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For the determination of streptococcal infection, it is necessary to test 3 antibodies, i.e., ASO, ASK and ADN-B at a time, and if 2 of the 3 titers are positive one can make diagnosis of fairly recent streptococcal infection, but if only one of the 3 titers are positive, previous or non-specific causes should be considered.
PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection) is a rare condition first described in 1998. It describes the presence of obsessive-compulsive disorder (OCD) or tics with an episodic course, and a temporal relationship to Group A beta haemolytic streptococcal infection (GABHS). Recurrent episodes can be disruptive and upsetting for a child, but the best way to treat the condition has yet to be established. Penicillin prophylaxis has not proved effective, and other therapies are experimental. There is some evidence in the literature to support the role of tonsillectomy in improving the condition. We report a case of a 6-year-old boy who presented with tic and hemi-chorea associated with GABHS throat infection. He had a recurrence of his symptoms associated with a further GABHS infection, but has had no further symptoms following tonsillectomy. This case report lends further evidence to the role of tonsillectomy in the management of PANDAS.
The changes in the epidemiological process of streptococcal infection in various periods are presented. From the great epidemics, extremely severe and with multi-annual evolution reported in the past, the last decades are characterized by a permanent decrease in incidence of scarlet fever and a progressive increase of streptococcal anginas. These aspects required a more careful surveillance of the agglomeration at epidemiological risk and an estimation of the late complications frequency. The role of some factors in making scarlet fever a benign affection with a diminished epidemic character, in lowering the incidence of streptococcal infections and of their complications, among which the social-economic conditions, the standardized treatment with Penicillin G and oral penicillin, the contacts' prophylaxis with oral penicillin is underlined. In conclusion it is mentioned that, as part of primary care, the surveillance--detection, isolation, adequate treatment should be improved.
BACKGROUND & OBJECTIVES: A possible relationship has been suggested between tic disorders and streptococcal infections. To understand the complex relationship between streptococcal infections and neuropsychiatric disorders in children the present study was done on colour Doppler echocardiography of patients with possible post-streptococcal tic disorders. METHODS: The patients were 23 children (22 males, 1 female) affected by tic disorders, who at the time of the observation presented (or had presented in the past) signs of streptococcal infections temporally related to the onset or recrudescence of tic disorders. Echocardiographic examination and laboratory tests were performed on these children. RESULTS: In 4 cases a mild mitral insufficiency and in 8 cases a minimal mitral insufficiency was seen, all haemodynamically not significant. Follow up studies (up to 1 yr) showed the consistency and persistence of these findings. Of the 12 patients with echocardiographic abnormalities, 10 displayed very high anti streptolysin O (ASO) titres, 5 showed positive cultures for GAS and 9 had abnormal ESR, even if no significant differences were found in respect to patients with tics and normal echocardiography. INTERPRETATION & CONCLUSION: With the caution due to the design of study and to low number of patients, our data seem to indicate that the pathophysiology of GAS-infection related tic disorders is similar to that SC, at least in some cases.
A model of virus-bacterial infection involving A (PR-8/34) influenza virus and group B streptococcus is proposed to demonstrate the cyclic manifestations of fatal synergism of the causative agents correlating with either the cyclic detection of influenza virus antigens in the infection focus on administration of avirulent streptococcal Fos4 strain, or with the time-course of activity shown by natural killers on administration of virulent streptococcal Fos8 strain. Based on the presented data on the cyclic character of fatalities, whose dynamics varies only slightly with the biological properties of the second agent, a conclusion has been derived on (1) the simultaneous influence of various factors in the formation of the mechanisms of infection transformation, (2) the capability of the cell receptor apparatus to respond to an external stimulus which is the most important of these mechanisms, and (3) the effects of the biological properties of the causative agents on the fatal effect manifestations.
AIMS: To assess the assumption that group B streptococcal infection is less common in the United Kingdom than it is in the United States. METHODS: All stillbirth and neonatal death records in the former Northern Health Region were scrutinised to determine how many babies had died of infection in 1981-96, and what had been the cause. RESULTS: Fifty one of 630 206 live born babies had died of confirmed group B streptococcal infection after becoming symptomatic within 48 hours of birth (0.8 neonatal deaths per 10,000 live births). There were a further 27 deaths from infection without a confirmed microbiological diagnosis, and 17 stillbirths from confirmed group B streptococcal infection. CONCLUSIONS: The incidence of death from early onset infection was marginally higher than the officially estimated rate for the United States before widespread prophylaxis was attempted. Strategies for perinatal prevention deserve greater attention in the United Kingdom.
We investigated the role of maternal antibody in neonatal Group B streptococcal infection with a radioactive antigen-binding assay employing a purified polysaccharide antigen with both Type III and Group B determinants. Serums from seven women who gave birth to infants who had invasive Group B streptococcal infection with Type III strains were all deficient in antibody. In contrast, serums from 22 of 29 pregnant Type III vaginal carriers whose infants were healthy contained antibody with a prevalence significantly different from that in women delivering infants with Type III disease (P less than 0.01). Three healthy neonates born to women with antibody in serums had demonstrable antibody in umbilical-cord serum. These data suggest that transplacental transfer of maternal antibody protects infants from invasive Group B streptococcal infection with Type III strains.
In the first part of the paper the author stresses the importance, and the necessity of laboratory investigation of streptococcal infections, in view of the establishment of the clinical and of the etiologic diagnosis, for assessing the efficiency of the treatment applied, for monitoring the recovery of patients, as well as of chronic patients, and for the prevention, and detection of late complications. The complex methodology of laboratory methods of diagnosis in streptococcal infections is presented, stressing the use, and the efficiency of micromethods and of rapid techniques for diagnosis. In the second part of the paper are presented a series of data concerning the epidemiology of streptococcal infecstions in our country, as well as in other countries, with reference to various forms of the acute disease, and of late complications, stressing some particular aspects of the streptococcal infection. Morbidity indexes are presented, as well as death rates for scarlet fever, acute rheumatic fever and rheumatic cardiopathies, as well as the incidence of different serologic groups of the haemolytic type, and the fluctuation of group A serotypes, which have been prevalent over the last years in our country. In view of lowering the morbidity the author recommends an extensive surveillance, organized along the lines of a primary prophylaxis program, as well as of a secondary program of streptococcal infections in high-risk collectivities.
Current status and prospects of laboratory diagnosis of streptococcal infections are analyzed. Available investigation schedules and methods for the detection and identification of Streptococcus pyogenes are assessed in epidemiologic terms. The importance of early laboratory diagnosis of first instances of disease is emphasized. Laboratory tests for streptococcal infection are an important element of prompt epidemiologic evaluation. They are to provide a preventive action rather than state fully-developed epidemics of scarlet fever or angina, as practiced currently. Approaches to the determination of the group and type of the causative agents are assessed critically. Additional investigation methods are presented and described.
Movement disorders as postinfectious manifestation of group A streptococcal infections have been reported and are thought to occur on an autoimmune basis. We describe an unusual case of multifocal myoclonus following strep throat infection. Clinical description and chart review were the method used. A 10-year-old boy developed focal myoclonus involving his right arm and shoulder 1 week after streptococcal throat infection treated with penicillin. His magnetic resonance image was normal, and he initially responded to clonazepam but did not sustain a response. The myoclonus spread to involve all limbs and the trunk becoming multifocal over the next few weeks. He did not have choreoathetosis of Syndenham's chorea. He was given one course of intravenous immunoglobulin and became asymptomatic after treatment. He remained symptom free for 8 months following intravenous immunoglobulin treatment. Various symptoms have been reported following group A streptococcal infections in children. These neurobehavioral abnormalities may be mediated through antineuronal antibodies. Our case demonstrates multifocal myoclonus as a poststreptococcal autoimmune phenomenon. To our knowledge, only two other cases of poststreptococcal myoclonus have been reported in the literature. Recognition of this unusual condition as a manifestation of autoimmune poststreptococcal disease in children is essential to avoid overinvestigation and to ensure early treatment.
Acute rheumatic fever and life-threatening group A streptococcal infections have reemerged during the past 15 years to once again become a serious health threat in the developed countries of the world. Reports of outbreaks of acute rheumatic fever in many parts of this country and others have shattered the complacency that the health-care community had acquired related to this devastating sequela of streptococcal pharyngitis. Invasive streptococcal infections, often associated with loss of limbs of life despite optimal antibiotic therapy, have underscored the potential virulence of these organisms. A new clinical entity, streptococcal toxic shock syndrome, has emerged as a consequence of the new invasive strains of group A streptococci. In this article, the authors summarize the recent changes in the epidemiology of group A streptococcal infections and rheumatic fever and review the potential reasons for the increased virulence of these organisms. In addition, they discuss prospects for a streptococcal M protein vaccine designed to control these infections and their sequelae.
The optimal clinical strategy to prevent neonatal group B streptococcal infection has not been established. The Maternal-Fetal Medicine Units Network assessed the feasibility of a randomized clinical trial to compare the effectiveness of two methods of prevention of streptococcal infection. The attack rates of early-onset group B streptococcal disease were estimated for the following: 1) a hypothetical program of universal prenatal screening and selective intrapartum chemoprophylaxis, and 2) a hypothetical program of selective intrapartum chemoprophylaxis based on clinical risk factors. Sample size requirements were calculated for a clinical trial to detect a significant difference in attack rates between the two hypothetical programs. Similar low attack rates using both strategies would require extremely large sample sizes to detect differences between programs. Until a satisfactory, rapid diagnostic test for intrapartum group B streptococcal carrier status is developed and clinical strategies are tested in populations with varying carriage frequencies, institutions will need to individualize their approaches to prevent early-onset neonatal group B streptococcal disease.
OBJECTIVE: To increase awareness and understanding of the putative role of streptococcal infection in the development of neuropsychiatric disorders in children and to discuss therapeutic options in this group of patients. METHODS: Case illustration and literature review. RESULTS: Two siblings, one with obsessive-compulsive disorder (OCD) and one with a tic disorder, had tonsillectomy for recurrent streptococcal pharyngitis. At the latest follow-up visit (11 mo postoperatively), both patients exhibited significant improvement in their psychiatric illnesses. We discuss these cases as well as the diagnosis, pathophysiology, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). CONCLUSION: PANDAS is an active area of research investigating the relationship between streptococcal infections and the development of obsessive-compulsive disorder or tic disorders (or both) in children. The etiopathogenesis of PANDAS is thought to reflect autoimmune mechanisms and involvement of the basal ganglia of susceptible hosts. Because otolaryngologists evaluate a large portion of pediatric patients with recurrent streptococcal pharyngitis, it is important to be aware of this association and to manage these patients appropriately.
The diagnosis of group A streptococcal disease still relies on isolation of group A streptococcal strains on sheep blood agar followed by presumptive identification based on bacitracin sensitivity or the results of the more precise serogrouping methods such as the Lancefield precipitin test. A technique that would permit rapid identification of streptococcal infections directly from throat secretions would allow immediate appropriate antimicrobial therapy for the management of streptococcal infections to be started. We have been able to identify soluble group A antigen directly from throat secretions by using a latex agglutination test. In a clinical trial in which latex (Streptex group A) and conventional culturing techniques were used, 53 throat secretion cultures were tested: 26 were positive by both procedures, 5 were positive by culture only, 3 were positive by the latex agglutination test only, and 19 were negative by both tests.
OBJECTIVE: To differentiate the features of serious, perinatal, group A streptococcal infection from other types of streptococcal toxic shock syndrome. DATA SOURCES: Thirty-eight obstetric cases that were fatal or fulfilled the criteria of Centers of Disease Control and Prevention for streptococcal toxic shock syndrome were reviewed. Three cases were from Asahi General Hospital, 26 from MEDLINE (1966-December 1998), four from Japana Centra Revuo Medicina (1987-November 1998) using the search terms "Streptococcus," "Streptococcus pyogenes," "Streptococcal infection," "pregnancy," "labor," "delivery," "sepsis," and "shock," and five from official records of the Ministry of Health and Welfare of Japan. Cases of early pregnancy or cases that had unclear intervals between delivery and deterioration were eliminated. INTEGRATION AND RESULTS: The 30 cases were divided into two groups by interval between delivery and deterioration. Seventeen cases deteriorated before, during, or within 12 hours of delivery (perinatal group). They were compared with 13 cases of the puerperal group. The mortality rates for infants and mothers in the perinatal group were higher than those of the puerperal group (infant: ten of 17 versus zero of 13, mother: 15 of 17 versus seven of 13). The other differences of description were unusually strong labor (eight of 17 versus one of 13), obvious serious inflammation (zero of 17 versus ten of 13), and evidence of serious sepsis (eight of 17 versus zero of 13). Purulent myometritis without neighboring inflammation was found in our three cases. In ten cases, subjects or their family members had preceding sore throats. CONCLUSION: The cases in the perinatal group had characteristic features. We suspected that after invading the myometrium through the upper respiratory tract, large amounts of cocci were dispersed into the systemic circulation of the mother by active uterine contractions caused by purulent myometritis. Unusual clinical signs were important for diagnosis.
Invasive group A streptococcal infection is an uncommon but severe disease. Bloodcultures usually yield growth of Streptococcus pyogenes and the bacteria may also be isolated from sterile sites e.g. muscle or pleura. The most serious manifestation is Streptococcal Toxic Shock Syndrome (STSS) with or without necrotizing fasciitis (NF). This condition may occur in about a fifth of the cases with a very high case-fatality rate. Preclinical data and case reports suggest that the fatality rate can be reduced by treatment of high-dose intravenous immunoglobulin. A European placebo-controlled clinical trial with immunoglobulin has been conducted but was prematurely terminated due to difficulties in patient recruitment. In our clinic we have during the last 3.5 years seen 41 patients with invasive group A streptococcal infection and 11 of these have received high-dose immunoglobulin. The indication for that treatment has been hypotension and multiorgan failure. All 11 patients but one fullfilled the criteria for STSS and 5 had NF. Most of the patients were treated with a single dose intravenous infusion of 50 g immunoglobulin. All patients were treated with both benzylpenicillin and clindamycin. Ten patients were fully recovered--case-fatality rate 9 percent. We suggest that patients with invasive group A streptococcal infections who develop STSS with or without NF should be treated with high-dose intravenous immunoglobulin.
BACKGROUND AND DESIGN: Although the association between streptococcal infection and guttate psoriasis is well known, to date there has been little information on whether only limited groups and/or serotypes of beta-hemolytic streptococci are involved. One hundred eleven patients with a sudden onset or deterioration of psoriasis were investigated for evidence of streptococcal infection. Of these patients, 34 had acute guttate psoriasis, 30 had a guttate flare of chronic psoriasis, 37 had chronic plaque psoriasis, and 10 had other types of psoriasis. RESULTS: Serologic evidence of recent streptococcal infection was present in 19 (58%) of 33 patients with acute guttate psoriasis compared with seven (26%) of 27 patients with guttate exacerbations of chronic psoriasis. Streptococcus pyogenes was isolated from 19 (17%) of all 111 patients (9 [26%] of 34 with acute guttate psoriasis, four [13%] of 30 with guttate exacerbations of chronic psoriasis, and five [14%] of 37 patients with chronic psoriasis) compared with seven (7%) of 101 of a control population of patients being seen for treatment of viral warts. Other beta-hemolytic streptococci were found with equal frequency in the study and control populations. Thirteen isolates of 10 different streptococcal serotypes were obtained from the 64 patients with guttate psoriasis. These serotypes were similar in distribution and prevalence to those present in the local community. CONCLUSIONS: This study confirms the strong association between prior infection with S pyogenes and guttate psoriasis but suggests that the ability to trigger guttate psoriasis is not serotype specific.
OBJECTIVE: To identify the incidence of early-onset group B streptococcal infection and to describe the antecedent maternal risk factors, in order to provide data to inform the design of interventional strategies that could be introduced in the UK to reduce the burden of this infection. DESIGN: A retrospective study with review of case notes of mothers and babies. SETTING: Seven maternity units in London during 1990-1999. Population All cases of proven early-onset neonatal group B streptococcal infection. METHODS: Identification of presence of risk factors that could be used to select women for the offer of intrapartum antibiotic prophylaxis. MAIN OUTCOME MEASURES: Incidence and case-fatality rate of invasive early-onset group B infection. RESULTS: One hundred and forty cases were identified among a birth cohort of 198,388 live births, an incidence of 0.71 per 1000 live births. Twenty-two babies died, a case-fatality rate of 15.6% or 1.1 per 100,000 live births. Women of black ethnic origin, and those who had had a previously affected infant, multiple pregnancy, preterm delivery, prolonged rupture of membranes or intrapartum fever all had a significantly increased risk of delivering an infected infant. CONCLUSIONS: These data suggest that the incidence of early-onset group B streptococcal infection in these London centres is sufficiently high to warrant administration of intrapartum antibiotics to at-risk women.