This document discusses rheumatic heart disease, defining it as a post-streptococcal inflammatory disease affecting the heart, joints, nervous system, skin, and tissues. It most commonly affects children ages 5-15 and both sexes equally. Incidence is higher in low socioeconomic groups and damp, crowded places. It causes pancarditis (inflammation of all heart layers), valvular lesions, and Aschoff nodules (small inflammatory structures in heart tissue). The mitral valve is most commonly and severely affected, followed by the aortic valve, with tricuspid and pulmonary valves rarely involved.

1. Dr Ravi
Shrivastava
Rheumatic Heart Disease

2. DEFINITION
 Rheumatic fever (RF)
 It is a systemic, post-streptococcal,
nonsuppurative inflammatory disease,
principally affecting the heart, joints, central
nervous system, skin and subcutaneous
tissues.
 The chronic stage of RF involves all the layers
of the heart (pancarditis) causing major cardiac

3. INCIDENCE
 Age:-
The disease appears most commonly in children
between the age of 5 to 15 years when the
streptococcal infection is most frequent and intense.
 Sex:-
Both the sexes are affected equally, though some
investigators have noted a slight female
preponderance.
 The geographic distribution,
incidence and severity of RF and RHD are generally

4.  The disease is seen more commonly in
 Poor socioeconomic strata of the society
 Living in damp and overcrowded places which
promote interpersonal spread of the streptococcal
infection.
 Its incidence has declined in the developed
countries as a result of
 improved living conditions
 early use of antibiotics in streptococcal
infection.

5. MORPHOLOGIC FEATURES
 RF is generally regarded as an autoimmune focal
inflammatory disorder of the connective tissues
throughout the body.
 Cardiac lesions of RF in the form of pancarditis,
particularly the valvular lesions, are its major
manifestations.
 Extracardiac lesions –
However, supportive connective tissues at other sites
like the synovial membrane, periarticular tissue, skin
and subcutaneous tissue, arterial wall, lungs, pleura

6. A. Cardiac Lesions
 The cardiac manifestations of RF are in the form of
focal inflammatory involvement of the interstitial
tissue of all the three layers of the heart, the so-
called pancarditis.
 The pathognomonic feature of pancarditis in RF is
the presence of distinctive Aschoff nodules or
Aschoff bodies.

7. THE ASCHOFF NODULES (BODIES)
 The Aschoff nodules or the Aschoff bodies are
spheroidal or fusiform distinct tiny structures, 1-2 mm
in size,
occurring in the interstitium of the heart in RF and
may be visible to naked eye.
 They are especially found in the vicinity of small blood
vessels in the myocardium and endocardium
occasionally in the pericardium and the adventitia of
the proximal part of the aorta.
 Lesions similar to the Aschoff nodules may be

8.  Cardiac histiocytes or Anitschkow cells are
present in small numbers in normal heart
 But their number is increased in the Aschoff
bodies;
therefore they are not characteristic of RHD.
 Anitschkow cells are large mononuclear cells
having central round nuclei and contain
moderate amount of amphophilic cytoplasm.

9. •The nuclei are vesicular and contain prominent central chromatin
mass
which in longitudinal section appears serrated or caterpillar-like,
while in cross-section the chromatin mass appears as a small
rounded body in the centre of the vesicular nucleus, just like an
owl’s eye.

10.  Some of these modified cardiac histiocytes become
multinucleate cells containing 1 to 4 nuclei and are
called Aschoff cells and are pathognomonic of RHD.

13. RHEUMATIC PANCARDITIS
 Although all the three layers of the heart are affected in
RF,
the intensity of their involvement is variable.
1. RHEUMATIC ENDOCARDITIS
 Endocardial lesions of RF may involve the valvular and
mural endocardium, causing
rheumatic valvulitis and
mural endocarditis, respectively.
 Rheumatic valvulitis is chiefly responsible for the major
cardiac manifestations in chronic RHD.

14. RHEUMATIC VALVULITIS
Grossly,
 The valves in acute RF show thickening and loss of
translucency of the valve leaflets or cusps.
 This is followed by the formation of characteristic,
small (1 to 3 mm in diameter), multiple, warty
vegetations or verrucae, chiefly along the line of
closure of the leaflets and cusps.
 These tiny vegetations are almost continuous so
that the free margin of the cusps or leaflets appears
as a rough and irregular ridge.

15.  The vegetations in RF appear grey-brown, translucent
and are firmly attached
so that they are not likely to get detached to form
emboli,
unlike the friable vegetations of infective
endocarditis.
 Though all the four heart valves are affected, their
frequency and severity of involvement varies:
mitral valve alone being the most common site,
followed in decreasing order of frequency, by
combined mitral and aortic valve (Fig. 14.26).
The tricuspid and pulmonary valves usually show
infrequent and slight involvement.

17. Thank You