym!!! Thank you!! :)

41
Q

How is endocarditis diagnosed?

A

echo and labs (90% will be blood culture +)

42
Q

Important factor in preventing endocarditis in those with prosthetic valves?

A

-ABX prophylaxis for “dirty” procedures- ie removal of an abscessed tooth- that may lead to septicemia

43
Q

What percentage of prosthetic valves have complications?

How long to porcine valves last?

A
  • 60% in 10 years

- All porcine valves degenerate within 10-15 years

44
Q

6 complications assc with prosthetic valves

A

endocarditis; degeneration of valve (porcine); stroke/ GI bleed (due to long term anticoag); shearing = hemolysis; poor healing= leaking; excess healing= overgrowth/ stenosis

DT3- EXAM 1 (26 decks)

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