A 52-year-old female presented with fatigue, shortness of breath, and occasional palpitations over the past 6 months. She reported a serious childhood illness with fever, rash, joint pain, and difficulty controlling movements that resolved after 1 month. On examination, she had a loud S1, opening snap, and diastolic rumble. Chest X-ray and echocardiogram were ordered to evaluate for likely rheumatic heart disease given her history of childhood illness and current cardiac examination findings.

1. Cardiovascular Pathology

2. A 52-year-old female developed fatigue
and shortness of breath that have been
worsening over 6 months. She also
complained of occasional palpitations.
She described a serious illness she had
as a child, with fever, rash, joint pain, and
difficulty controlling her movements.
She recovered after a month.
Cardiac examination reveals a loud S1,
an opening snap, and a diastolic rumble.
What do you want to examine more?
What test do you want to order?

3. LEARNING OBJECTIVES
•Understanding the pathophysiology of
Rheumatic fever
•To know about the epidemiology of the
disease
•Describe the natural history and pathology of
Acute rheumatic fever and rheumatic heart
disease
•To know about the clinical features, minor
and major criteria for the diagnosis of
rheumatic fever.
•To know morphological features of the
disease.
•To know pathology of chronic rheumatic heart
disease and Rheumatic pericarditis.
•Enlist components of vegetation.

4. Chest X-ray Echo

5. What is your likely diagnosis?
What is underlying cause?

6. Vulvar heart
diseases
Toxic symptoms:
Fever, sore throat,
arthralgia etc…
Untreated
Infection
Rheumatic
fever
Carditis

7. Rheumatic Heart
Diseases

8. -Acute RHD: Rheumatic fever
-Chronic RHD

9. Rheumatic Fever: Acute

10. - It is a preventable immune mediated and multisystemic
inflammatory disease, triggered by group A B-hemolytic
streptococcus pharyngitis, in genetically predisposed
individuals.
- It occurs within 1-4 weeks of untreated infection.
- Common in F>M and in age between 5-15 years of life.
- It may spread to affect: heart, joint, connective tissue, and
brain.

12. - The body immune system produce antibody against
Streptococcus bacteria that cross react with human
body tissue.
- It occurs due to antigenic similarity between bacteria
M-protein and body tissue.
- There is no direct invasion of the bacteria to the body
tissue.
Pathogenesis

15. - Most common complication of
Rheumatic heart disease is valvular
fibrosis and defects.
- VHD occurs secondary to
rheumatic pancarditis
- Mitral or aortic defect are more affected such as mitral
stenosis. Left ventricle is always not affected.
- Vulvar stenosis can complicate to arrhythmia and heart
failure.

17. Rheumatic pancarditis
results in:
a- Chronic granulomatous
myocarditis
b- Verrucous endocarditis
c- Fibrinous pericarditis
and Serosanguinous
pericardial effusion
What is the clinical
presentation ?

18. What do you seen in Pathology of
myocardium in mitral vulvitis ?

19. ASCHOFF BODY

23. Chronic Rheumatic Disease

24. - It is irreversible deformity of heart valves mainly affecting mitral valve
(90%)
- If the mitral valve affected, it causes stenosis more than regurgitation
- It occurs due to calcification and scarring
- It results in shortening and fusion of chordae tendineae
- Complications: arrythemia, CHF, LVH and dilatation,
thromboembolism and infective endocarditis.

25. Trick notes:
- Treating streptococcus pharyngiotonsilitis will prevent Rheumatic
disease.
- Child present with fever, rash and cardiac symptoms alert acute
rheumatic fever
- Young or middle age patient presents with vulvar disease alert VHD
secondary to chronic RHD
- Treating VHD prevents complications

26. VALVULAR HEART DISEASES

27. LEARNING OBJECTIVES
• Types of valve heart disease.
• To know pathophysiology, etiology and morphology of
valve heart diseases.

28. VHD
Stenosis Regurgitation
Mitral stenosis
Aortic stenosis
Mitral Regurgitation
Aortic Regurgitation

29. - Valve abnormalities could be
congenital or acquired.
- The most common abnormalities
are acquired stenosis of the mitral
and aortic valves.
- Valve abnormalities produce
abnormal heart sounds called
murmurs

30. Mitral Stenosis

31. Mitral stenosis
less than 4 cm
Prevent blood flow
from LA to LV
LA enlargement
AF and Pulmonary
congestion

32. Pathological features:
- Thick rigid leaflets
- Narrow orifice
- Fish-mouth deformity
- LA dilatation/hypertrophy
- Thick endocardium

33. Causes:
- Rheumatic heart disease
- Radiation treatment
- Blood clot
- Congenital heart disease
- Tumours
- Unknown

34. Complications:
- Atrial fibrillation
- Pulmonary HTN
- Right heart failure
- Systemic embolization
- Chest infection

35. Mitral Regurgitation

36. Mitral
insufficiency
Leaking of blood
from LV to LA
Increased pressure in
LA and LV
LV hypertrophy

37. Pathological features:
- Retracted leaflets
- Retracted orifice
- LV dilatation/hypertrophy

38. Causes:
Dysfunction of any mitral valve
leaflets components:
1- Mitral annulus due to:
a- Repeated MI
b- DCM
c- CRF
d- degenerative changes
2- Papillary muscles due to
ischemia and dilatation
3- Chordae tendineae due to
rupture from trauma or ischemia
4- Other affecting the leaflets such
as SLE, RHD and infective
endocarditis

39. Complications:
- Pulmonary congestion
- Atrial fibrillation
- Congestive heart failure

41. Aortic stenosis
and Regurgitation

42. Aortic stenosis Aortic regurgitation
Calcified AS (ageing) Rheumatic fever
Rheumatic AS - common Infective endocarditis
Congenital bicuspid valve Trauma
Aortic root diseases
“Anuluaortic ectasia” 80%
idiopathic. Secondary due
to syphilis, SLE, Marfan
syndrome, OI, Behcet
disease

44. Aortic stenosis Aortic regurgitation
Thick valve cusps Thick valve cusps
Narrow triangular orifice LV hypertrophy
LVD and hypertrophy
Pathological features

45. Aortic stenosis – Triangular cusps Calcified aortic stenosis

46. Calcified aortic stenosis

47. Mitral Valve Prolapse
(MVP)

49. -It occurs when two mitral valve
flaps fail to close smoothly which
bulge upward to the LA
-It is due to myxomatous
degeneration of mitral valve
-It occurs in adult and in range 3-
5% of population
-Risk factors : EDS, Marfan, PKD
-It is usually asymptomatic
-It is associated with mid or late
systolic murmur
-It can complicates to MR and
infective endocarditis.

50. Gross: ballooning of
leaflets into LA.
Elongated chordae
tendineae
Microscope: Excessive
edematous connective
tissue in spongiosa

51. Break

52. A 38-year-old male who is
known as IV drug abuser
developed fatigue and fever
over 2 weeks. On physical
exam, he showed fingers
clubbing, mild splenomegaly
and lower leg rash.
Cardiac auscultation found
systolic murmur.
What is differential diagnosis

53. Toxic symptoms:
Fever, fatigue, rash
etc… + cardiac
symptoms
Infection
Bacteremia ?
Infection of
endocardium
to reach the
valve
Vegetation ?

54. Infective Endocarditis

55. LEARNING OBJECTIVES
•Etiology
•Risk factors
•Pathophysiology
•Clinical manifestations
•Complications
•Morphology

56. Acute Subacute
Organism High virulant
staphylococcus
aureus 20%
Low virulant
hemolytic
streptococcus
Viridans 60%
Valve Normal and
deformed valves
Deformed valve
Progression Rapid Slow
Response Little local reaction,
lesion is
destructive
Local inflammation,
lesion is less
destructive
Resolution Death (50%) Recovery
(antibiotics)

57. Other Microorganisms:
- Coagulase negative staphylococci
(epidermidis) affect prosthetic valve
- Gram negative bacteria (rare)
- Fungus : candida and aspergillum

58. Risk factors:
- Congenital vulvular heart disease
- Prosthetic heart valve
- Intravenous drug abuse (usually
affect right side)

59. Vegetation

60. Complications:
- Regurgitation
- Perivalvular ring myocardial abscess
- Systemic embolism of vegetation
- Mycotic aneurysm
- Renal complication

62. NBTE: Non bacterial
thrombotic
endocarditis
- It is non bacterial, steriled,
thrombotic inflammatory
condition affecting valve
leaflets forming a mall
nodule less than 5 mm.
- Most common location
mitral valve
- It can be associated with
lung cancer and DVT
- Other example is Libman
sacks endocarditis that is
associated with SLE

63. Take Notes to Home:
- RHD is rare disease in developed countries.
- Rheumatic fever occurs secondary to
untreated group A streptococcus infection
associated carditis.
- CHD is long standing effect of rheumatic fever
that
can cause VHD, commonly mital stenosis
- VHD has many causes, most common RHD
- VHD, if uncontrolled or treated, leads to IE

64. Question
A 40 year-old west African female intravenous drug
abuser for the last 8 years presented with acute
confusion and high grade fever. Her physical
examination showed leg edema and tachypnea.
Cardiac examination revealed loud S1 and mild
pericardial rub. There was disturbed renal function
test with very high Creatinine level. Which one of
the following is most likely diagnosis:
•a. Chronic rheumatic pericarditis
•b. Mitral regurgitation and acute mitral stenosis
•c. Chronic renal injury due to infective endocarditis
•d. Acute rheumatic fever
•e. Acute myocardial infarction

65. Question
A 60 year-old Caucasian male has been diagnosed
with rheumatic heart disease since childhood. He
developed congestive heart failure 5 years ago. His
EF dropped to 10% and unfortunately he developed
complications and passed away in 5 days.
Postmortem examination of his heart showed thick
aortic valve cusps. Histological section examined
under microscope revealed Endomyocardial
plaques. The most likely underlying pathological
cause is:
•a. Aortic regurgitation
•b. Mitral stenosis
•c. Calcified aortic stenosis
•d. Combined mitral and aortic regurgitation
•e. Mitral valve prolapse

66. Thank you
Resources:
1- Robin Basic Pathology
2- Cardiovascular Pathology- Buja
2- Pathology-outline
3- Web-Pathology
4- PubMed