Rheumatic heart disease &

Infective endocarditis
II MBBS
Dr. Maitrayee Roy MD FRCPath

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Heart: Anterior view

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Heart: short axis cross section

RV IVS LV

IVS
RV IVS LV

RV IVS LV

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Heart: longitudinal/
coronal section

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Histology of
cardiac wall
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Endocardium

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Myocardium

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 Epicardium
(aka visceral layer of pericardium)

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Epicardial fat contains coronary vessels

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Normal heart circulation

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Heart valves are the specialized flap or cusp-like structures inside the
heart composed primarily of dense connective tissues that maintain the
one-way flow of the blood inside the heart i.e., prevent the backward flow
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of the blood
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The chordae tendineae and papillary muscles prevent
prolapse of heart valves
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Echocardiogram: Apical
4-chamber view 17
 Echocardiogram:
Parasternal long axis view

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Rheumatic heart disease

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 Acute rheumatic fever
• Rheumatic fever (RF) is an acute, immunologically
mediated, multisystem inflammatory disease
classically occurs ~2 to 6 weeks after an episode of
group A streptococcal pharyngitis or less
commonly streptococcal skin infection.

• Most common age group: 5 to 15 years

• Organs affected: Heart, joints, CNS, skin and

subcutaneous tissue

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Group A beta hemolytic streptococcal (GAS) infection of pharynx/ skin

Molecular mimicry

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Etiopathogenesis of acute rheumatic fever

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Rheumatic fever – Clinical features & Diagnosis

CNS: Sydenham chorea

Heart: Pancarditis
Joint: Polyarthritis
Skin: Erythema marginatum
Subcutaneous nodules

Modified Jones criteria

used for diagnosis

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Rheumatic fever – Modified Jones criteria

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 Erythema marginatum

Subcutaneous nodules

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Acute rheumatic pancarditis

Aschoff bodies found in

all three layers of heart
(pancarditis) :

➢Endocarditis &
vegetations over heart
valve (verrucae).
➢Subendocardial
MacCallum plaques.
➢Myocarditis.
➢Fibrinous pericarditis.

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 Small vegetations (verrucae) are
visible along the line of closure
of the mitral valve leaflet
(arrows).

Microscopic appearance of an
Aschoff body: nodule of
macrophages, lymphocytes &
few plasma cells.
Macrophages are large,
activated, have prominent
nucleoli, & chromatin
condensed into long, wavy
ribbons (aka caterpillar cells)
(arrow). 29
 Rheumatic heart disease
• Acute rheumatic pancarditis (i.e. involving all 3 layers
of heart) is a common manifestation of active RF →
progress over time to chronic rheumatic heart disease
(RHD), mainly valvular abnormalities.

• RHD is characterized by deforming fibrotic valvular

disease, mostly affects left heart valves (mitral>>aortic).

• 2/3rd patients: mitral valve involved (m/c cause of

mitral stenosis).

• 1/3rd patients: mitral and aortic valve involved.

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Mitral stenosis in chronic RHD with diffuse fibrous
thickening and distortion of the valve leaflets and commissural
fusion (arrows) → fish mouth or buttonhole appearance.
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Infective endocarditis

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 Definition of IE
• Infective endocarditis (IE) is a microbial infection of
the heart valves or mural endocardium that leads
to the formation of vegetations.

• Vegetations are composed of thrombotic debris

and organisms, often causing destruction of the
underlying cardiac tissue.

• Acute or sub-acute IE based on clinical grounds.

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 Types of IE
• Acute IE: Infection of previously normal heart valve
by highly virulent organism (e.g. staphylococcus
aureus) → rapidly produces necrotizing and destructive
lesions

• Subacute IE: infection of previously damaged or

deformed valves by organisms of lower virulence
(e.g. streptococci viridans) → less destruction of valve

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 Etiology of IE
• Streptococcus viridans (normal component of oral cavity
flora) → 50-60%; affecting previously damaged or abnormal
valves
• Staphylococcus aureus → 20-30%; affecting healthy or
deformed valves & IV drug abusers
• Staphylococcus epidermidis (coagulase negative) →m/c
cause of prosthetic valve endocarditis
• Other bacteria: Enterococci, HACEK group of organisms
• Rare: Fungus
• 10% cases: no organisms identified
HACEK: Haemophilus, Actinobacillus, Cardiobacterium,
Eikenella, Kingella 36
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Modified Duke
criteria for infective
endocarditis diagnosis

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 Signs and symptoms of IE
Osler node
FROM JANE (mnemonic)
• Fever Roth spot in retina

• Roth spots Petechiae

• Osler node
Splinter
• Murmur hemorrhage

• Janeway lesions
• Anemia
• Nail splinter hemorrhage, petechiae Janeway lesion

• Embolism of vegetation fragments

Nail bed infarct due 39

to septic emboli
 Duke criteria for IE diagnosis
BE - FEIVER (mnemonic)
• Blood culture positive for known organism Major
• Endocardial vegetations seen by Echocardiogram criteria

• Fever
• Echo findings (suggestive but not diagnostic of IE)
• Immunological findings (e.g. Roth spots, osler nodes, Minor
glomerulonephritis) criteria
• Vascular lesions (e.g. petechiae, splinter nail hemorrhage,
Janeway lesion, septic emboli)
• Evidence from microbial blood culture (unusual organism)
• Risk factors (predisposing valvular heart disease, IVDU)
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Modified Duke criteria for infective endocarditis diagnosis

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1. Clinical suspicion
2. Blood culture
3. Echocardiogram

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Valve vegetations seen on Echo

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Infective endocarditis. A, Subacute endocarditis of mitral valve
(caused by Streptococcus viridans). The large, friable vegetations are
denoted by thin black arrows. B, Acute endocarditis of congenitally
bicuspid aortic valve (caused by Staphylococcus aureus) with
extensive valve cusp destruction and ring abscess (thick black arrow).

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Thank you

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