Patients with mitral stenosis may or may not have a history of rheumatic fever, but the classic pathology and echocardiographic morphology must be appreciated. After initial medical management, the criteria for timing of intervention may include pulmonary hypertension in addition to symptoms of dyspnea. More importantly, physicians should know the impact of valve morphology, various scoring systems, and their corresponding hemodynamic and echocardiographic features that influence the short- and long-term outcomes of the valvuloplasty or valve replacement and help in informed decision-making.

Summary : This figure illustrates the pathophysiology and clinical presentation of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), and shows a histological image of Aschoff bodies in myocardium. flowchart and photo: # Panel A: Pathophysiology and Clinical Presentation Flowchart ## Nodes : • Streptococcus pyogenes infection (text node) • Tonsillopharyngitis (rectangle) • Antibody develops to molecules in bacterial group A carbohydrate or streptococcal M protein (rectangle) • Antibody recognizes same molecules present on the heart, brain, joints and/or skin in susceptible host (rectangle) • Infiltration of autoreactive T cells and inflammation (rectangle) • Erythema marginatum, Subcutaneous nodules (rectangle, branch) • Carditis (rectangle, branch) • Chorea (rectangle, branch) • Arthritis (rectangle, branch) • Valvulitis (rectangle) • Autoreactive T cells continually activated by cardiac proteins that serve as antigens (rectangle) • Chronic inflammatory response to cardiac tissue (rectangle) • Valvular stenosis and regurgitation (rectangle) • Cardiac chamber dilation (rectangle, branch) • Pulmonary hypertension (rectangle, branch) • Arrhythmia (rectangle, branch) • Heart failure (rectangle, branch) ## Connectors : • Linear downward arrows connect each main step. • Branching arrows from "Infiltration of autoreactive T cells and inflammation" to four clinical features: erythema marginatum/subcutaneous nodules, carditis, chorea, arthritis. • Branching arrows from "Valvular stenosis and regurgitation" to four complications: cardiac chamber dilation, pulmonary hypertension, arrhythmia, heart failure. ## Layout : • Vertical, left-to-right flow with two main phases: ARF (2–4 weeks) and RHD (years). • Branches at clinical presentation and complications. • Timeline markers on the right: "2–4 weeks" for ARF, "Years" for RHD. # Panel B: Histological Image ## Scene Overview : • Main subject: Myocardial tissue section stained with hematoxylin-eosin. • Central focus: Cluster of cells (Aschoff body) within pink-stained cardiac muscle fibers. • Colour palette: Pink (muscle), purple/blue (nuclei and inflammatory infiltrate). ## Technical Details : • Staining: Hematoxylin-eosin. • Magnification and scale bar: Not specified. • Tissue: Myocardium. ## Spatial Relationships : • Aschoff body is centrally located, surrounded by elongated muscle fibers. • Dense cellular infiltrate contrasts with the striated background. # Analysis : • The flowchart in Panel A details the progression from streptococcal infection to autoimmune-mediated heart damage, highlighting both acute and chronic clinical manifestations and complications. • The histological image in Panel B visually confirms the presence of Aschoff bodies, a hallmark of rheumatic carditis, within the myocardium.

Clinical photograph showing the dorsal surface of a human hand, specifically focusing on the interphalangeal joints. Two prominent subcutaneous nodules are visible over the joint space, indicated by black arrows. These nodules appear as firm, well-circumscribed, painless elevations under the skin. They are flesh-colored to slightly pale, with smooth overlying skin and no signs of acute inflammation, erythema, or ulceration. This finding is a characteristic major Jones criterion for the diagnosis of acute rheumatic fever. The image serves as an educational tool for identifying extra-articular manifestations of rheumatological and post-streptococcal conditions in a clinical setting.

I. INTRODUCTION II. EPIDEMIOLOGY OF RHEUMATIC HEART DISEASE III. BASIC CONCEPTS OF PATHOPHYSIOLOGY, CLINICAL PRESENTATION, AND SCREENING III.A. Pathophysiology and Clinical Presentation III.B. Echocardiographic Screening in Acute Rheumatic Fever Key Points Recommendations IV. RHEUMATIC VALVE LESIONS IV.A. Mitral Stenosis IV.A.1. Anatomic Considerations in the Assessment of Mitral Stenosis IV.A.2. Hemodynamic Considerations in the Assessment of Mitral Stenosis IV.A.3. Mitral Stenosis in Pregnancy Key Points Recommendations IV. B. Rheumatic Mitral Regurgitation IV.B.1. Anatomic Considerations in the Assessment of Rheumatic Mitral Regurgitation IV.B.2. Hemodynamic Considerations in the Assessment of Rheumatic Mitral Regurgitation Key Points Recommendations IV.C. Rheumatic Aortic Valve IV.C.1. Anatomic Considerations in the Assessment of the

This clinical photograph shows a gross pathological specimen of a human heart, specifically an atrial view of the mitral valve. The image demonstrates hallmark signs of chronic rheumatic heart disease. Key features include significant thickening and fibrosis of the valve leaflets, resulting in a 'fish-mouth' or 'buttonhole' appearance of the valvular orifice. There is evidence of extensive commissural fusion and multiple focal areas of yellowish-white calcification along the leaflet margins and within the valve body. These structural changes characterize severe mitral stenosis, where the restricted opening of the valve impairs blood flow from the left atrium to the left ventricle. The surrounding atrial endocardium appears thickened, consistent with chronic pressure overload. This visual is highly representative for educational purposes in cardiology and pathology to illustrate the long-term sequelae of rheumatic fever on cardiac valves.

This clinical photograph displays a close-up view of the right upper extremity, specifically the extensor surface of the elbow region. The primary clinical finding is the presence of multiple, small subcutaneous nodules. These nodules appear as firm, rounded, non-tender-looking elevations beneath the skin surface, typically measuring less than 1 cm in diameter. The overlying skin is intact, displaying normal pigmentation and texture without visible erythema, warmth, or ulceration. Prominent hair follicles are visible as dark punctate spots across the skin. In a clinical context involving polyarthralgia and carditis, these nodules are a major Jones criterion for the diagnosis of acute rheumatic fever (ARF). This image serves as a teaching tool for medical students and clinicians to recognize the dermatological manifestations of systemic streptococcal-related diseases and rheumatological disorders.