Week 10: Acute Pericarditis and Rheumatic Heart Disease Flashcards Preview

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Flashcards in Week 10: Acute Pericarditis and Rheumatic Heart Disease Deck (19):
1

Acute rheumatic fever

  • autoimmune consequence of infection with group A strep infection
  • results in a generalized inflammatory response affecting brains, joints, skin, subQ tissues and heart
  • clinical presentation vague and difficult to dx
  • currently the modified duckett-jones criteria form the basiss of the diagnosis of the condition

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rheumatic heart disease

  • defined by the constellation of results of the physical exam, autoimmune marker and other serologic tests, tissues patho, and imaging
  • recognition of clinical patterns remains essential for dx bc there is no single dx test and results may be positive in the abscence of disease
  • permanent heart valve damage (mitral #1, aortic #2)

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causes of rheumatic heart disease

  • inflammatory immune response
  • only develops in kids and adolescents following group a beta-hemolytic strep pharyngitis
  • genetic studies show strong correlation b/w progression to rheumatic heart disease and human leukocyte antigen (HLA)-DR class II alleles and the inflammatory protein-encoding genes MBL2 and TNFA

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patho rheumatic heart disease

  • infection leads to rheumatic fever several weeks after the sore throat resolves in 0.3-3% 
  • organism spreads by direct contact with oral or resp secretions.  Enhanced spread by crowded living/work environment
  • pt remains infected for several weeks after symptomatic resolution of pharyngitis and mya serve as a reservoir for infecting others

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epidemiology of rheumatic heart disease

  • uncommon among US children
  • affects females worse than men
  • decreased incidence attributed to introduction of penicillin or a change in the virulance of strep

6

major diagnostic criteria for rheumatic heart disease dx

  • confirming antecendent rhumatic fever
  • presence of 2 major or 1 major and 2 minor criteria
  • major: carditis, polyarthritis, chorea, subQ nodules, erythema marginatum, pancarditis, syndenham chorea
  • minor: fever, arthralgia, leukocytosis and raised ESR

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phsyical findings of RHD

  • cardiac and noncardia manifestations
  • lean forward, it gets better
  • pancarditis: most serious and second most common (50%)
  • new onset murmor
  • dyspnea, mild-to-moderate chest discomfort, edema, cough, orthopnea, CHF, pericarditis

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murmors of acute rheumatic fever are typically due to?

  • valve insufficiency
  • most common are: apical pansystolic, apicial diastolic, basal diastolic

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congestive heart failure and RHD

  • develops secondary to severe valve insufficiency or myocarditis
  • physical findings associated with hf include: tachypnea, orthopnea, JVD, rales, hepatomegaly, gallop rhythm, edema, swelling of peripheral extremities

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pericarditis and RHD

  • friction rub indicates it's present
  • increased cardiac dullness to percussion and muffled heart sounds
  • paradoxical pulse (accentuated fall in systolic bp) with decreasd systemic pressure and perfusion evidence of diastolic indentation of the right ventricle on echocardiogram reflect impending pericardial tamponade

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non cardiac manifestations of RHD

  • polyarthritis
  • chorea erythema marginatum: 1-3 cm diameter pink-red nonpruritic macules or papules located on trunk and proximal limbs but never on face.  Spread outward to form a ring with margins and central clearing
  • sub Q nodules
  • abd pain
  • arthralgias
  • epistaxis
  • fever
  • rheumatic pneumonia

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cardiac hemolutic anemia

  • related to disruption of RBC's by a deformed valve
  • increased destruction and replacement of platelets occurs

13

lab studies for RHD

  • throat culture: throat culture findings for group a beta hemolytic strep are usually negative by the time symptoms are rheumatic fever or rheumatic heart disease appear
  • rapid antigen detection test: allows rapid detection of group A strep antigen and allows dx of strep pharyngitis and the initiation of antibiotic therapy while the pt is still int he physicians office
  • antistrep antibodies: begins at time of antistrep antibody levels are at the peak.  Titers checked every 2 weeks to detect rising. (aso, dNase, antistreptokinase, antistreptococcal esterase, anti-DNA)

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rapid detection test for d8/17

this immunoflourescence technique for identifying the B cell marker d8/17 is positive in 90% of patients with rheumatic fever

15

imaging studies for RHD

  • chest reontgenography: cardiomegaly, pulmonary congestions, and other findings consistent with heart failure may be seen on chest radiography.  Helps differentiate form HF
  • Doppler echo: identifies and quantitates valve insufficience and ventricular dusfunction  Left ventricle frequently dilated.  Can help track the progression of valve stenosis and help determine time of surgical intervention

16

histologic findings

  • patho exam of insufficient valves reveal verucous lesions at the line of closure
  • in pericardium fibrinous and serofibrinous exudates may produce an appearane of "bread and butter" pericarditis

17

treatment and management of RHD

  • includes attempts to prevent
  • if already developed, therapy is toward eliminating group A strep, supressing inflammation from autoimmune response, and providing supportive treatment for CHF
  • after acute episode, therapy directed towards preventing recurrent rheumatic heart disease in children and monitoring for complications and sequalae of chronic RHD in adults

18

prevention of RHD

  • PO penicillin is drug of choice, but ampicillin and amoxicillin are equally effective
  • can use single dose of IM benzathine penicillin G or benzathine/procain penicillin combination is therapeutic
  • do not use tetracyclines or sulfonamides to treat GABHS pharyngitis

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