JCU MB4 Term 1 Week 1 (RHD)

1

11yo boy, leg pain on running. BP 165/90, radial pulse 4+, dorsalis pedis pulse 1+.


  Rheumatic heart disease

  ASD

  PDA

  Coarctation of aorta

  Fallot's tetralogy


Differential pulse is a common presentation of coarctation of the aorta.

2

A 42-year-old woman with progressive lower extremity oedema is found also to have a prominent midsystolic flow murmur over the pulmonary area, jugular venous distention, and increased hepatic span. Her chest x-ray shows a prominent right heart border. An example of her cardiac lesion is shown. What is the diagnosis?

ASD


  MI with perforation

  VSD

  PDA

  ASD

  RHD with mitral stenosis


The defect is visible in the centre of the image. The mitral valve is not showing any abnormality - it has normal appearance, being thin and translucent. VSD would be possible with the history, but the picture excludes it.

3

A 54-year-old man with hypertension and a 60-pack-year smoking history has prolonged chest pain radiating to his neck. He abruptly develops severe dyspnoea 3 days later. Examination revelas hypotension and tachycardia, with diffuse rales and a high-pitched holosystolic murmur radiating to the axilla. He dies in florid pulmonary oedema. A picture of his heart at autopsy is shown. What is the cause of pulmonary oedema?

Mitral valve papillary muscle rupture


  ARF with rupture

  RHD-MS

  MI-MR

  RHD-AS

  RHD-MR


Holosystolic (pan-systolic) murmur is indicative of mitral regurgitation, distinguished from tricuspid regurtiation by the fact that it radiates to the axilla. The image shows papillary muscle rupture, which usually happens within the first 9-10 days after a myocardial infarction.

4

13-year-old female, fever, joint pain. Heart specimen shown. What gross feature is shown?

Fibrinous pericarditis


  ARF vegetations

  Ashoff bodies

  Pancarditis

  Endocarditis

  Pericarditis

5

22-year-old male, SOB 5y. Picture shows mitral valve. What is the diagnosis?

Chronic RHD - Mitral Valve


  Rheumatic vegetations

  Chronic RHD

  SBE

  Aschoff bodies

  Floppy mitral valve


The picture shows valve deformity (due to fibrous tissue). Rheumatic vegetations occur only with Acute Rheumatic Fever (usually after a few weeks). In that case, the mitral valve would appear transparent with vegetations along the bottom border.

6

12-year-old female, fever 2 weeks, knee pain. Picture shows mitral valve. What is the diagnosis?

ARF - Mitral valve vegetations


  Rheumatic vegetations

  Chronic RHD - MS

  Infective vegetations (SBE)

  Thrombotic vegetations

  Bacterial endocarditis


The picture shows vegetations lining the border of the valve, and the history is consistent with Acute Rheumatic Fever. Infective vegetations would present with destruction of the valve and irregular yellowish-red vegetations in clumps.

7

26-year-old female, SOB. Picture shows the mitral valve, viewed from the left atrium. What is the diagnosis?

Chronic RHD - Mitral stenosis


  Acute Rheumatic Carditis

  Rheumatic Heart Disease

  Atrial Septal Defect

  Rheumatic Pancarditis

  Ventricular Septal Defect


The picture shows the RHD secondary complication of infective endocarditis. In ARF, the valve would be translucent with vegetations lining the valve border.

8

10-year-old girl, 2 weeks following URTI develops skin nodules over elbow, friction rub, knee and hip joint pain. She is tired and weak. Which of the following serum findings is most characterist of this condition?


  Elevated cardiac troponin

  Positive ANA test

  Elevated creatinine

  Elevated ESR

  Elevated ASO level


The history is consistent with ARF, in which ASO is the most specific because it is specific to Streptococci. Elevated ESR is not wrong, but ASO is better.

9

A 40-year-old woman with congential bicuspid valve receives an aortic valve bioprosthesis. Four months later, she develops a 3-week history of low-grade fever and malaise. She dies of an embolic cerebrovascular infarct. The bioprosthetic valve at autopsy is shown. What organism do you expect on blood cultures?

Bioprosthetic valve - endocarditis


  Staphylococcus aureus

  Streptococcus viridans

  Mycobacterium tuberculosis

  Streptococcus pyogenes

  Mixed culture


Staphylococcus aureus is usually associated with external infections, e.g. wounds, surgical infections. Internal infections are usually Streptococcus.

10

16-year-old female, SOB. Picture shows the mitral valve. What complication is not shown?

ARF - Mitral Valve


  Fibrotic mitral valve

  Rheumatic vegetations

  Short chordae tendinae

  Aschoff bodies

  Fused chordae tendinae


The picture shows classic RHD. Aschoff bodies are only visible on microscopy, and are found in the myocardium.

11

A 13-year-old boy has been cyanotic since birth with a complex set of cardiac murmurs. Despite surgical shunts, he eventually requires cardiac transplantation; his explanted heart is shown. What congenital heart disease is present?

Fallot's Tetralogy


  Coarctation of the aorta

  VSD

  PDA

  ASD

  Fallot's tetralogy


The picture shows a VSD but the patient has cyanosis. The two major cyanotic heart defects are Fallot's tetralogy and transposition of the great arteries. Other defects may present with cyanosis later on with the development of right-to-left shunt (Eisenmenger's syndrome).

12

10-year-old female, chest tightness, SOB, pulmonary hyperflow. The patient is stable, afebrile and acyanotic. Pulse 88 BPM, sinus rhythm, ECG shows right axis deviation at V1, notched R-wave. Image shows appearance at surgery. What is the likely diagnosis?

Atrial Septal Defect


  VSD

  Fallot's tetralogy

  Coarctation of the aorta

  PDA

  ASD


The patient is not cyanotic, which rules out Fallot's tetralogy. The features may also be indicative of VSD, but the ASD is clearly visible in the image.

13

18-year-old female, fever, joint pain. Heart microscopy shown. What is the circled feature?

Aschoff body


  Rheymatic vegetations

  Aschoff body

  Rheymatic nodule

  Focus of RHD lesion

  Anitschow cells


Aschoff bodies are simply granulomas - central necrosis surrounded by macrophages and T-cells (a granulomatous reaction due to auto-antibodies). Anitschow cells cannot be identified at this magnification.

14

18-year-old female, fever, joint pain. Heart microscopy shown. What is the feature indicated by arrow A?

ARF microscopy with marked features


  Lymphocyte

  Aschoff body

  Fibrinoid necrosis

  Giant cell

  Anitschow cells


A - giant cells, B - necrosis, C - macrophages, D - lymphocytes.

15

A 13-year-old girl develops malaise and fever, an irregular circular rash, and forearm subcutanous nodules 3 weeks after a painful pharyngitis. A new heart murmur and friction rub are heard. Her mitral valve anterior leaflet would appear as shown. What is the diagnosis?

ARF with vegetations


  Chronic RHD

  Bacterial endocarditis

  Acute rheumatic vegetations

  Congenital mitral floppy valve

  Thrombotic vegetations


Note classic presentation of ARF, and the transparency of the mitral valve (despite the appearance of blood valves indicating that this may be one of a recurrent series of attacks). Inflammation suggests vegetation (chronic appearance is only scarring).

16

A 48-year-old woman with a 5-year history of worsening orthpnoea is found on examination to have atrial fibrillation and a rumbling diastolic murmur with opening snap. The gross appearance of her heart at surgical valve replacement is shown. What are the possible complications?

Mitral Valve Stenosis


  Pedal oedema

  LV rupture

  Aneurysm

  Myocardial infarction

  Pulmonary oedema


The picture shows severe mitral stenosis, of which the commonest complications are pulmonary oedema and cardiac failure.

17

A 45-year-old man with a 6-year history of progressive exertional dyspnoea is found by echocardiography to have an ejection fraction 28% (normal is 50-60%) with systolic dysfunction and mitral regurgitation. His native heart after cardiac transplantation is shown. What is the diagnosis?

Dilated Cardiomyopathy


  Bacterial endocarditis (mitral valve)

  Hypertrophic cardiomyopathy

  LV aneurysm

  Toxic cardiomyopathy

  Dilated cardiomyopathy


The presentation is very characteristic of dilated cardiomyopathy, which is also the commonest form of cardiomyopathy. The marked dilation of the heart is readily visible in the image.

18

An infant girlwith a late systolic murmur has upper extremity pulses and blood pressures greater than in her lower extremities. She also has a webbed neck and short fourth metacarpals. If an autospy were performed at this point, we might see a heart and great vessels as shown. What is the cardiovascular lession?

Coarctation of the aorta


  Coarctation of the aorta

  VSD

  PDA

  ASD

  Fallot's tetralogy


The picture and history are characteristic of coarctation of the aorta.

19

One year after a myocardial infarction, a 65-year-old woman has congestive heart failure with an ejection fraction of 25% (normal is 50-75%). She has a sudden embolic stroke and dies; her heart is shown at autopsy. Explain the diminished cardiac output.

MI with long term complications


  Dilated cardiomyopathy

  Hypertrophic cardiomyopathy

  Restrictive cardiomyopathy

  Decreased ventricular function

  Mitral stenosis & regurgitation


The aneurysm is non-contractile due to endocardial fibrosis.

20

52-year-old female with T2DM, presented with fever for 2 weeks and SOB. Her mitral valve is shown in the images. What is the cause of her presentation?

Mitral valve - bacterial destruction


  Rheymatic mitral stenosis

  Congenital floppy valve

  Congenital calcific valve

  Thrombotic vegetations

  Bacterial vegetations


Destruction and perforation are characteristic of infective endocarditis. If the vegetations were thrombotic there would be no perforations.

21

38-year-old male, died 7 days following sudden sever chest pain in the hospital. The image shows his heart at autopsy. What is the diagnosis?

Cardiac tamponade


  Marfan syndrome

  Coronary occlusion

  Malignant melanoma

  Dilated cardiomyopathy

  Penetrating chest trauma


Young age with sudden severe chest pain indicates aortic dissection, which is very common in Marfan's syndrome. However, this would result in accumulation of blood outside the pericardium, whereas the picture shows blood inside the pericardium, which would result in cardiac tamponade. Therefore the mostly likely cause of death is myocardial infarction secondary to coronary occlusion.

22

A 30-year-old intravenous drug user with a 2-day history of fever is found to have coard systolic and diastolic murmurs, splenomegaly, and nail bed splinter haemorrhages. His CK-MB is elevated. He experiences sudden cardiac arrest. His aortic valve at autopsy is shown. Why did he die?

Endocardial infective vegetations


  Septicaemia

  Haemorrhage

  Aneurysm of aorta

  MI

  Thromboembolism


While the picture shows extensive descruction characteristic of infective endocarditis (also consistent with the history) which could lead to septicaemia, the elevated CK-MB and sudden death point to myocardial infarction as the primary cause of death. In this case, it is likely caused by blockage of the coronary sinus due to the bacterial vegetations.