BALIUAG UNIVERSITY
COLLEGE OF NURSING
BALIUAG, BULACAN
PEDIATRIC RHEUMATIC HEART DISEASE
NICU
Submitted by:
Sheela Marie D. Gracia
BSN IV-D/ GROUP-4
Submitted to:
Mrs. Julieta Del Mundo RN, MSN
Clinical instructor
Rheumatic Heart Disease
I. DEFINITION
Rheumatic heart disease is a complication of rheumatic fever, which is also a complication of
sore throat and mumps. So basically this disease is the end result of untreated common
infections.
The valves of the heart are damaged; they may not be opening and/or closing properly which
then causes regurgitation of blood.
The heart is inflamed and thus scarring may result, which then causes accumulation of blood
on the scars, causing damage to the heart membranes.
The heart gets damaged by the toxin of streptococcus (the bacteria that causes rheumatic
fever) thus causing it to beat abnormally.
Heart ventricles are also damaged causing it to dysfunction.
o Rheumatic pancardiditis
1. Rheumatic endocarditis
(a).Rheumatic valvulitis
(b).Rheumatic mural endocarditis
2. Rheumatic myocarditis
3. Rheumatic pericarditis
1(a).Rheumatic Valvulitis
Grossly Microscopically
Acute Acute
1.Thickening and loss of translucency 1.Edema
of the valve leaflets 2.Cellular infiltration
2.Gray brown, watery vegetations 3.Vegetations of fibrin
Chronic
1.Permanent deformity of on one or Chronic
more valves (mitral or aortic) 1.Thicken by fibrous tissue with hyalinization (Calcification
2.”Fish mouth” or “button hole” rarely)
3.Thickening, shortening and fusion of 2.Thickened blood vessels with narrowed lumina
chordae tendinae
1(b).Rheumatic mural endocarditis
Grossly Microscopically
MacCallum’s patch:- MacCallum’s patch:-
Lesions of endocardial surface in the a. Edema
posterior wall of the left atrium just above b. Fibrinoid changes in collagen
posterior leaflet of the mitral valve c. Cellular infiltrate of lymphocytes
d. Plasma cells
e. Macrophages
f. Anitschkow cells*
2. Rheumatic Myocarditis
Grossly Microscopically
Acute Acute
Left ventricular myocardium soft and Aschoff nodules are scattered (inter venticular septum, left
flabby ventricle and left atrium)
Intermediate stage
Intermediate stage In Aschoff:- Granuloma with central fibrinoid necrosis and
Interstitial tissue of the myocardium shows surrounded by palisade of anitschkow cells
small foci of necrosis Late stage
Aschoffs bodies are replaced by small fibrous scars
Late stage
Foci of aschoff bodies are visible
3. Rheumatic Pericarditis
Grossly Microscopically
chronic chronic
a). Deposition of fibrous exudates (Loss of a). Fibrosis aschoff bodies on the surfaces
normal shiny pericardial surface)
b). Accumulation of fibrous exudates in the
pericardial sac b). Infiltrated sub serosal connective tissue
(“Bread and butter” appearance)
c). Chronic adhesive pericarditis
c). Adhesions between visceral and parietal surfaces
ANTOBODIES AGAINST
Beta-Haemolytic streptococci group A
Anti-streptolysin O (ASO)
Anti-streptokinase
Anti-streptohyaluronidase
Anti DNA ase B
II. COMPLICATIONS:
• Severe mitral stenosis progresses to left atrial hypertrophy and dilatation,
• Mural thrombosis,
• Pulmonary congestion,
• Pulmonary vascular sclerosis and then right ventricular hypertrophy.
• The left ventricle is normal is isolated pure mitral stenosis.
Other complications of chronic RHD include:
• heart failure,
• Arrhythmias particularly AF in case of M.S,
• Thrombo embolic complications and infective endocarditis.
• The long term prognosis is highly variable
• Rx- Surgical replacement of diseased valves
with prosthetic device
*anitschkow cell: are the cardiac histocytes present in small numbers in the normal heart. The nuclei
are vesicular and contain prominent central chromatin mass which in longitudinal section appears
“serrated” or “caterpillar” like and in cross section it look like an “owl’s eye”
**Aschoff bodies: are spheroidal or fusiform distinct microscopic structures occurring in the intestitium
of the heart in RHD.(it contains almost four anitschkow cells )
III. CLINICAL MANIFESTATION:
Fever, the most common (although not everyone will have high temperature)
Migratory joint pain and swelling
Skin rash, usually pale pink
Malaise, fatigue
Chest pain,
Jerking body movements
Nose bleeding
If your children seemed to be tired all the time and have no appetite, ask if he/she feels pain in her/his joints.
Even if he/she has no fever, she might be having rheumatic fever.
On my experience, during the height of my rheumatic fever, I could not eat, I felt like I was so tired all the time,
there was this dullness that I felt that I don’t seem to have any strength most of the days. There were times also
when my stomach was upset, not in the kind that I have eaten something wrong but it just feels like there so
much in it, I have to throw up. There was also this feeling that I thought I was having the fever because I felt
hot, but in fact I didn’t have the temperature.
I also felt irritated and really down for no apparent reason. And I easily get tired. My heart seemed to beat
rapidly and so I feel like I was nervous all the time and I just felt so very tired every now and then.
If you see one or two of the symptoms above in your children, especially when after they had sore throat or
mumps, go to the doctor at once.
Immediate diagnosis of the disease is important, so that immediate treatment could be given to the patient.
Delayed treatment allows it to progress to rheumatic heart disease.
IV.PATHOPHYSIOLOGY
Autoimmune mechanism has been proposed
Attack of group ‘A’ beta hemolytic streptococci
↓
Pharyngitis
↓
Antibodies directed against the M proteins of certain strains of streptococci cross-react with tissue glycoprotein
in the heart, joints and other tissues.
↓
(Heart)
Edema of connective tissues and increased acid mucopolysaccharide in the ground substance.
↓
Accumulation of ground substance.
↓
Separation of collagen fibers.
↓
Collagen fibers become fragmented and disintegrated.
↓
Proliferation of cells (lymphocytes, plasma cells, a few neutrophils, cardiac histocytes (anitschkow cells) at the
margin of the lesion
↓
Aschoff nodules (12 to 16 weeks)
↓
Anitschkow cells nodule becomes spindle shaped with diminished cytoplasm.
↓
AFTER YEARS
Aschoff body becomes less cellular and collagenous tissue is increased
↓
Fibro collagenous scar
↓
Formation of chronic sequelae (endocardium , myocardium, pericardium)
V. MEDICAL MANAGEMANT:
Treatment and Prevention
Specific treatment for rheumatic heart disease will be determined by your child's physician based on:
your child's overall health and medical history
extent of the disease
your child's tolerance for specific medications, procedures, or therapies
expectations for the course of the disease
your opinion or preference
The best treatment for rheumatic heart disease is prevention. Antibiotics can usually treat strep throat (a
Streptococcus bacterial infection) and stop acute rheumatic fever from developing. Antibiotic therapy has
sharply reduced the incidence and mortality rate of rheumatic fever and rheumatic heart disease.
Children who have previously contracted rheumatic fever are often given continuous (daily or monthly)
antibiotic treatments to prevent future attacks of rheumatic fever and lower the risk of heart damage.
If inflammation of the heart has developed, children may be placed on bed rest. Medications are given to
reduce the inflammation, as well as antibiotics to treat the Streptococcus infection. Other medications may
be necessary to handle congestive heart failure.
If heart valve damage occurs, surgical repair or replacement of the valve may be considered.
The best way to prevent rheumatic heart disease is to seek immediate medical attention to a strep throat and
not let it progress to rheumatic fever.
VI. NURSING MANAGEMENT
Care
Treatment depends on the exact type of rheumatic heart disease you have and its severity. In
most cases, blood thinners (Coumadin or aspirin) are prescribed to prevent clots. The doctor may also
prescribe beta blockers and calcium channel blockers to slow the heart, and digitalis and other heart
drugs to boost its efficiency. Water pills may be needed to counteract the fluid buildup caused by a
weakened heart.
Because rheumatic fever sufferers are prone to further attacks and yet more heart damage, you
will most likely be prescribed monthly or daily antibiotic treatments, perhaps for life. You'll probably
have to restrict your exercise as well.
For severe cases, surgical options are available—the most common being the implantation of an
artificial valve or the opening of an excessively narrow valve. A non-surgical procedure, called a
balloon valvuloplasty, is yet another choice for those patients who are poor candidates for surgery. This
process involves snaking a balloon-tipped catheter through the arteries and into the valve, where the
balloon is inflated to open the leaves of the valve.
WHAT PATIENT SHOULD KNOW:
Follow your medication program carefully. The drugs are designed to prevent serious complications.
Make sure that all healthcare providers are aware of your condition. You will need antibiotic treatment
prior to any dental or surgical procedures.
Work with your physician on an effective exercise program, then follow it daily. Regular exercise
strengthens the heart and lowers blood pressure. Walking and golfing, for example, are excellent forms
of exercise for those suffering from rheumatic heart disease. However, you should consult your doctor
before engaging in other, more rigorous forms of exercise such as basketball or strength training
workouts.
Eat a well balanced, heart-healthy diet low in fat, salt, and cholesterol.
Maintain a healthy weight. Too much weight can put added stress on your heart.
Get at least seven hours of sleep each night and nap during the day if you feel tired.
Quit smoking. If you are having trouble quitting, ask your doctor for help or for additional resources that
can assist you.
