Rheumatic fever Occurs usually after an attack of phyrangitis or sore throat between age group of 5-15years.Male and females are equally affected.

1. RHEUMATIC FEVER By Dr Bashir Ahmed Dar Chinkipora Sopore Kashmir Associate Professor Medicine Email [email_address]

9. What are these Streptococci A ‘coccus’ is a spherical bacteria Staphylococcus tend to cluster in groups While Streptococcus tend to line up in strings Some are pyogenic while others are non pyogenic.

16. Pharyngitis

19. Scarlet fever

21. Necrotising fascitis

24. Skin infections

34. Antigenic Structure Capsule: . The capsule of group A streptococci is composed of hyaluronic acid (hyloronidase) that breaks down connective tissue and is antiphagocytosis The group B streptococci contain M protein binds IgM, IgG and  2-macroglobulin; interfere with phagocytosis. Lipoteichoic acid: binds to epithelial cells . F protein : a major adhesin of S. pyogenes , binding with fibronectin.

36. Pathogenesis So streptococci is able to cause Adherence to the epithelial cells; invasion into the epithelial cells; Which in turn is mediated by M protein and F protein and is important for persistent infections and invasion into deep tissues

37. Enzymes and toxins secreted or produced by S.cocci Streptokinase (fibrinolysin) Can lyse blood clots and may be responsible for the rapid spread of the organism. Used (IV injection) for treatment of pulmonary emboli, coronary artery thrombosis and venous thrombosis. Streptodornase (DNases A to D) Decreases viscosity of DNA suspension. A mixture of this and streptokinase is used in enzymatic debridement-liquifies exudates and facilitates removal of pus and necrotic tissue. C5a peptidase Prevents streptococci from C5a-mediated recruitment and activation of phagocytes, and is important for survival of S. pyogenes in tissue and blood.

38. Also produces Hemolysins like Streptolysin O : O 2 -labile; causes hemolysis deep in blood agar plates. ASO (antistreptolysin O) titer >160-200 units suggests recent infection or exaggerated immune response to an earlier respiratory infection. However, skin infection does not induce ASO. Streptolysin S : O 2 -stable. Causes  -hemolysis on the surface of blood agar plates. Cell-bound, not antigenic. Produced in the presence of serum. Kills phagocytes by releasing the lysosomal contents after engulfment.

42. Epidemiology . Crowding increases the opportunity for the pathogen to spread, particularly during the winter months. the organisms are introduced into the superficial or deep tissue through a break in the skin. Low social economic conditions are at risk. Portal of entry through droplets,contact,food,fomites.

48. Vegetation Mitral Valve Stick in Perforation

49. Acute Rheumatic vegetations: Mitral v. Valve Vegetations Papillary muscle

58. Aschoff Body & Anitskow cell Aschoff Body

59. Aschoff Giant Cells:

60. Acute Rheumatic Fever-Rh nodule

63. Acute Rheumatic vegetations: Mitral v. Valve Vegetations Papillary muscle

64. Fish mouth stenosis:

67. Acute on Chronic RHD Note: Thickening of valve, opaque, inflammed, irregular border, shortening of chordae tendinae also seen.

68. Chronic RHD Note: Thickening of valve, opaque, vascularized irregular border, shortening of chordae tendinae. (no significant inflammation)

72. Fish mouth Mitral stenosis Scar nodule Left Atrium Mitral Valve

73. Chronic RHD - Aortic Valve Stenotic, Fused valve Coronary Artery (normal)

74. Fish mouth Mitral stenosis:

78. Infective endocarditis with perforation of mitral valve leaflet Vegetation Mitral Valve Stick in Perforation

86. Granular Visceral Pericardial Surface of Fibrinous Pericarditis

87. Fibrinous Pericarditis:

89. Migratory arthritis

96. Subcutaneous nodules

107. Acute Rh Fever: Erythema Marginatum

118. Normal & Rheumatic Mitral valve: Normal valve is Transparent, avascular, thin flexible membrane. RHD: Thick, fibrous scarred stenotic & fixed (MS/MR) with Blood Vessels.  Recurrent Inflammation Scarring 