Studies on Rheumatic Carditis With Special Reference to Sub-Clinical Rheumatism

Lannigan, Robert (1956) Studies on Rheumatic Carditis With Special Reference to Sub-Clinical Rheumatism. MD thesis, University of Glasgow.

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In a group of 175 with mitral valve disease submitted to valvotomy, changes suggesting an active disease process were present in 64 per cent of cases. Of the patients showing active disease 23 per cent showed lesions which do not appear to have reached the stage of developed Aschoff type lesions. In a proportion of patients (8%) the lesions are of the earliest type described in rheumatic disease as mucoid oedema, and 15% show lesions in which the earliest type of change in the collagen is present. The changes in the collagen correspond to the changes described by Gross and Ehrlich as preceding the formation of the coronal type of Aschoff body and differ in appearance from the reticular Aschoff body which I believe corresponds to the rheumatic "Fruhinfiltrat" of Klinge. A fibrin staining component was not detected in any of the auricular appendages, reliance being placed on Mallory's phosphotungstic acid haematoxylin stain which requires no differentiation. Preceding any detectable alteration in the collagen there is an accumulation of acid mucopolysaccharide in the tissue spaces and this persists but in reduced amount to the later tyres of lesions. The altered collagen appears to contain a variable amount of periodic-acid-Schiff positive material and possibly a tyrosine-containing protein. The staining reactions of the altered collagen in most cases are similar to those of collagen. Preservation of the fibrils is suggested by the preservation of birefringence in the altered collagen and the configuration of the material within some of the lesions. The healing process described by Gross and Ehrlich can be recognised but it is suggested that healing can occur with retention of the radiate arrangement of cells found in coronal lesions and also that a fibrillary stage may not occur in some cases, thickened collagen fibres being left in place of fibrillary scars. The early exudative phase appears to be much more extensive than the developed lesions would suggest. The differences between acute and sub-clinical rheumatic fever may lie in the extent of the exudativedegenerative phase tnd .also in the intensity of the alteration to the collagen. A close correlation was found between the presence of active lesions in the left auricular appendage and the ventricular myocardium. Skin and muscle from patients with active rheumatic lesions in the left auricular appendages showed no abnormality. In an autopsy series of 61 cases of rheumatic heart disease, active lesions were found in 12 cases. In 28 of these patients in the same age group and with valve lesions comparable to the biopsy series, 7 cases (25%) showed active rheumatism. As compared with a control series of non-rheumatic hearts, a large proportion of patients with rheumatic heart disease showed metachromasia in the auricular appendage and the left atrial wall. In a clinico-pathological correlation it has been shown that there is a marked difference in the incidence of lesions in patients with sinus rhythm and auricular fibrillation. The explanation for this has not been found but it applies at all age groups above the age of thirty. No evidence of clinical activity was found in the valvotomy cases and because the earliest changes of rheumatic disease can be found in some specimens this is put forward as proof that sub-clinical rheumatism is an entity and present clinical and laboratory methods are inadequate to detect this. The incidence of active rheumatism in the valvotomy series and the histories of these patients suggest that the acute attack of rheumatic fever is a rare occurrence in the course of the disease and that the bulk of the damage to the heart is the result of repeated episodes of sub-clinical rheumatic fever which may overlap, or to a continuous rheumatic process. One major difference is detected between the autopsy series and the valvotomy series. There is a marked change in the proportion of patients in auricular fibrillation and it is suggested that this factor may account at least in part for the low incidence of active lesions in the autopsy series. The majority of patients with rheumatic heart disease who die in this centre die in auricular fibrillation and show no histological evidence of active rheumatism. It is tentatively suggested that the increase in metachromasia in the hearts of patients with valvular disease who die with no evidence of rheumatic activity may be the result of early rheumatism. The results of chemical estimations of the hexosamine/ hydroxyproline ratio in auricular appendages showing active lesions and without active lesions were inconclusive.

Item Type: Thesis (MD)
Qualification Level: Doctoral
Keywords: Medicine, Histology
Date of Award: 1956
Depositing User: Enlighten Team
Unique ID: glathesis:1956-79181
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 05 Mar 2020 11:32
Last Modified: 05 Mar 2020 11:32

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