Unusual presentation of rheumatic fever in a 3-year-old child in the UK

In the developed world, acute rheumatic fever (ARF) is rare. When it does arise, symptoms commonly include fever, arthralgia and rash. We describe a presentation of a 3-year-old child with ARF in a UK District General Hospital. The patient had a 6-week history of diarrhoea, rash and intermittent right hip arthralgia. This was initially thought to be a viral illness until she re-presented with shortness of breath and fever with a pan-systolic murmur. A throat-culture was negative, but an anti-streptolysin titre was elevated, with a bedside echocardiogram demonstrating moderate to severe mitral regurgitation. The young child was transferred to the local tertiary centre for further management; however, she went on to develop acute left ventricular failure. This case illustrates the need to be vigilant for the presentation of a rare illness, such as rheumatic fever, as there can be significant impacts on the quality of life of young patients.

Neuropsychiatric symptoms following sore throat in a young boy

A previously healthy 6-year-old boy was referred to us by his primary provider, with a history of sudden onset behavioural abnormalities including irritability, sleep disturbance and anxiety. Physical examination revealed no significant findings; further analyses were not suggestive of meningitis, encephalitis, metabolic abnormalities, toxicity or any other obvious cause. On rechecking the patient's history, an episode of throat pain 1 week prior to the symptom onset was noted. Therefore, the possibility of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) was considered. The antistreptolysin O titre was high (1078 IU/mL), and it increased to 1194 IU/mL 4 weeks later, leading to a diagnosis of PANDAS. He was started on ampicillin and administered one dose of intravenous immunoglobulin. His abnormal behaviours subsided and he returned to a normal state within 48 hours of treatment. This report aims to provide insights into the symptomology and diagnosis of PANDAS in children.

UNSPECIFIC INCREASE OF ANTISTREPTOLYSIN-O TITER IN ACUTE GUTTATE PSORIASIS

An acute streptococcal infection is well-known to be a predisposing factor in acute guttate psoriasis. This study also revealed a high ASO titer in 11 of 13 patients at first examination. However, a non-specific ASO increase due to non-immunological reaction of serum lipoproteins with antistreptolysin-O, was found in 5 of these patients who visited our clinic at the evolving phase, 2 or 3 weeks after onset of the eruption but was no longer observed at 5-6 weeks and thereafter. On the other hand, specific ASO increase, which was not related to lipoproteins, was observed first in some patients at 3-4 weeks and at 7-10 weeks in all patients examined. These observations suggest the role of streptococcal lipoprotein alteration in the occurrence of this disease.

One-off streptococcal serologic testing in young children with recurrent tonsillitis

OBJECTIVES

Recurrent acute tonsillitis in children under 4 years of age is usually viral, making antibiotic therapy inappropriate and the indication for tonsillectomy uncertain. Identifying those young children with bacterial infections is therefore important. The purpose of this study was to determine whether one-off streptococcal serologic testing is a useful tool in assessing recurrent acute tonsillitis in young children.

METHODS

We performed a retrospective study of 45 children (35 male and 10 female) under the age of 4 years who were found by a staff otolaryngologist to have recurrent acute tonsillitis over a 5-year period and had one-off serologic testing for anti-streptolysin O titers and anti-deoxyribonuclease B levels. Data were collected by chart review.

RESULTS

Three children (6.7%) had clearly positive titers for either one or both streptococcal antibodies. Children with negative serologic results were significantly less likely to have shown a significant response to antibiotic therapy for their acute episodes (26% versus 100%; p = .026). Nine children (20%) eventually underwent tonsillectomy, all of whom had negative serologic results.

CONCLUSIONS

Anti-streptolysin O and anti-deoxyribonuclease B levels may aid clinical evaluation of recurrent acute tonsillitis in young children in differentiating between those cases due to group A beta-hemolytic Streptococcus and those that are viral in origin.

Poststreptococcal syndrome uveitis: a descriptive case series and literature review

PURPOSE

To describe the clinical features in a series of patients with poststreptococcal uveitis and to review literature on the pathophysiology and management.

DESIGN

Retrospective and descriptive case series.

PARTICIPANTS

Ten consecutive cases of poststreptococcal syndrome uveitis diagnosed between 1996 and 2003.

METHODS

Review of patient case notes.

MAIN OUTCOME MEASURES

Age, laterality, clinical features, and anti-streptococcal lysin O titers.

RESULTS

Ten consecutive cases of poststreptococcal syndrome uveitis were identified. All our cases had bilateral nongranulomatous inflammation and raised anti-streptococcal lysin O titers. Collating data from previous reports and this series showed that 96% of the patients were below 40 years of age, and 87.5% had evidence of previous streptococcal infection. One third of the patients had posterior segment involvement. In our patients, this was in the form of vitritis, focal retinitis, optic disc swelling, and multifocal choroiditis.

CONCLUSIONS

Poststreptococcal syndrome uveitis should be considered in the etiology of acute bilateral nongranulomatous uveitis in children and young patients.

A clinical study of Suogudan Granule in the treatment of rheumatoid arthritis

OBJECTIVE

To study the clinical efficacy of Suogudan Granule (SGDG) in the treatment of rheumatoid arthritis (RA).

METHODS

Ninety patients with RA were randomly divided into the treated group and the control group. The treated group was administered orally with SGDG 6 g each time, thrice a day, while the control group with the combined therapy of Fenbid Capsules 0.3 g each time, twice a day and Tripterygium tablet 20 mg each time, thrice a day. The treatment course for both groups was 6 weeks. The changes of clinical symptoms and signs, and laboratory indices such as erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), antistreptolysin O (ASO), routine examination of blood and urine, liver and kidney function, etc. before and after treatment were observed.

RESULTS

(1) The total effective rate in the treated group (88.0%) was obviously higher than that in the control group (67.5%) with significant difference (P < 0.05). (2) The improvement in arthralgia, joint swelling, time of morning stiffness, 15-meter walking, analgesia initiation and persistence in the treated group was better than that in the control group (P < 0.05, P < 0.01), but there was no obvious difference in improvement of joint tenderness, range of joint motion, grip strength, and initiating detumescence time (P > 0.05). (3) The improvement in ESR and RF in the treated group was better than that in the control group with significant difference (P < 0.05). The negative-conversion rate of ASO in the treated group was also higher than that in the control group (P < 0.01). (4) No evident abnormality in blood, urine, liver or kidney function was found in either group.

CONCLUSION

SGDG is effective and safe for the treatment of RA.

New normal ranges of antistreptolysin O and antideoxyribonuclease B titres for Australian children

OBJECTIVE

To determine age-specific upper limit of normal (ULN) values of the ASO and ADB titres in children aged 4-14 years in urban Melbourne. Serology is often used to diagnose a preceding Streptococcus pyogenes infection, particularly in potential cases of rheumatic fever and post-streptococcal glomerulonephritis. The most commonly used antigens are antistreptolysin O (ASO) and antideoxyribonuclease B (ADB). Reference ranges used in Australia for these serological markers are usually based on data in adults from other countries. There are no age-specific reference values for Australian children.

METHODS

Sixty-six sera from children with no history of recent streptococcal infection were obtained in May-June 2002. The children were divided into three age groups for analysis: 4-5 (n = 20), 6-9 (n = 19) and 10-14 (n = 25) years. The geometric mean titre and ULN (defined as the 80th percentile) for the ASO and ADB titres for each age group were determined in both international and log units.

RESULTS

The ULN for ASO titres in each age group was 120 (2.08 log units), 480 (2.68) and 320 (2.51). The ULN for ADB titres in each age group was 100 (2.00 log units), 400 (2.60) and 380 (2.58).

CONCLUSION

The ASO and ADB ULN values in school-aged children are higher than the current reference ranges suggest.

Long-term use of penicillin for the treatment of chronic plaque psoriasis

A continuing sub-clinical streptococcal infection might be responsible for chronic plaque psoriasis. In this open study, we investigated thirty patients with moderate to severe chronic plaque psoriasis. The majority of the patients had been ill for 5 years or more (21 out of the total 30), and they had taken various treatment modalities for psoriasis with no significant improvement and frequent relapses. Total duration of the study was two years. Initially benzathine penicillin 1.2 million units, was given I.M. AST fortnightly. After 24 weeks benzathine penicillin was reduced to 1.2 million units once a month. Relevant investigations and clinical assessment was done at regular intervals to detect side effects and to observe the progress of disease. Significant improvement in the PASI score was noted from 12 weeks onwards. All patients showed excellent improvement at 2 years. Patients tolerated the therapy well. Controlled studies are needed to further confirm the benefits of long-term use of benzathine penicillin in the treatment of psoriasis.

[Asymptomatic myocarditis after infection of the upper respiratory tract]

HISTORY AND CLINICAL FINDINGS

A 20-year-old patient was hospitalized with persistent high fever after tonsillitis and swelling of the talocalcanean joint.

INVESTIGATIONS

The ECG showed a partial right bundle branch block pattern and pathological T inversions on the left precordial leads. Cardiac Troponin I levels were slightly elevated and echocardiography revealed a dyscinetic area at the right ventricular apex. The anti-streptolysin titer was elevated.

DIAGNOSIS

Post-streptococcal rheumatic myocarditis. THERAPY AND FOLLOW-UP: Antibiotic therapy for 2 weeks. The patient showed subjective full recovery after 6 weeks. The anti-streptolysin titer further increases. Nuclear spin tomography of the heart reveal postinflammatory alterations at the apex of the right ventricle.

CONCLUSION

Rheumatoid fever is a rare diagnosis in developed countries. This case, however, illustrates that the true prevalence of rheumatoid carditis might be underestimated in the presence of only minimal heart-and joint-specific symptoms.

[Clinical immunological characteristics of the pathogenesis of catarrhal gingivitis (Communication 1)]

In order to evaluate the relationship between cellular and humoral immunity, washings from the gingival sulcus were analyzed in 15 patients with catarrhal gingivitis and 15 subjects with intact periodontium aged 19-22 years. The results indicate a close relationship between local immunity and humoral and cellular defense factors. It seems that decreased IgA level, complement component, and increased activities of C-reactive protein and antistreptolysin-O are the key factors in the development of chronic gingivitis. Permanent bacterial aggression leads to dysfunction of phagocytic and epithelial cells.

Occurrence of subclinical post-streptococcal glomerulonephritis in family contacts

OBJECTIVE

There are few data in the published literature on the occurrence of subclinical post-streptococcal glomerulonephritis. In order to estimate the incidence of subclinical disease, 75 families of index cases with sporadic clinical post-streptococcal glomerulonephritis were screened for the presence of subclinical disease.

METHODS

Three hundred and seventeen family contacts were investigated 1-7 days after the admission of the index cases. The diagnosis of subclinical disease was based on the presence of abnormal urinalysis, transitory hypocomplementaemia and increased antistreptolysin O titre.

RESULTS

No cases of clinical/subclinical disease were detected among 147 parents. Abnormal urinalyses were found in 22.3% of sibling contacts. The incidence of nephritis among 170 siblings was 9.4% and the calculated ratio subclinical/clinical disease was 0.11. There were 16 siblings (9.4%) whose abnormal urinalyses could not be explained by appropriate tests; 11 of them had dysmorphic microhaematuria and significantly elevated antistreptolysin O titre.

CONCLUSIONS

Sibling contacts have increased risk for the development of clinical/subclinical post-streptococcal glomerulonephritis compared with their parents. Sibling contacts with unexplained urinary abnormalities might have subclinical nephritis in evolution; their complement levels normalized before occurrence of nephritis in index cases.

Antistreptococcal response is exaggerated in children with familial Mediterranean fever

Familial Mediterranean fever (FMF) is an autosomal recessive disorder. Although the pathogenesis of the disease is not yet completely understood, enhanced acute-phase responsiveness is considered to be one of the most important mechanisms. The presence of high levels of antistreptolysin O (ASO) antibodies and streptococcus-associated diseases, such as acute poststreptococcal glomerulonephritis (AGN) and acute rheumatic fever (ARF), has been reported in patients with FMF. In order to better understand the effect of FMF on antistreptococcal antibody response, we measured ASO and antideoxyribonuclease B (anti-DNAse B) levels in patients with FMF and compared them with those in healthy controls. The study consisted of two parts. In the first step, antistreptococcal antibody levels were analysed in 44 patients with FMF and 165 healthy children who had no history or clinical evidence of upper respiratory tract infection (URTI) for the last 4 months. In the second step, antistreptococcal antibody levels were measured in 15 patients with FMF and 22 healthy controls in response to documented group A beta-haemolytic streptococcal pharyngitis. In the first part of the study, ASO and anti-DNAse B levels in patients with FMF were found to be significantly higher than those in healthy controls (P<0.001). In the second part, ASO and anti-DNAse B titres were found to be significantly higher in patients with FMF than in controls (P<0.001 and <0.05, respectively) 4 weeks after a positive throat culture. We concluded that patients with FMF have an exaggerated response to streptococcal antigens and might be prone to poststreptococcal non-suppurative complications, such as ARF.

Multicentric reference values for some quantities measured with Tina-Quant reagents systems and RD/Hitachi analysers

Ten clinical laboratories in different regions of Spain have shared the search for reference individuals and the production of reference values for quantities concerning ferritin, transferrin, rheumatoid factors, C-reactive protein and antistreptolysin O, using Tina-Quant reagents systems and RD/Hitachi analysers. All the logistic work has been done in co-operation with the supplier of the reagents and analysers (Roche Diagnostics España, S.L., Barcelona). The reference limits produced in the virtual laboratory are derived from the blend of reference values obtained by each laboratory. The multicentric reference limits were estimated according to the recommendations of the International Federation of Clinical Chemistry. The work done is a model of co-operation between the in vitro diagnostic industry and clinical laboratories for the production of reference values.

The diagnostic value of streptococcal serology in early arthritis: a prospective cohort study

OBJECTIVE

To evaluate the diagnostic value of streptococcal serology in adult early arthritis patients in discriminating between post-streptococcal reactive arthritis (PSRA) and arthritis with other causes.

METHODS

The antistreptolysin-O (ASO) and anti-DNase B tests were performed at baseline in 366 consecutive, newly referred early arthritis patients. After 1 yr of follow-up the patients were classified according to international classification criteria and were evaluated for the presence of persistent arthritis. The outcome measures were the predictive value of streptococcal serology for the diagnosis of PSRA and the ability of this serology to discriminate at the first visit between the self-limiting and persistent forms of arthritis.

RESULTS

With a positive serological result, the probability of having PSRA increased from 2 to 9%, whereas the probabilities of having rheumatoid arthritis or undifferentiated arthritis continued to be high (23 and 29%). The serological tests did not discriminate between the self-limiting and persistent forms of arthritis. The major Jones criteria apart from arthritis were not observed.

CONCLUSION

Streptococcal serology has no diagnostic value in adult early arthritis patients in whom major Jones criteria other than arthritis are not present.

Post-streptococcal uveitis

BACKGROUND

We report additional evidence supporting the association between the occurrence of bilateral nongranulomatous uveitis and previous infection by group A streptococci--i.e., post-streptococcal syndrome.

METHODS

As shown through a series of case reports, physical examination and laboratory blood analysis--including antistreptolysin O (ASO) antibody titer--were ordered due to a recent history of sore throat and presence of nongranulomatous bilateral anterior uveitis.

RESULTS

Serological laboratory testing revealed elevated ASO antibody titer. The etiology of the uveitis was attributed to streptococcal infection. Bilateral uveitis responded to topical corticosteroids. Systemic antibiotic treatment was used to treat possible post-streptococcal syndrome sequelae with resolution of symptoms.

CONCLUSION

Uveitis should be considered a possible manifestation of post-streptococcal syndrome. ASO antibody quantification should be included in the serologic testing performed in evaluating the cause of seemingly idiopathic bilateral nongranulomatous anterior uveitis associated with signs and symptoms that suggest previous streptococcal infection.

Preliminary findings of antistreptococcal antibody titers and basal ganglia volumes in tic, obsessive-compulsive, and attention deficit/hyperactivity disorders

BACKGROUND

Previous studies have provided preliminary serological evidence supporting the theory that symptoms of tic disorders or obsessive-compulsive disorder (OCD) may be sequelae of prior streptococcal infection. It is unclear, however, whether previously reported associations with streptococcal infection were obscured by the presence of diagnostic comorbidities. It is also unknown whether streptococcal infection is associated in vivo with anatomical alterations of the brain structures that have been implicated in the pathophysiology of these disorders.

METHODS

Antistreptococcal antibody titers were measured in 105 people diagnosed as having CTD, OCD, or attention-deficit/hyperactivity disorder (ADHD) and in 37 community controls without a disorder. Subjects were unselected with regard to their history of streptococcal exposure. Basal ganglia volumes were measured in 113 of these subjects (79 patients and 34 controls).

RESULTS

A DSM-IV diagnosis of ADHD was associated significantly with titers of 2 distinct antistreptococcal antibodies, antistreptolysin O and anti-deoxyribonuclease B. These associations remained significant after controlling for the effects of CTD and OCD comorbidity. No significant association was seen between antibody titers and a diagnosis of either CTD or OCD. When basal ganglia volumes were included in these analyses, the relationships between antibody titers and basal ganglia volumes were significantly different in OCD and ADHD subjects compared with other diagnostic groups. Higher antibody titers in these subjects were associated with larger volumes of the putamen and globus pallidus nuclei.

CONCLUSIONS

These findings suggest that the prior reports of an association between antistreptococcal antibodies and either CTD or OCD may have been confounded by the presence of ADHD. They also support the hypothesis that in susceptible persons who have ADHD or OCD, chronic or recurrent streptococcal infections are associated with structural alterations in basal ganglia nuclei.

[IgM-lambda type monoclonal gammopathy of undetermined significance showing non-specific anti-streptolysin O activity by a latex immumoaggregation method]

We report a case of IgM-lambda type monoclonal gammopathy of undetermined significance showing non-specific anti-streptolysin O activity of extremely high level. An 83-year-old man developed high grade fever, cough and sputum. He was admitted to our hospital under a diagnosis of acute pneumonia by chest X-ray. He showed anti-streptolysin O (ASO) activity in extremely high level measured by a latex immunoaggregation method (LA-method). Although antibiotics cured the acute pneumonia, the ASO activity had remained in high level. Serum protein electrophoresis disclosed existence of M-protein and the M-protein was found to be IgM, lambda class by immunoelectrophoresis. The ASO activity measured by the LA method was ascribed to the M-protein because the level of M-component shown by the electrophoresis was decreased by absorption of the serum with streptolysin O-coated latex beads that were used in the LA-method. However, ASO activity measured by Rantzs-Randall method was in normal level. The ASO activity measured by the LA-method was absorbed with bovine serum albumin coated latex beads without streptolysin O. Therefore, it was concluded that the M-protein was not reacted with streptplysin O itself but was reacted with bovine serum albumin coated latex beads. The ASO activity of extremely high level in our case was non-specific reaction caused by the M-protein.

[Determination of antibodies to streptolysin O]

A new procedure for the assessment of the antibody against streptolysin O by a micromethod was tested by comparison with the photometric reference method. Agreement between the two methods was very good. The differences in titres did not exceed the titration error of the method. Based on the tested micromethod, a diagnostic set was produced in the Czech Republic which is to be used for common titration of antistreptolysin O in serum. The ITEST ASO was tested in relation to the photometric reference method and standardized neutralization micromethod of the National reference laboratory for streptococci and enterococci in Prague. From a group of 135 selected sera with different titres there was agreement between all tested methods. Selected kits used abroad for the titration of antistreptolysin O were tested in the National reference laboratory by using the authors own standardized materials and methods.

Neutrophilic figurate erythema of infancy

We describe a transient figurate erythema in an 11-month-old female infant with a 2-month history of arcuate and annular erythematous lesions localized on the face, trunk, and limbs. Constitutional symptoms were absent. Previous medical history was unremarkable. Full blood examination, erythrocyte sedimentation rate, antistreptolysin-O titer, anti-Ro, and anti-La antibodies were within normal limits or negative. Histologic examination revealed a superficial and deep perivascular and interstitial dermatitis constituted mostly of neutrophils and abundant nuclear dust. The lesions resolved spontaneously within a few months without scarring or atrophy. Recurrence has not occurred. This case suggests that figurate erythemas in infants rarely may disclose a neutrophilic histologic pattern, which must be differentiated from that of other neutrophilic dermatoses.

Long-term follow-up of juvenile-onset cutaneous polyarteritis nodosa associated with streptococcal infection

Polyarteritis nodosa (PAN) is a multisystem inflammatory disease associated with necrotizing vasculitis of small and medium arteries. Although predominantly an adult disease, PAN is well described in children. It can occur in a systemic form with manifestations in skin, joints, heart, nervous system, gastrointestinal tract, lungs and kidneys, and a limited form in which disease is confined to the skin, muscles, joints and peripheral nerves. In either case, streptococcal infection has been implicated by a positive throat swab or a significant increase in either antistreptolysin O (ASOT) or antihyaluronidase titres. The limited form is thought to run a benign course, but little has been written about its long-term outcome. We describe two patients who developed a cutaneous vasculitis following a probable streptococcal infection. Both have run a relapsing and remitting course with significant elevations of ASOT and in one, at least, prophylactic penicillin has had a strikingly beneficial effect. In both patients, the disease seems to have receded during childhood, only to recur, retaining its original form, in adult life. Their current ages are 22 and 19 yr, respectively.

Elevated IgG titer against the C region of streptococcal M protein and its immunodeterminants in patients with poststreptococcal acute glomerulonephritis

OBJECTIVE

To determine the immune responses to the streptococcal M protein in patients with poststreptococcal acute glomerulonephritis (PSAGN).

STUDY DESIGN

The gene coding type 12 M protein of group A streptococcus (M12), a known PSAGN-associated serotype, was cloned and expressed in Escherichia coli to investigate the specific immune responses to the M12 protein in patients with PSAGN. Recombinant M proteins for the variable N-terminal half (AB region) and conserved C-terminal half (C region) were produced separately. IgG titers against each region were measured by enzyme-linked immunosorbent assay in patients with PSAGN (n = 51), uncomplicated streptococcal pharyngitis (n = 26), chronic glomerulonephritis (n = 10), and in healthy control subjects (n = 51). Immunodominant domains within the M protein in PSAGN were further investigated by use of overlapping synthetic peptides.

RESULTS

IgG titers against the C region, but not the AB region, were markedly higher in the PSAGN group than in other groups (p < 0.01), and these titers were maintained for at least several months after antistreptolysin O or antistreptokinase levels had returned to normal. Studies with overlapping synthetic peptides demonstrated that increased IgG reactivity was observed against the C repeat blocks.

CONCLUSION

IgG titers against the C region are significantly elevated in patients with PSAGN, and it may be a diagnostic marker for PSAGN.

Scleritis, uveitis, and glaucoma in a patient with rheumatic fever

PURPOSE

To determine the origin of scleritis, uveitis, and glaucoma in a boy with fever, sore throat, joint pains, and malaise.

METHODS

The patient underwent extensive hematologic, serologic, rheumatologic, and radiologic examinations.

RESULTS

The patient recovered after extensive medical therapy. He met the Jones criteria for the diagnosis of acute rheumatic fever and had an increased result for antistreptolysin O antibody titer.

CONCLUSIONS

Antistreptococcal antibody testing is helpful in diagnosing rheumatic fever as a cause of scleritis, uveitis, and glaucoma.

Recurrent juvenile dermatomyositis and cutaneous necrotizing arteritis with molecular mimicry between streptococcal type 5 M protein and human skeletal myosin

An adult patient had a syndrome associating the features of juvenile dermatomyositis and cutaneous polyarteritis nodosa that followed a cyclic course from childhood; recurrences were always associated with a rise of serum antistreptococcal antibodies. Regions of homology between streptococcal type 5 M protein and skeletal myosin were found. These findings suggest that streptococcal infection, possibly through a molecular mimicry mechanism, played a role in the pathogenesis of the disease in our patient.

Group A streptococcal infection in an aboriginal community

OBJECTIVE

To determine whether group A streptococcal infection and poststreptococcal sequelae are still a significant health issue for Aboriginal communities.

DESIGN

A cross-sectional survey of streptococcal carriage, infection and antibody levels.

SETTING

A north Queensland Aboriginal community.

PARTICIPANTS

One hundred and twenty preschool and school-aged children (2 to 12 years of age) living in the Lockhart River Community on Cape York Peninsula.

RESULTS

Pyoderma was present in 43% of the children and in 76% of these culture of skin lesions grew group A streptococci. Group A streptococci also grew from 13% of throat swabs, making a total of 36% of children culture positive. Anti-streptolysin O and anti-DNAase B levels were remarkably high and increased with age.

CONCLUSIONS

The evidence presented confirms a high level of group A streptococcal carriage and infection in children of the Lockhart River Community. Further investigation of this problem is warranted in other Aboriginal communities with a view to instituting appropriate control programs.

Streptococcal infection and renal disease markers in Australian aboriginal children

OBJECTIVE

To demonstrate an association between markers of streptococcal infection and markers of glomerulonephritis in Aboriginal children.

DESIGN

A cross-sectional study of Aboriginal children of school age.

SETTING

Three Aboriginal communities in the Northern Territory--two, coastal and one, desert.

PARTICIPANTS

Sixty children, randomly selected from the school roll, were studied in each community; thus there were 180 children in total, aged 5-17 years. Midstream urine and venous blood was collected and swabs were taken from the pharynx and from impetiginous skin lesions or axillary skin in the absence of impetigo. Clinical records were examined for evidence of past glomerulonephritis.

MAIN OUTCOME MEASURES

Swabs were cultured for beta-haemolytic streptococci and isolates were grouped; serum was tested for titres of antistreptolysin O (ASO) and antideoxyribonuclease B (anti-DNaseB). Protein and creatinine levels were measured in urine, and a ratio of protein to creatinine (UPC) of more than 50 mg protein per mmol creatinine was taken as a measure of significant proteinuria. Urine was examined microscopically for glomerular haematuria (greater than 10 red blood cells per microL with at least 20% dysmorphic red cells).

RESULTS

Group A beta-haemolytic streptococci were isolated from the throat swabs of two children and from skin swabs of 25 (13.9%) children; 20 of these were from impetiginous lesions and five from normal axillary skin. beta-Haemolytic streptococci of group C or G were grown from the throat swabs of 13 (8.1%) children. The median titre of ASO (256 IU) was raised compared with a reference level, and the median titre of anti-DNaseB (3172 IU) was particularly high; ASO titres were significantly higher in 31 children with impetigo than in 149 children without impetigo. Significant proteinuria was present in 7 (3.9%) children and glomerular haematuria in 16 (8.9%). Glomerular haematuria was present in 2/7 (28%) children with proteinuria, 4/21 (19%) children with a past history of post-streptococcal glomerulonephritis, in 5/31 (16%) of those with impetigo and in 4/25 (16%) of those with positive skin cultures. However, none of these prevalences was significantly greater than the prevalence of glomerular haematuria among the other children. The prevalence of proteinuria differed significantly between communities and increased significantly with age. Furthermore, the differences in childhood proteinuria observed between communities in this study were parallel with community differences in the prevalence of proteinuria in a related study of adults.

CONCLUSIONS

Group A streptococci are important causes of impetigo in Aboriginal children. Streptococcal skin infection may contribute to glomerular haematuria, proteinuria and persistent glomerulonephritis in Aboriginal children, and possibly to chronic glomerulonephritis in adult life. Public health programs are needed to reduce the prevalence of impetigo and group A streptococcal infections in Aboriginal communities; longitudinal studies are needed to test the relationship between streptococcal skin infection in Aboriginal children and chronic renal disease in later life.

[Common cold: diagnostic steps? Antibiotics?]

The common cold is caused by more than 100 virus types. However, the clinical manifestation is always similar with rhinorrhea, stuffiness, sneezing, pharyngitis, laryngitis and cough. The local inflammatory reactions are not due to the presence of virus but caused by locally produced inflammatory mediators. Bacterial superinfections may cause otitis or sinusitis. Bacterial nasopharyngitis has been described in children. This entity possibly exists also in adults. Traditional viral cultures are rarely positive and are not recommended in the daily routine. In children, antigen detection for adenovirus, respiratory syncytial virus, parainfluenza and influenza virus are recommended to confirm the viral etiology or for epidemiological surveillance. The presence of group-A streptococci must be proven by culture or antigen detection before treatment with penicillin. Antiviral treatment is limited to interferon or ribavirin. New antiviral substances are in development. Today, treatment of common cold is limited to symptomatic measures, and antibiotic treatment is not justified.

[Antistreptolysin O]

Automated analyzers based on the quantitative immunochemical methods have been developed and can allow quantitative measurements of antistreptolysin O concentrations in the clinical laboratories. Automated ASO determinations improve in point of operation, time, effort, precision and accuracy, compared with the usual semiquantitative methods of tube dilution techniques based on the method of Rantz and Randall or some modification thereof, microtitration of the Edward method and agglutination test using latex or other particles. However, confusion and many kinds of problems have been brought about by the rapid development of automated ASO measurements in routine use. The principle quantitative immunochemical measurements of automated ASO determinations are immune agglutination assays, which are nephelometric immunoassay (NIA), latex agglutination photometric immunoassay (LAPIA) and turbidimetric immunoassay (TIA). Principles and methods of these automated immunoassay, reagents, ASO standard serum, automated analyzers, precision and accuracy, the present conditions and problems of automated analysis in the clinical laboratories were discussed in comparison with usual semiquantitative measurements. There was a good correlation between automated immune agglutination assay (NIA, LAPIA and TIA) and the usual semiquantitative assay. However, the quantitative accuracy of automated immune agglutination assay was decreased in the regions of low and high ASO values. Availability, precision and accuracy of ASO measurement were improved by the automated analysis. However, the methods of ASO measurements were increased and varied by the automated assay. Therefore, it is necessary to standardize the automated ASO measurements. The limitation and the clinical significance of the automated immune agglutination assay of ASO have to be studied for practical use in the future.

[From qualification to quantification in immunoserological testings]

During the 1980's, quantifications of immunoserological testings, especially C reactive protein, rheumatoid factor and antistreptolysin O, progressed rapidly. However, marked interlaboratory differences in these quantifications have been observed. In this brief review, difficulties to satisfy requirements for good quantitative performance in immunochemical assays are discussed.

[Relation between foci of chronic oral infection, rheumatic fever and general or local anesthesia]

We make a study about Rheumatic fever diagnostical on boys who need an exeresis of bucals focus, which we make under general or local anaesthesia effects, and we verify the quantity of ASLO descent which depended on type of anaesthesia and the number of sessi that we make.

Evaluation of a new latex agglutination test for detection of streptolysin O antibodies

Acute- and convalescent-phase serum specimens were collected from 50 patients with group A streptococcal pharyngitis. The anti-streptolysin O (ASO) titer for each serum specimen was determined by using both the standard neutralization assay and the latex agglutination (LA) test (Rheumagen ASO; Biokit Inc., New Britain, Conn.). When the ASO titers derived by the two methods were compared, the correlation coefficient was 0.93. When the ability of the LA test to demonstrate a significant ASO titer rise (greater than or equal to 2 dilutions) was compared with that of the standard neutralization assay, the LA test had a sensitivity of 91%, a specificity of 86%, a positive predictive value of 83%, and a negative predictive value of 92%. Triplicate LA test determinations were performed on a subset of 31 serum specimens, and for 29 (94%), the repeated ASO titers were all within 1 dilution of each other; the width of the 95% confidence interval for the triplicate measurements of each serum specimen was +/- 32.8 IU. We found the Rheumagen ASO to be a simple, rapid LA procedure for measuring ASO titers that produces results that are highly reproducible, show little lot-to-lot variability, and are comparable to the ASO titers obtained with the standard neutralization assay.

[A critical review of the methods used in evaluating the antistreptolysin titre as a diagnostic index]

Authors review the most common laboratory tests showing an immunologic response caused by group A beta-hemolytic streptococcus infections. After a preliminary evaluation on characteristics and peculiarities of different methods the results obtained are compared with the usually employed systems. The survey of most common analytical methods and personal experience lead to confirm and emphasize the laboratory results supporting and confirming, without substituting, the clinical data.

Waning significance of anti-streptolysin O (ASO) titres in diagnosing streptococcal infections in Lagos, Nigeria

A total of 200 serum specimens comprising 100 specimens from patients with streptococcal disease conditions, 50 from patients with other diseases and another 50 specimens from apparently healthy individuals were collected from Lagos University Teaching Hospital and from various areas of Lagos metropolis and screened for the presence of anti-streptolysin O (ASO). For streptococcal disease conditions, other diseases and for apparently healthy persons, anti-streptolysin O titres above 250 iu/ml recorded for each category of clinical conditions in terms of the number examined were 34%, 36% and 28% respectively. It is therefore suggested that high anti-streptolysin O (ASO) titres occur in apparently healthy individuals with no history of streptococcal infection and individuals with disease conditions other than those of streptococcal origin. Consequently the diagnosis of streptococcal diseases based on high titres of ASO in Lagos, is not pathognomonic, should be interpreted with caution and must not be definitive since healthy individuals and others without streptococcal infections develop high ASO titres.

[Possibilities and prospects of multiparameter immunologic examination in the diagnosis and prognosis of rheumatoid arthritis]

The authors have analysed data from literature and their own results concerning multiparameter examination of the patients with rheumatoid arthritis. An effort has been made to establish a correlative relationship between changes in the following immunologic values: the level of rheumatoid factor, circulating immune complexes, antibodies to streptolysin-0 and immunoglobulin G; the number of T-lymphocytes and the quantity of natural cells of the killers and the hormone regulatory activity of thymus. Positive interdependence between the presence of rheumatoid factor and that of antibodies to streptolysin-0 as well as an increase in the content of circulating hormone complexes has been determined. In view of absence of one value which is strictly specific and compulsory for rheumatoid arthritis, it is only complex investigation that allows to describe the trends in changes of the immunologic state of the patient with rheumatoid arthritis.

Comparison of latex and haemolysin tests for determination of anti-streptolysin O (ASO) antibodies

A latex agglutination test was compared with the micro-titration haemolysin inhibition method for the detection of anti-streptolysin O (ASO) antibodies in 428 serum samples. After slight modification of the latex method to produce maximal agglutination good agreement was shown between the results obtained by the two methods. The latex test had a sensitivity of 83.6%, a specificity of 93.3%, a predictive positive value of 86.5% and a predictive negative value of 91.6%. It was convenient, required less labour than the haemolysin test, and permitted economic testing of small numbers of sera.

Immunological abnormalities in children with acute rheumatic carditis and acute post-streptococcal glomerulonephritis

Immunological functions were investigated in 10 children with acute rheumatic fever and 11 children with acute nephritis to try and elucidate the cause of heart damage in acute rheumatic fever. Children with acute rheumatic fever and carditis showed an increase in serum IgG, IgA and antistreptococcal antibodies during the acute stage. Lymphocyte transformation responses to phytohaemagglutinin and streptococcal antigens were reduced but this was due to a serum suppressor effect. After recovering from acute rheumatic fever a lymphocytosis and an increased lymphocyte blastogenic response to streptococcal antigen were found. T-cells, T-helper cells and T-suppressor cells showed some changes in acute rheumatic fever but these were not statistically significant in our study. None of the changes in immunological responses that were seen in acute rheumatic fever were found in acute nephritis. These results support the hypothesis that an abnormal immune response to streptococcal products is involved in the development of carditis and the other phenomena observed in acute rheumatic fever.

Comparison of three rapid methods for detection of antibodies to streptolysin O and DNase B

Three commercial systems were compared for ability to detect antibodies to streptolysin O (ASO) and DNase B (ADB). Streptozyme (Wampole Laboratories, Cranbury, N.J.) exhibited high sensitivity (100%) for detecting ASO but low sensitivity for ADB (22.2%). The LeapStrep (Organon Teknika, Malvern, Pa.) and Check-Spectra (Diagnostic Technology, Hauppauge, N.Y.) tests had low sensitivities for detecting ASO (35.3 and 21.4%, respectively) and ADB (22.2 and 33.3%, respectively).

Sera from patients with high titers of antibody to streptolysin O react with listeriolysin

Sera of patients with suspected rheumatic fever and elevated titers of antibody to streptolysin O were examined by an immunoblotting technique. All but two serum samples, which yielded relatively low titers, bound to a 60-kilodalton protein in the supernatant from a culture of Listeria monocytogenes, which presumably represents the listeriolysin.

The group A streptococcal carrier state. A reexamination

Streptococcal infection usually is defined as a positive throat culture with a serologic response to group A beta-hemolytic streptococci, and a patient with a positive throat culture and no serologic response is a streptococcal carrier. Studies suggest that streptococcal carriers should show little clinical response to antibiotic therapy when compared with patients with true streptococcal infections. Patients with acute pharyngitis were divided into three groups: group 1--38 patients with negative throat cultures; group 2--72 patients with a positive throat culture and a significant rise in streptococcal antibody titers; and group 3--77 patients with positive throat cultures and no significant rise in streptococcal antibody titers. Patients in group 2 and group 3 had a comparable and dramatic clinical response to antibiotic therapy that was considerably greater than the clinical response in the patients in group 1. These findings raise questions about the appropriateness of using streptococcal antibody responses to distinguish between the streptococcal carrier state and a true streptococcal infection.

Homogeneous liposome lysis assay for determination of anti-streptolysin O antibody titer in serum

We developed a liposome lysis assay for determining anti-streptolysin O antibodies (ASO) in human sera involving the use of carboxyfluorescein-entrapped multilamellar liposomes. This assay system was based on the inhibition of streptolysin O-induced liposome lysis by ASO. Briefly, after incubation of a given amount of streptolysin O with ASO for 30 min at 37 degrees C, carboxyfluorescein-entrapped liposomes composed of egg yolk phosphatidylcholine and cholesterol in a molar ratio of 1:1 were added to the mixture to determine the residual streptolysin O activity. Liposome lysis, detected as carboxyfluorescein release from the liposomes, was inversely proportional to the ASO titer. The results of within-run and between-run precision studies indicated that the liposome lysis assay is accurate and gives reproducible data. Bilirubin, hemoglobin, and triglycerides did not interfere with the liposome lysis assay. The ASO titers of 100 patient sera, evaluated by our new method and the Rantz-Randall method, showed good correlation.

Bacteriological and serological aspects of group A streptococcal pharyngotonsillitis caused by group A streptococci

Several bacteriological and serological variables were studied in connection with a clinical treatment trial in 212 patients with group A streptococcal pharyngotonsillitis. Anaerobic incubation was not superior to incubation in 5% CO2 in air for the detection of group A streptococci. Saliva cultures were inferior to conventional throat cultures in detecting group A streptococci. No strains from patients with recurrences were found to be tolerant to penicillin. In several patients (all asymptomatic), group C and G streptococci were found in follow-up cultures. Group A streptococci serology was more often positive after two months than after one month, also in patients without recurrence.

Immunological relation between serum antibodies against pneumolysin and against streptolysin O

The immunological relation between serum antibodies to pneumolysin and to streptolysin O was studied in patients with pneumococcal pneumonia (n = 40), patients with infections due to beta-haemolytic streptococci (n = 35), healthy human controls (n = 60) and in rabbits immunized with pneumolysin. There was no correlation between anti-pneumolysin and anti-streptolysin O titers (r = -0.279). The distribution of anti-pneumolysin titers in patients with high anti-streptolysin O titers did not differ from healthy controls. However, there was a tendency to increased or rising anti-streptolysin O titers in patients with pneumococcal infection. Antibodies obtained during pneumococcal infection might thus give false-positive reactions in the streptolysin O neutralization test. Serum antibodies to streptolysin O do not cross-react with pneumolysin in an ELISA. The pneumolysin ELISA for detection of pneumococcal disease will therefore not be disturbed by false-positive reactions due to antibodies directed against beta-haemolytic streptococci.

Characterisation of various intravenous immunoglobulin preparations

Five commercially available immunoglobulin preparations are characterised with regard to molecular weight distribution, immunoglobulin subclass distribution and antibody content. Preparations processed utilising enzymic or chemical modification demonstrate considerable variance of molecular weight species and subclass distribution when compared to native preparations. Similarly, cytomegalovirus and anti-streptolysin O antibody content is dramatically reduced in the modified preparations. Possible reasons for the differences are discussed. In-process inactivation of Human Immunodeficiency Virus is reviewed with regard to one of the native preparations.

Tests for streptolysin-O antibodies in health and suspected streptococcal infections in Saudi Arabia

'Upper limits of normal' antistreptolysin-O (ASO) titres were determined in various age groups in Saudi Arabia using the conventional haemolysin and the newer, passive agglutination (Blue-ASO) tests. The upper limit of normal values were found to vary with age, being the highest (166 Todd units or 1:320) among the school age children. Serum samples from 744 patients with various clinical manifestations associated with streptococcal infections such as rheumatic fever, glomerulonephritis, tonsillitis, rheumatoid arthritis and polyarthritis were tested by both methods, with the geometric mean titres (GMT) being determined in each age group. In case of school age children with suspected rheumatic fever, and found positive by the tests, a GMT of 458 Todd units (1:1080) was obtained--much higher than the ASO levels detected in positives with glomerulonephritis or tonsillitis. Apart from its relative simplicity, rapidity and ease of performance, the Blue-ASO test was able to detect positivity in 15% of sera from patients of various age groups with suspected rheumatic fever, polyarthritis and tonsillitis who exhibited insignificant levels of ASO by the haemolysin test.

Dilemmas of streptococcal pharyngitis

Although the Group A beta-hemolytic streptococcus is the most common cause of acute bacterial pharyngitis in childhood, the clinical diagnosis is often not straightforward and throat cultures are advisable. To avoid unnecessary antibiotics, treatment should be delayed until culture results are available. Patients with negative cultures should discontinue any antibiotics already started on clinical grounds. Positive cultures may represent a carrier state, which can be identified by serologic studies.