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A 40-year-old man had rheumatism since childhood. Rheumatic defect of the left atrioventricular valve of the heart was diagnosed in the patient. He was admitted to a hospital with activation of rheumatic process and manifestation of chronic cardiovascular failure. On admission, he presented with marked cyanosis; edema of the lower extremities, enlargement of the liver (the liver edge was 9 cm below the costal margin). He suddenly developed left-side hemiplegia. The patient died of cardiovascular failure progression. 1. What clinicomorphological form of rheumatism was present in the patient? Cardiovascular 2. What changes of the mitral valve can be found in rheumatic heart disease? Sclerosis of valvular cusps and stenosis of the cerebral of mitral valve 3. What changes of this valve can be diagnosed in an attack of rheumatic process? Reverse warty endocarditis 4. What change in the brain was the cause of hemiplegia? Ischemic infarction of the brain 5. What is the cause of this change in the brain? Thromboembolism of the cerebral arteries 6. What is the name of the liver in chronic cardiovascular failure? Nutmeg liver

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rheumatic heart disease AND pathology

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rheumatic heart disease pathology verrucous endocarditis mitral stenosis cerebral embolism

Your answers are largely correct, with a few terminology corrections.
  1. Clinicopathological form:
    Cardiovascular form of rheumatism, specifically chronic rheumatic heart disease with recurrent active rheumatic endocarditis/pancarditis and decompensated chronic heart failure.
  2. Chronic mitral-valve changes in rheumatic heart disease:
    • Fibrous thickening and sclerosis of the cusps
    • Fusion of commissures
    • Thickening, fusion, and shortening of chordae tendineae
    • Often calcification
    • Resulting in a narrowed, funnel-shaped "fish-mouth" mitral stenosis. Rheumatic mitral disease commonly evolves from early regurgitation to later stenosis, as described in this pathology review.
  3. Valve change during an acute rheumatic attack:
    Recurrent verrucous (warty) endocarditis. Small sterile vegetations form along the line of valve closure. Not “reverse warty endocarditis.”
  4. Brain lesion causing left hemiplegia:
    Ischemic cerebral infarction, most likely in the right cerebral hemisphere, because motor pathways cross.
  5. Cause of cerebral infarction:
    Thromboembolism of a cerebral artery, usually from a mural thrombus in the dilated left atrium or left atrial appendage in rheumatic mitral stenosis. Atrial fibrillation, if present, further increases this risk.
  6. Liver appearance in chronic congestive heart failure:
    Nutmeg liver, meaning chronic passive venous congestion of the liver. Long-standing severe congestion may progress to cardiac cirrhosis.

Pancarditis

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rheumatic heart disease AND pancarditis

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acute rheumatic fever pancarditis endocarditis myocarditis pericarditis

Yes. For question 1, the expected answer is:
Cardiovascular form of rheumatism: recurrent rheumatic pancarditis.
Pancarditis means inflammation of all three layers of the heart:
  • Endocarditis: verrucous endocarditis of the mitral valve
  • Myocarditis: may cause progressive heart failure
  • Pericarditis: usually fibrinous pericarditis
The chronic consequence is rheumatic mitral stenosis due to fibrous scarring, commissural fusion, and deformity of the valve. This is consistent with Robbins & Kumar Basic Pathology, which describes rheumatic fever as causing pancarditis.
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