Rheumatic heart disease

What is Rheumatic heart disease(RHD) ?

Rheumatic Heart Disease Definition | Rheumatic heart disease(RHD) is a serious complication of acute Rheumatic fever,  in which permanent damage of  one or more heart valves from one or more attacks of acute Rheumatic fever. Which is caused by an infection with hemolytic streptococcus Bactria. Only 40-60% of patient develop Rheumatic heart disease from Acute Rheumatic fever. The commonest valves are Mitral Valve (most common), aortic valve, Tricuspid and pulmonary(least).

What is Acute Rheumatic Fever?

Acute Rheumatic fever is disease which is caused by  untreated Streptococcus bacterial infection (sore throat, skin infection). Acute Rheumatic fever follows 0.3% of cases of Group A beta haemolytic streptococcus infection .Untreated rheumatic fever lead to Rheumatic heart disease.

Rheumatic Fever Causes:

Group A beta haemolytic streptococcus Pharyngitis in children.

Epidemiology of Rheumatic fever: 

- Incidence of Rheumatic fever more in crowed population (1 to 3 %) and 0.3 % western countries.
- Rheumatic heart disease primarily affect younger children with age group 5 - 15.
- Both sex are equally affected
- Mitral valve problem and chorea are more in female
- Aortic valve involvement more often seen in males.

Predisposing factor of Rheumatic fever

Poor socio-economic status
Poor nutrition

Rheumatic Heart Disease Pathophysiology

1.) Rheumatic heart disease(RHD) is a serious complication of acute Rheumatic fever, Streptococcus pyrogens lurk in Body.
2.) Streptococcus pyrogens Attack skin cell lining of nose, throat and respiratory tract  causing sore throat, Headache, Fever.
3.) Disease progress to Rheumatic heart  disease leads to an autoimmune attack in body.
4.) As blood flows to heart, Bacteria can affect heart valves leading to
 Irregular heartbeat, valvular stenosis. Bacteria also affect other organ as well leading to symptoms such as stomach pain, rashes , arthritis.

Rheumatic Fever Symptoms

Dyspnea, fatigue, palpitation, edema
-  Migratory and fleeting Polyarthritis  of Major joint such as knee, ankle, elbow and wrist. Arthritis does not progress to chronic disease.
- Carditis  : pancarditis (endocarditis, Myocarditis, Pericarditis)
Acute phase : Vulvitis
Chronic phase: Fibrosis, Calcification and stenosis of valves.
- Sydenham Chorea : late manifestation appears at least 3 month after episodes of Acute Rheumatic Fever.
- Erythema Marginatum : Unique, transient lesions of 1-2 inch in size, pale in center with red irregular margin, more on trunk and limbs which is non itchy.
- Subcutaneous Nodules : Painless pea shaped palpable nodules, mainly over joints, spine, scapula and scalp.

Rheumatic Fever Signs

Atrial fibrillation/flutter
Cardiomegaly
Apical pansystolic murmur + thrill
Signs of RHF and pulmonary hypertension
Crepitations, pulmonary oedema

Pathology of Rheumatic Fever

- Aschoff bodies : Central fibrinoid necrosis surrounded by fibrosis.
- Antischkow cells

Rheumatic fever criteria

If you see fever with two or more of jones  criteria.

Jones criteria: 

Jones criteria Mnemonics
 Major Criteria “JONES”
J: Joint (Arthritis)
O : O look like Heart (myocarditis)
N : Nodules, subcutaneous
E : Erythema Marginatum
S : Sydenham Chorea

Minor Criteria of Rheumatic fever
Mnemonics “CAFE PAL”
C : CRP raised
A : Arthalgia
F : Fever
E: Elevated ESR

P : Prolonged PR interval
A : Anamnesis of Rgeumatism
L : Leukocytosis

Diagnosis of Rheumatic Fever

1.) Two major criteria OR
2.) One major criterion and two minor criteria
 With essential criteria : ASO/ strep antibodies/ positive throat culture, recent history of sore throat.

Treatment of Rheumatic Fever

- Bed Rest
- Anti inflammatory drugs:
- Aspirin:  90-120 mg/kg/day in 4-6 divided doses for 4-6 weeks then tapering 75 mg/kg/day in next 2 weeks.
-  Corticosteroid
- Antibiotics : penicillin G benzathine - 1.2 million U IM q4wk

Prevention of Rheumatic Fever

- Penicillin prophylaxis for streptococcal sore throat

What is Chronic Rheumatic fever?

Chronic Rheumatic fever is long term of  Acute Rheumatic fever. Patient with Chronic Rheumatic heart disease develop valve stenosis with certain degree of regurgitation, arrhythmia, atrial dilation & Dysfunction of ventricles.

Read more about Hantavirus