Sketchy Path: Acute Rheumatic Fever & Mitral Stenosis (Rheumatic Heart Disease)

Question 1

What kind of infection can cause acute rheumatic fever?

Answer 1

Streptococcal pharyngitis (like how the baker wearing the mitral hat has a red handkerchief)

Question 2

Acute rheumatic fever is much more common in ______________.

Answer 2

developing countries, because pharyngitis is usually treated with antibiotics in this country

(Think of the “Flavors From Around the World” poster beneath the RHUbarb PiE.)

In fact, acute rheumatic fever is one of the top causes of death in those younger than 50 worldwide.

Question 3

True or false: only a small percentage of those with Strep pharyngitis will develop rheumatic fever.

Answer 3

True. It’s about 1%.

Question 4

How soon does acute rheumatic fever develop after pharyngitis?

Answer 4

2-3 weeks (like the baker circling the date two weeks from today)

Question 5

What kind of reaction is acute rheumatic fever?

Answer 5

A type II hypersensitivity (like the baker with the antibody-shaped tongs holding the cupcake)

The bacteria don’t invade, but the M protein mimics heart tissue and leads to a delayed immunoglobulin response.

Question 6

What are the JONES criteria?

Answer 6

Joint pain
pancarditis (the O is supposed to look like a heart) 
Nodules in the skin
Erythema migrans
Sydenham chorea 

(Think of the cupcakes with JONES in frosting.)

Question 7

Describe erythema marginatum.

Answer 7

C-shaped, nonpruritic areas of erythema on the skin

Question 8

Pancarditis can present with _______________.

Answer 8

pericarditis (like the red heart case on the back counter) or myocarditis (like the heart-shaped cookies on fire)

Question 9

The most common cause of death in acute rheumatic fever is _______________.

Answer 9

heart failure from myocarditis (like the floppy heart balloon above the oven)

Question 10

What cells will be found in a heart biopsy from someone with acute rheumatic fever?

Answer 10

Aschoff bodies: granulomas with multinucleated giant cells and lymphocytes

(Think of the “hAndS OFF” sign with the cage around the purple cupcakes.)

Question 11

What are Anitschkow cells?

Answer 11

Activated macrophages with “caterpillar nuclei” (like the caterpillar made of purple cupcakes)

Question 12

What valve disorder can be present in acute rheumatic fever?

Answer 12

Sterile, fibrinoid necrosis on the edges of the mitral leaflet (like the stupid baker in the back decorating his hat with frosting)

Question 13

Valves are considered part of the _______________.

Answer 13

endocardium (like the valves above the fire INSIDE the heart-shaped oven)

Question 14

The valvulitis caused by ARF can cause ____________.

Answer 14

mitral regurgitation (like the other stupid baker regurgitating frosting on his face with the systolic murmur in the background)

Question 15

Although less common, ARF can also affect the ______________.

Answer 15

aortic valve (like the little girl with the princess cap)

Question 16

Aortic involvement in ARF leads to _______________.

Answer 16

aortic regurgitation (like the diastolic diamond on the princess –this symbolizes the diastolic murmur heard in aortic regurgitation)

Question 17

How can ARF be treated?

Answer 17

Prevention is the main treatment. Penicillin during the pharyngitis episode can prevent it.

Once ARF has begun, anti-inflammatory drugs can help with arthralgia, but that’s it.

Question 18

After one Strep infection, _______________.

Answer 18

the subsequent ones will be much worse due to immunologic memory (like the bacteria lanterns that get more damaged as the string goes along)

Question 19

Chronic rheumatic heart disease is caused by ________________.

Answer 19

years of wear on the fibrotic areas where Aschoff bodies formerly were

Question 20

How does mitral stenosis affect the heart?

Answer 20

It leads to left atrial dilation (like the little girl squeezing the balloon so that the upper-left part pops out).

Question 21

What can left atrial dilation cause?

Answer 21

• Atrial fibrillation (like the static on the TV above the scared girl).
• Mural thrombi (cupcakes on wall)
• Impingement of the recurrent laryngeal nerve (yellow reins on horse –HOaRSEness… get it?)
• Dysphagia (like the lump in the horse’s throat)

Question 22

Mitral stenosis can cause what pulmonary symptom?

Answer 22

Pulmonary edema (like the baker’s sweaty shirt)

Question 23

What murmur is typical of mitral stenosis?

Answer 23

Mid-diastolic opening snap with subsequent rumble (like the girl with the diastolic diamond earrings who is snapping)

Question 24

How can the murmur help you diagnose the severity of mitral stenosis?

Answer 24

The diastolic snap happens during diastole (after S2). During the first part of the disease, it takes a long time to open the valves because the left atrium isn’t strong. With time, however, the left atrium becomes stronger and the snap will be closer to the S2.

(Think of the S2 sisters holding each other close because the princess’s mood is severe.)

Question 25

What other disorder can cause mitral calcification?

Answer 25

Annular calcification, though this is mostly an incidental finding in the elderly and does not cause mitral stenosis (like the grandma with milk around her mouth – she’s totally separate from this scene).