Title: CARDIOVASCULAR PATHOLOGY
1CARDIOVASCULAR PATHOLOGY
- Tutorial II
- William H. Luer M.D.
2TOPICS
- Endocarditis
- Myocarditis
- Pericardial disease
3ENDOCARDITISCAUSES
- Rheumatic fever (covered in lecture)
- Infection
- Non-infective
- Nonbacterial thrombotic endocarditis
- Endocarditis of systemic lupus
- erythematosis (SLE)
- Carcinoid heart disease
-
4INFECTIVE ENDOCARDITIS
- Definition the infection of the endocardium
(esp. heart valves) by a microbiological agent,
with the formation of thrombotic debris and
organisms known as vegetations.
5INFECTIVE ENDOCARDITIS CAUSES
- Bacteria, most common
- Fungi
- Rickettsiae (Q fever)
- Chlamydiae
6CAUSES OF BACTERIAL ENDOCARDITIS
- Alpha-hemolytic streptococci esp. with damaged
or otherwise abnormal native valves - Staphylococcus aureus healthy or deformed
valves, esp. in intravenous drug abusers - Coagulase-negative staphylococci esp. with
prosthetic valves - HACEK group Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, Kingella
(commensals of oral cavity) - Gram-negative bacilli
7PREDISPOSING FACTORS FOR INFECTIVE ENDOCARDITIS
- Rheumatic heart disease
- Myxomatous mitral valve
- Calcific valvular stenosis
- Bicuspid aortic valve
- Artificial (prosthetic) valve (but may develop on
previously normal valve)
8PREDISPOSING FACTORS (CONT.)
- Neutropenia
- Immunodeficiency
- Therapeutic immunosuppression
- Diabetes mellitus
- Alcohol or IV drug abuse
- Sepsis
- Invasive procedures
9PATHOLOGY OF INFECTIVE ENDOCARDITIS
- Vegetations of fibrin, inflammatory cells,
bacteria or other organisms - Vegetations located most commonly on heart
valves, esp. aortic mitral - Vegetations may erode perforate valve, may
erode into underlying myocardium to produce an
abscess (ring abscess) - Vegetation may produce emboli that produce septic
infarcts in brain, kidney, myocardium, other
organs
10Vegetation
Stick in Perforation
Mitral Valve
Infective endocarditis with perforation of
mitral valve leaflet
11 Microscopic View of Vegetation of Endocarditis,
Fibrin Inflammatory Cells
12CLINICAL FEATURES OF INFECTIVE ENDOCARDITIS
- Fever, chills
- Fatigue, weight loss, flu-like syndrome
- Murmur (may change as vegetation and/or damage to
valve changes) - Petechiae
13COMPLICATIONS OF INFECTIVE ENDOCARDITIS
- Valvular insufficiency or stenosis with resulting
congestive heart failure - Myocardial ring abscess
- Suppurative pericarditis
- Septic infarcts abscesses
- Focal diffuse glomerulonephritis
14NONBACTERIAL THROMBOTIC ENDOCARDITIS (NBTE)
- Definition The deposition of sterile
vegetations on the leaflets of cardiac valves,
also called MARANTIC ENDOCARDITIS
15NBTE PATHOLOGY
- Vegetations of fibrin, platelets, other blood
elements (i.e.. a thrombus) - Vegetations are sterile, nondestructive,
noninflammatory small (1-5mm) - Vegetations occur singly or multiply along the
lines of closure of heart valves
16NBTE PATHOGENESIS
- Probably occurs as a consequence of a
hypercoagulable state - Seem with concomitant venous thrombosis /or
pulmonary embolism - May be seen with hyperestrogenic state, extensive
burns, or endocardial trauma from indwelling
catheters
17NBTE CLINICAL
- Local effect on valve unimportant
- May produce emboli with resultant infarcts
- May eventually organize leaving delicate strands
of fibrous tissue
18ENDOCARDITIS OF SLE
- Also known as Libman-Sacks endocarditis
- Small sterile vegetations on mitral tricuspid
valves or fibrous thickenings occurring with the
antiphospholipid syndrome - Circulating antiphospholipid antibodies also
associated with venous or arterial thrombosis,
recurrent pregnancy loss, and thrombocytopenia
19PATHOLOGY OF SLE ENDOCARDITIS
- Vegetations are small (1-4 mm), single or
multiple, sterile, granular, and pink - Frequently located on the undersurfaces of AV
valves, but may be elsewhere on valves or even on
mural endocardium of atria or ventricles - Vegetations consist of finely granular fibrinous
eosinophilic material - May have valvulitis, characterized by fibrinous
necrosis, contiguous with vegetation - Can result in fibrosis and valve deformity that
can resemble chronic rheumatic heart disease
20CARCINOID HEART DISEASE (CarHD)
- Seen in one half of patients with carcinoid
syndrome (episodic skin flushing, cramps, nausea,
vomiting, and diarrhea) - Involves endocardium and valves of the right side
of the heart
21CarHD PATHOLOGY
- Intimal thickenings on the inside surfaces of the
cardiac chambers valvular leaflets, mainly on
the right side of the heart - Thickenings consist of smooth muscle cells
sparse collagen fibers embedded in an acid
mucopolysaccharide rich matrix that expands the
endocardium - Underlying structure of the heart intact
22CarHD PATHOPHYSIOLOGY
- Carcinoid tumors produce a variety of bioactive
products including serotonin, kallikrein,
bradykinin, histamine, prostaglandins,
tachykinins - Serotonin appears to induce the cardiac lesions
23CarHD LOCATION
- Lesions are usually right sided since serotonin
inactivated by pulmonary vascular endothelial
monoamine oxidase - Can see left sided lesions if have high levels of
serotonin not completely inactivated by lungs,
pulmonary carcinoid, or right to left cardiac
shunts
24CARCINOID-LIKE HEART LESIONS
- Left sided lesions can be seen with methysergide
or ergotamine treatment for migraine headache
since these serotonin analogs are metabolized to
serotonin by lungs - Left sided lesions can be seen with fenfluramine
phemtermine (fen-phen) appetite suppressants
since they affect serotonin metabolism
25MYOCARDITIS
- Definition inflammatory processes of the
myocardium that result in injury to the cardiac
myocytes.
26CAUSES OF MYOCARDITIS INFECTIONS
- Viruses (e.g., coxsackie, ECHO, HIV)
- Chlamydia (e.g., C. psittaci)
- Rickettsiae (e.g., R. typhi)
- Bacteria (e.g., C. diphtheria)
- Fungi (e.g., Candida)
- Protozoa (e.g., toxoplasmosis)
- Helminths (e.g., trichinosis)
27CAUSES OF MYOCARDITIS IMMUNE-MEDIATED
- Postviral
- Poststreptococcal (rheumatic fever)
- Systemic lupus erythematosus
- Drug hypersensitivity (e.g., methyldopa,
sulfonamides) - Transplant rejection
28CAUSES OF MYOCARDITIS OTHER
- Sarcoidosis
- Giant cell myocarditis
29MYOCARDITIS GROSS PATHOLOGY
- Heart may appear normal or dilated, some
hypertrophy may be present - Ventricular myocardium may be flabby and mottled
by pale foci and/or minute hemorrhage foci - May have mural thrombi
30MYOCARDITIS MICROSCOPIC PATHOLOGY
- Interstitial inflammatory infiltrate, may be
patchy, most commonly have mononuclear cell
infiltrate, predominantly lymphocytes - Focal necrosis
- Hypersensitivity myocarditis has lymphocytes,
macrophages, eosinophils - Giant cell myocarditis has multinucleated giant
cells with lymphocytes, eosinophils, plasma
cells, macrophages with necrosis
31MYOCARDITIS MICROSCOPIC PATHOLOGY (cont.)
- Healing myocarditis results in fibrosis
- Chagas disease has parasitization of myofibers by
Trypanosomes with neutrophils, lymphocytes,
macrophages, and eosinophils
32MYOCARDITIS CLINICAL
- Fatigue, dyspnea, palpitations, precordial chest
pain, fever - Can be asymptomatic
- Heart failure, dilated cardiomyopathy
- Arrhythmias
- Mitral regurgitation
- Can result in sudden death
33PERICARDIAL DISEASE
- Pericardial effusion
- Pericardial hemorrhage
- Pericarditis
34PERICARDIAL EFFUSION
- Distention of pericardial sac by transudate
- Causes include infection, autoimmune disease,
congestive heart failure, renal failure,
malignancy, myocardial infarction, drugs, and
radiation - Clinically may see low blood pressure, dyspnea,
dizziness, and chest pain - If fluid compresses heart get cardiac tamponade
with severe decrease in cardiac output
35PERICARDIAL HEMORRHAGE
- Bleeding into the pericardial sac
- Causes include cardiac rupture from myocardial
infarction or perforating trauma and ruptured
aortic dissection - May produce compression of the heart with
resulting cardiac tamponade
36PERICARDITIS TYPES
- Serous pericarditis
- Fibrinous serofibrinous pericarditis
- Purulent or suppurative pericarditis
- Hemorrhagic pericarditis
- Caseous pericarditis
- Adhesive mediastinopericarditis
- Constrictive pericarditis
37PERICARDITIS CAUSES
- Infections
- Rheumatic fever
- Autoimmune disease
- Drug reaction
- Myocardial infarction
- Uremia
- Malignancy
- Radiation
38SEROUS PERICARDITIS
- Characteristically produced by noninfectious
inflammations (e.g. rheumatic fever, SLE,
scleroderma, tumors, uremia) - May be produced by adjacent infection (e.g.
bacterial pleuritis) - Microscopically see inflammatory reaction in
epicardium and pericardium with PMNs,
lymphocytes, and histiocytes - Slow leakage of fluid of high specific gravity
rich protein content into pericardial sac, (about
50-200 ml)
39FIBRINOUS SEROFIBRINOUS PERICARDITIS
- Most frequent types of pericarditis
- Composed of serous fluid mixed with a fibrinous
exudate - Common causes include acute myocardial
infarction, uremia, radiation, rheumatic fever,
SLE, trauma, postinfarction syndrome
40FIBRINOUS SEROFIBRINOUS PERICARDITIS (CONT)
- In fibrinous pericarditis, have finely granular
pericardial surface may produce a pericardial
friction rub - In serofibrinous pericarditis, inflammation leads
to leakage of fluid inflammatory cells into
pericardial sac in addition to fibrin - Fibrin may be digested or organize
41 Granular Visceral Pericardial
Surface of Fibrinous Pericarditis
42PURULENT OR SUPPURATIVE PERICARDITIS
- Pus in pericardial sac usually from infective
organisms - Acute inflammatory reaction involving pericardium
with purulent exudate - If survive usually organizes, may produce
constrictive pericarditis
43HEMORRHAGIC PERICARDITIS
- Blood mixed with fibrin or pus
- Can be seen with tuberculosis and other bacterial
infections, malignancy, and following cardiac
surgery
44CASEOUS PERICARDITIS
- Usually due to tuberculosis
- Caseous granulomatosis inflammation involves the
pericardium - May lead to fibrocalcific chronic constrictive
pericarditis
45ADHESIVE MEDIASTINOPERICARDITIS
- May follow suppurative or caseous pericarditis,
cardiac surgery, or mediastinal radiation - Pericardial sac obliterated adherence of the
outer portion of the parietal pericardium to
surrounding structures produces great stain on
cardiac function - Increased work on heart leads to cardiac
hypertrophy and dilatation
46CONSTRICTIVE PERICARDITIS
- May follow suppurative, hemorrhagic, or caseous
pericarditis - Pericardial sac obliterated heart surrounded by
dense adherent layer of scar tissue with or
without calcification (if extreme encasement
called concretio cordis) - Encasing scar limits diastolic expansion of heart
leading to decreased cardiac output