CVS

MICROBIoLOGY
SYLLABUS
Acute Rheumatic Fever/ Rheumatic heart Disease: (P. 877)
Aetiopathogenesis (P. 877), clinical features, laboratory diagnosis (P. 878)
Infective Endocarditis: (P. 878)
Types of endocarditis, predisposing factores, Causative agents (Streptococcus viridians, Staphylococci, Gram
Negative bacilli, HACEK group (haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
Collection of appropriate specimen, Laboratory diagnosis (P. 880)

III

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III

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MICROBIOLOGY

RHEUMATIC FEVER & RHEUMATIC Etiopathogenesis [10, 08, 06, 05, 04]
HEART DISEASE  Group A β- hemolytic Streptococcus
Past Questions:
Pathogenesis
1. Define rheumatic heart disease (RHD). Explain
Pharyngitis by group-A, β hemolytic Streptococcus
the aetiopathogenesis of RHD and its Laboratory

diagnosis. (2+4+4=10) [08 Jan]
M1 protein of Streptococcus pyogens released in
2. Describe aetiology and pathogenesis
circulation
(aetiopathogenesis) of acute rheumatic fever and

its laboratory diagnosis.
Symptoms of pharyngitis subside in 97%
(4+6=10,2+3+5=10) [10 July, 06 June, 05 June, 04 June]

3. Describe the Laboratory diagnosis and In 0.3 to 3% people, after 3-5 weeks development of
interpretation of findings of acute rheumatic antibodies against M1-protein by host immune system 
fever. (1+5+4=10) [04 Dec]

4. Acute Rheumatic heart disease [10 Jan] Molecular similarity between m1 protein and human
5. Rheumatic heart disease cell membrane, hence antibodies directed against m1
[08 July, 06 June, 02 June] protein cross react with glycoprotein antigens in
6. Laboratory diagnosis of rheumatic heart disease. heart, joint, skin and brain
III
(5) [11 July] 
7. Rheumatic fever [09 July] Rheumatic fever

Definition
On second attack, with same bacteria, reactivation of
 Rheumatic fever: immune system
- Multi system, immune mediated non 
suppurative acute inflammation, which occurs Cross reaction takes place
2-4 weeks after pharyngitis by group A 
Streptococcus  hemolyticus is called acute Continuous progressive damage to heart result in
rheumatic fever. permanent damage to heart valves and myocardium
- Occurs in children between 5 and 15 years 
- Repeated rheumatic fever may progress to Rheumatic heart disease
chronic rheumatic heart disease, of which
M1 protein in bacterial surface resembles:
valvular abnormalities are key manifestations. Endocardium: Tropomyosin
 Rheumatic heart disease: Valves: Laminin
- A condition in which permanent damage Joint: Vimentin
occurs to heart as a consequence of rheumatic Skin: Keratin
fever Brain: Lyso gangliosides

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 Microbiology

Diagnosis MINOR crITERIA

1. Lab Diagnosis [11, 10, 08, 06, 05, 04] - Inflammatory cells, leukocytes

a. ASO (Anti Streptolysin O) test - Temperature high i.e. fever

- Confirmatory test for ARF - ESR/CRP increased
Test: - Raised or prolonged PR interval
- 1 drop serum + commercially available Ag - Itself i.e. previous history of rheumatic fever
(ASO-reagent)
- Athralgia (joint pain)
 
Mix and observe after 2 minutes Investigation
Result:  Chest x-ray
Clumping : Positive
- Cardiomegaly
No clumping: Negative
- Pulmonary congestion
For Diagnosis:
- Rise of ASO titre more than 4 times or  ECG
>300 in children - First degree heart block
> 200 in adult - Features of pericarditis
b. Histology - T wave inversion
- Aschoff’s body demonstration
- Reduction in QRS complexes
- Occasional plasma cells
- Plump activated macrophages i.e. Anitschkow  Echocardiography
cell (caterpillar cell) - Cardiac dilation
Note: Aschoff’s bodies are foci of lymphocytes - Valve abnormalities
III c. CRP (C-reactive protein) increases (but not
confirmatory)
d. Culture
INFECTIVE ENDOCARDITIS
- Negative Past Questions:
- Because Streptococcus pyogens won’t appear 1. Define infective endocarditis. Describe the
in the body after 5 weeks
laboratory diagnosis of endocarditis.
e. Anti-DNAse B test
(2+8=10) [10 Jan]
2. Clinical Diagnosis
2. Define bacterial/ infective endocarditis. Write
 Jone’s criteria:
Group A Streptococci infection +2 major criteria the pathogenesis and Laboratory diagnosis of
Or infectious endocarditis.
Group A Streptococci infection +1 major +2 minor (2+4+4=10, 2+3+5=10) [08 July, 05 Dec]
criteria 3. Name the agents producing bacterial
MAJOR CRITERIA endocarditis. Describe in detail laboratory
J - Joint: Migratory polyarthritis diagnosis of the disease. (5+5=10) [03 Dec, 02 Dec]
 - Heart: Pancarditis 4. Describe the laboratory diagnosis of Bacterial
N - Nodules: Sub-cutaneous nodules endocarditis. (5) [10 July]
E - Erythema marginatum 5. Infective endocarditis
S – Syndenham’s chorea (saint vitus dance)
[08 Jan, 06 June, 05 June, 04 June]

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 Exudative and progressive inflammatory Pathogenesis [08, 05]

alterations of the endocardium
Congenital heart disease Infection of virulent
 Characterized by colonization and invasion of or any valvular deformity organism
heart valve or mural endocardium by microbe
 
 Most cases are caused by bacteria
Less virulent organism Reach to valve via blood
Classification (On the clinical basis) colonize and get and adhere there
a. Acute IE protected by thrombus
- Infection of previously normal valve by highly 
virulent organism Pathogen - host tissue interaction
- Produce necrotizing, destructive and ulcerating 
lesion Vegetation formation and local tissue damage
- Difficulty to treat with antibiotics, they need 
surgery Dissemination of infection to other tissue sites and
elicitation of systemic findings
Cause [03, 02]
Clinical Diagnosis
- Staphylococcus aureus (25%)
- Streptococcus pneumoniae (10%) Duke’s Criteria
MAJOR CRITERIA:
- Streptococcus pyogenes
1. Positive blood culture for Infective Endocarditis
- Streptococcus agalactie
- Typical microorganism consistent with IE from
b. Subacute IE
2 separate blood cultures, as noted below:
- Infection to deformed valve by organism of
• Streptococcus viridans, Streptococcus bovis III
lower virulence or HACEK group or
- Respond to antibiotics treatment • Community-acquired Staphylococcus
Cause [03, 02] aureus or Enterococci, in the absence of a
a. Bacteria: primary focus
- Streptococcus viridans (60-80%) or
• Microorganisms consistent with IE from
- Staphylococcus epidermidis (10%)
persistently positive blood cultures defined as:
- HAECK (Commensals of oral cavity)
a. 2 positive cultures of blood samples
 Hemophilus parainfluenza drawn >12 hours apart, or
 Actinogacillus b. All of 3 or a majority of 4 separate
 Eiknella cultures of blood (with first and last
sample drawn 1 hour apart)
 Cardiobacterium
2. Evidence of endocardial involvement
 Kingella
- Positive echocardiogram for IE defined as:
b. Fungi:
• Oscillating intracardiac mass on valve or
- Candida albicans supporting structures, in the path of
- Aspergillus regurgitant jets, or on implanted material in
the absence of an alternative anatomic
explanation, or

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• Abscess, or b. Processing
• New partial dehiscence of prosthetic valve - Blood culture bottle are incubated
or aerobically at 370c and blind subcultures are
- New valvular regurgitation (worsening or made on 24 hrs, 48 hrs, 72 hrs, 6th day and
changing of preexisting murmur not sufficient) 10th day.
MINOR CRITERIA: - The subcultures are made on.
1. Predisposition: Predisposing heart condition or  Blood agar
intravenous drug use
 Macconkey agar
2. Fever: Temperature >38.0oC (100.4oF)
 Chocolate agar
3. Vascular phenomena: major arterial emboli,
 Saboraud’s dextrose agar
septic pulmonary infarcts, mycotic aneurysm,
c. Inspection
intracranial hemorrhage, conjunctival
hemorrhages, and Janeway lesions - Inspected twice daily for sign of growth

4. Immunologic phenomena: glomerulonephritis,  Floccular deposit on the top of broth

Osler's nodes, Roth spots, and rheumatoid factor layer

5. Microbiological evidence: Positive blood culture  Uniform turbidity

but does not meet a major criterion or serological  Hemolysis
evidence of active infection with organism  Coagulation of broth
consistent with IE  Surface pellicle
6. Echocardiographic findings: consistent with IE but  Production of gas
do not meet a major criterion as noted above
iii. Non- specific findings
III Clinical criteria for infective endocarditis:
- Anemia
- Two major criteria, or
- Leucocytosis
- One major and three minor criteria, or
- Microscopic hematuria
- Five minor criteria
- Elevated ESR
Lab-Diagnosis [10, 08, 05, 03, 02] - Elevated C- reactive protein
i. Sample collection - Circulating immune complexes
- Best sample collected during febrile period - Decreased serum complement
- 3 to 6 sample collected over 24 hours Investigations
- Different samples collected at different sites
 Chest x-ray
and different time
- Cardiomegaly
ii. Blood culture
- Cardiac failure
a. Blood inoculation
 ECG
 10 ml of blood is inoculated in blood culture
- AV block
bottle as:
 Echocardiography
a. 1st 5 ml with 50 ml glucose broth
- Detection and progression of vegetation
b. 5 ml with 50ml bile broth
[Ratio 1:10]

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Rheumatic Heart Disease V/S Infective Endocardities

Rheumatic Heart Disease Infective Endocardities
a. Immune mediated a. Infection mediated
b. Chronic valvular heart disease produced by recurrent b. Acute infection caused by infection of endocardium,
rheumatic fever. cardiac valves and rarely extracardiac vascular
endothelium.
c. Commonly affected age group: 5-15 years c. All age groups are equally affected.
d. It is preceded by Streptococcal pharyngitis. d. It may or may not preceded by infection.
e. Causative agents: Group A- β- hemolytic e. Causative agent:
Streptococcus - Acute: Staphylococcus aureus, Streptococcus
pyogens
- Subacute: Viridans group, Enterococcus, HAECK
group
f. Causes pancardititis f. Does not cause pancardititis
g. Vegetation: g. Vegetation:
- Macroscopic: Small, multiple, warty, grey - Macroscopic: Large, single or multiple, grey,
- Microscopic tawny to greenish, irregular
i. Composed of fibrin with superimposed platelet - Microscopic
thrombi with no bacteria i. Outer eosinophilic layer
ii. Endocardium show edema ii. Underneath this layer is basophilic zone
containing bacterial colonies.
iii. Aschoff bodies are present III
iv. Anitschowk cells are present iii. Deeper zone consists of non specific
inflammatory reaction.
h. For clinical diagnosis: Jone’s criteria h. For clinical diagnosis: Duke’s criteria
i. Subcutaneous nodules i. Subcutaneous nodules
- Present in the back of the wrists outside the - Present in the pulps of finger, in the palmar
elbow and front of knees surface and soles of foot
- Painless, firm - Painful

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SPECIAL POINTS FOR MCQs

1. Rheumatic Endocarditis is immune mediated inflammation of endocardium.
2. Infective Endocarditis (IE) is microorganism mediated inflammation of endocardium.
3. Most common bacteria causing acute infective endocarditis is Staphylococcus aureus.
4. Most common bacteria causing subacute IE is Streptococcus viridans.
5. Most common organism causing IE in i.v. drug users is Staphylococcus aureus.
6. Most common organism causing IE in person with prosthetic valve is Staphylococcus epidermidis.
7. Most common organism causing IE in person with recent heart surgery is Staphylococcus aureus
and coagulase negative Staphylococcus.
8. Most severe form of IE is fungal infective endocarditis.
9. Regurgitant defect in valve are more prone to IE than stenotic defect.
10. HAECK group (Haemophilus, Actinobacillus, Eikenella, Cardiobacterium, Kingella) are commensals in
oral cavity and are responsible for IE latter to dental surgery.
11. In Rheumatic fever, complement level is unaffected.
12. Most common age group in Rheumatic fever is 5-15 years.
13. Cross reaction in Rheumatic fever is Type II hypersensitivity reaction.
III
14. Penicillin prophylaxis is essential in Rheumatic fever.
15. In Rheumatic fever, rise of ASO titre more than four folds or >300 in children and >200 in adult.

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