Twelve to seventeen-year follow-up of patients with poststreptococcal acute glomerulonephritis in Trinidad

Three patients of the 760 with symptomatic poststreptococcal acute glomerulonephritis in Trinidad who were chosen for follow-up in 1968 or 1970 apparently had not healed initially and consistently had hematuria, usually with proteinuria, in our studies. One of these patients died in renal failure between 1972 and 1976 (six to 10 years after her initial illness). The other two are now 19 and 25 years old, 12 and 15 years after their initial illnesses, with normal blood pressures and serum creatinine values. Another 14 of the 534 patients currently examined had persistent abnormalities: three of these 14 appeared to have had lipoid nephrosis in the beginning, with recurrent proteinria since then; two had urinary-tract infections when examined; one had probably had a third attack of poststreptococcal acute glomerulonephritis; and eight had acquired proteinuria, which may or may not have been related to poststreptococcal acute glomerulonephritis. Thus, our data continue to indicate a good long-term prognosis for most of the patients with this disease in Trinindad.(AU)

Continued absence of clinical renal disease seven to 12 years after poststreptococcal acute glomerulonephritis in Trinidad

Continued improvement was noted among 722 patients in Trinidad seven to 12 years after the onset of poststreptococcal glomerulonephritis. In the five years since earlier follow-up, two of 709 patients with previous symptomatic disease apparently had died from renal failure, and 10 patients had died from unrelated causes. Nineteen patients presently had proteinuria, three had hematurias, and three had proteinuria plus hematuria. Of these abnormalities, proteinurias in only three patients and proteinuria plus hematuria in three more patients were persistent. Thus, 0.8 per cent of the study group had persistent abnormalities. When one adds those dead with renal disease, the percentage with renal damage becomes 1.1 per cent. In addition, six patients had protein in the two urine samples obtained after assuming the lordotic position for 10 minutes and in only one of the two urine samples obtained upon rising in the morning, making 1.4 per cent with probable evidence of chronic renal disease including the dead patients. Hypertension was present in 16 (2.3 per cent) of the patients and was much more common in those more than 20 years old (18.4 per cent). However, this prevalence of hypertension did not exceed that found in normal Trinidadians. Only three patients had serum creatitine values greater than 1.2 mg/dl. None of 13 patients with previous asymptomatic glomerulonephritis presently showed any abnormality. Thus, very few cases of chronic poststreptococcal glomerulonephritis appear to have developed in the 722 patients studied (AU)

Tropical acute rheumatic fever and associated streptococcal infections compared with concurrent acute glomerulonephritis

Ninety-three patients with acute rheumatic fever and 195 patients with acute glomerulonephritis were observed in Trinidad during an outbreak of scabies with a high incidence of secondary streptococcal infections. Clinical and laboratory manifestations of ARF were the same as those seen in temperate zones, except that antistreptolysin O titers were less markedly increased. The patients with ARF were similar to those with AGN in respect to sex, race, location of residence, and living conditions, but were older and had markedly fewer skin infections. Currently prevalent nephritogenic streptococcal strains never were isolated from patients with ARF even when M55 streptococci appeared and led to an epidemic of AGN.(AU)

The families of patients with acute rheumatic fever or glomerulonephritis in Trinidad

The families of 21 patients with acute rheumatic fever (ARF) and 44 patients with acute glomerulonephritis (AGN) in Trinidad were examined in their homes. The ARF and AGN families were equally large and crowded and they lived in the same largely rural areas. However, only 22 percent of the ARF family members had skin infections in contrast to 61 percent of the AGN family members. Sixty-eight per cent of skin infections in ARF families and 69 percent of skin infection in AGN families yielded group A streptococci. Throat cultures were positive in 19 percent of ARF family members and 25 percent of AGN family members. Thirty-two per cent of 51 group A strains isolated from ARF family members (29 from throat, 22 from skin) were M11 of "M41" strains which were associated with ARF during the study, while only 8 percent were M1, T4 (MNT or 60) or M55 strains which were associated with AGN. In contrast, 49 percent of 171 group A strains isolated from AGN family members (64 from throat, 107 from skin) were M1, T4 (MNT or 60) of M55 while only 10 percent were M11 of "M41." Serum antibody titres were similar in both groups: antistreptolysin-0 titres were not markedly increased in either while anti-hyaluronidase and/or antideoxyribonuclease-B titres were increased in both. Evidence of subclinical AGN was found equally often in both groups: 6 percent of each had abnormal urine and 4 percent of each had decreased serum complement while 2 percent of the ARF and 3 percent of the AGN family members had both abnormal urine and decreased serum complement.(AU)

Epidemic acute nephritis associated with re-appearance of type 55 streptococcus - abstract

A large epidemic of acute glomerulonephritis occurred in South Trinidad in 1971, the fourth since 1952. Seven hundred and forty-three (743) cases were admitted to the San Fernando hospital during the year. After a high endemic period during the first 5 months, an epidemic broke out in June, 1971 and 598 patients were admitted with acute glomerulonephritis from June to the first week of December. This coincided with an epidemic of scabies in the island. Fifty-five per cent of the patients had scabies with secondary infection. Pyoderma was found in 441 patients (43.7 percent). Sixty-one families had more than one case of acute nephritis. Laboratory investigation included cultures of the skin and throat, grouping and typing of the streptococci, serial estimations of compliment (BIC), Antistreptolysin O titre, BUN and weekly urinalysis. Group A Beta haemolytic streptococci were isolated from 434 patients (73 percent). There were 335 positive cultures from skin sores and 278 from the throat. One hundred and seventy-nine (179) patients had Beta haemolytic streptococci in both skin sores and throat. Of the strains that were M-typed, 245 (60.6 percent) were M-typed 55. T-typing of the streptococci showed that 78.3 percent agglutinated with all the pools (T, U, W, X, Y, and Z). Type 55 streptococcus was first discovered in Trinidad in 1965 and its re-appearance with the 1971 epidemic confirms its nephritogenicity. In marked contrast, there was no increase in the number of cases of acute rheumatic fever, although these patients came from the same socio-economic group and the same areas affected by the epidemic of post-streptococcal acute glomerulonephritis (AU)

Observations on acute rheumatic fever in Trinidad during an outbreak of scabies and acute nephritis - abstract

We have been looking for differentiating aspects of the streptococcal infections associated with acute rheumatic fever (ARF) and acute alonerulonephritis (AGN) in Trinidad since November 1969. At this meeting last year, we reported our first 10 months' observation which were made during a period when AGN was endemic. Since then an outbreak of scabies accompanied by a major epidemic of AGN has occurred which afforded an excellent opportunity to study and compare the related streptococcal infections. Observations to be reported presently include the following: (1) While the number of cases of AGN increased nearly 10-fold to over 150 in both August and September, ARF increased only to less than 20 cases a month during the height of the epidemic of AGN. (2) The scabies epidemic was associated with AGN while skin lesions continued to be relatively rare in patients with ARF. (3) The streptococcal strains isolated from patients with AGN and ARF were not the same, the epidemic M-type 55 being associated with AGN but not ARF while M-type 11 strains were found in many patients with ARF and in none with AGN, (4) Antibody titres were similar in the two groups of patients as reflected by ASO and AH titres; the former continued to be low, while the latter continued to be increased. Thus, we conclude that although the antibody responses of patients with ARF and AGN are similar in Trinidad, skin infections are associated with AGN but not with ARF and the nephritogenic and rheumatogenic streptococcal strains are different (AU)

Epidemic diphtheria and skin infections in Trinidad

Patients with nephritis and schoolchildren in South Trinidad were surveyed for the presence of Corynebacterium diphtheriae in throats and skin lesions. The incidence of positive cultures was higher in skin leisons than in throat cultures. None of the children experienced symptoms of systemic intoxication. Subsequent to the increase in cutaneous infections, however, the indidence of symptomatic nasopharyngeal diphtheria also increased in Trinidad, suggesting that the skin lesions constituted an important reservior of infection. One group of schoolchildren was reexamined after six months, and the levels of antitoxin in serum were correlated with the presence of C. diphtheriae in skin leisons and throat cultures. The high levels of antitoxins observed apparently resulted from natural immunization in the absence of clinical signs of diphtheria. No effect of C. diphtheriae was noted on the colonization of skin lesions by streptocci or on the incidence of acute glomerulonephritis in the population. (AU)

Relationship of acute rheumatic fever to acute glomerulonephritis in Trinidad

The incidence of acute rheumatic fever decreased during a major epidemic of acute glomerulonephritis in Trinidad in 1965. Subsequently, several minor increases in the incidence of acute rheumatic fever have been coincident with more marked increases in the incidence of acute glomerulonephritis. The relation of streptococcal infections to acute glomerulonephritis has been studied in Trinidad for the past six years. Their relation to acute rheumatic fever also has been examined during the last year of these studies. The streptococcal strains isolated from patients with acute rheumatic fever generally have differed from those found in patients with acute glomerulonephritis. Moreover, while streptococcal skin infections have been associated with acute glomerulonephritis, no such association has been apparent with rheumatic fever. However, titers of antistreptolysin O were relatively low, while titers of antihyaluronidase were makedly increased in the patients with acute rheumatic fever, much as they have been in most patients with acute glomerulonephritis in Trinidad (AU)

Epidemiology of acute rheumatic fever in South Trinidad - abstract

Streptococcal infections have been studied in South Trinidad during and for five years following a major epidemic of acute glomerulonephritiis (AGN). Many of these infections have been in the skin, especially in children in the rural areas. The relation of these infections to acute rheumatic fever (ARF) also has been examined with the following conclusions: During the mafor epidemic of AGN in 1964 and 1965, the incidence, of ARF decreased. This is in accordance with the current hypothesis that rheumatogenic streptococcal strains rarely are nephritgenic and vice versa. Since 1966, however, three increases in incidence of AGN have been accompanied by modest increases in the incidence of ARF. The streptococcal strains isolated from patients with ARF usually were not of the types concurrently isolated from patients with AGN. Moreover the lack of skin infections in the patients with ARF is striking in comparison with "normal" school children as well as with patients with AGN. Antristreptolysin O (ASO) titres in patients with ARF, as with AGN, increased only slightly or not at all while antithyaluroindase titres increased to similar high values in patients with both AGN and ARF. The lack of increased ASO titres in patients with ARF is in control to observations in other geographic areas where they consistently have been high. The lack of increased ASO titres in patients with AGN in Trinidad, as in other areas where AGN is associated with skin infections, has been attributed to the site of infections. However, no cases of ARF have been definitely related to skin infections in Trinidad or elsewhere (AU)

Epidemic scabies and acute glomerulonephritis in Trinidad

In September, 1970, an increasing number of the patients admitted with acute glomerulonephritis to San Fernado General Hospital in Trinidad were noted to have skin lesions characteristic of scabies. á-haemolytic streptococci were isolated from these lesions and also from similar scabetic lesions in members of the patients' families, in " normal" schoolchildren, and in the general population of a small village. Concomitantly, many dogs in nephritic households, as well as others running wild, were observed to have lesions compatible with scabies from which á-haemolytic streptococci also were isolated. Sarcoptes scabiei were indentified in lesions of both patients and dogs and were morphologically indentical. After the onset of this infestation with scabies, the admission-rate of patients with acute proportions which have proved, since this study, to be the beginning of the largest epidemic of acute glomerulonephritis yet recorded in Trinidad.(AU)

Subclinical nephritis in South Trinidad

Incidental urines from 2019 members of the family households of 369 patients hospitalized wih acute glomerulonephritis, 1605 residents of a village, and 1299 school-children were tested with Hema-Combistix. (In this report, the family of a patient is termed a nephritis family.) Hematuria was more frequent in nephritis family members under 10 years old than in similiar control subjects. Proteinuria was more frequent in nephritis family members aged 10 to 30 and 40 to 60 years than in similiar village residents. The control school-children (tested at school) had proteinuria more frequently than did nephritis family children (tested at home). Urine abnormalities were found in 219 of the nephritis family members. Subtracting similiar urine abnormalities found in the control groups from those of the nephritis family members leaves 98 of these abnormalities presumably attributed to family asociation with currently hospitalized cases of acute nephritis. Serum á-1-C gloulin was decreased in 16 of the nephritis family members with urine abnormalities and in only one of 207 subjects from the control groups. Decreased serum á-1-C globulin was associated with mild stigmata of acute glomerulonephritis in the nephritis family members (AU)

Changing types of nephritogenic streptococci in Trinidad

The relation of seven different M types of streptococci to acute glomerulonephritis associated with skin lesions in South Trinidad has been studied by means of type-specific antibody assays as well as by isolation and identification of the strains. The data indicate that, one after another, five of these strains have prevailed among patients with acute glomerulonephritis during the past five years. At least three of the strains (M-types 55,49,57, and/or 60) were associated with epidemic increases in nephritis cases. The appearance of five consecutively predominant types of nephritogenic streptococci during a relatively short period of time is in contrast to the continuing prevalence of M-type 12 strains among nephritogenic streptococci primarily associated with respiratory infections in temperate zones. These observations suggest that the skin sores commonly found on children in tropical Trinidad, provide a particularly suitable environment for development of nephritogenic types. It remains to be seen whether these types will recur or whether new types will continue to emerge in Trinidad. (AU)

Streptococcal skin infections and epidemic acute nephritis in Trinidad

We have presented bacteriological evidence for an association of acute glomerulonephritis with several streptococcal strains isolated from skin lesions in Trinidad: Types 52 and 55 during the first wave and type 49 during the second wave of the 1964-65 epidemic; atypical "type 2" in a sub-epidemic rise in cases during an endemic year; type 57 during a subsequent epidemic period; and type 60 most recently. Immunological confirmation of association of these strains with acute glomerulonephritis was obtained only for type 55. Low incidence of serum type specific antibodies to types 49 and "type 2" may be attributed to their poor antigenicity. However, this is not the case with type 57. Emergence of at least five and perhaps six apparently new types of nephritogenic streptococci during a relatively short period suggests that each recurrent epidemic wave of acute nephritis is the result of a newly introduced or newly developed strain of nephritogenic streptococci. Several questions might be asked: From where do these different types come? Does a skin infection represent a particularly suitable environment for development of new streptococcal antigens? (Summary)

Characteristics of beta hemolytic streptococci associated with acute glomerulonephritis in Trinidad, West Indies

Twenty-seven strains of beta hemolytic streptococci from patients with acute glomerulonephritis and 212 strains from school children were isolated in Trinidad during an epidemic of nephritis involving over 1,000 patients. Sixty-two per cent of the 27 strains from nephritic patients and 3 strains from school children belonged to an apparently new serotype referred to here as Trinidad type A. Type-specific antibodies against this type were found in 50 per cent of 56 patients 1 to 3 months after acute glomerulonephritis. Six of the 10 remaining strains from patients with nephritis and 34 strains from school children were characterized as a second new type B. This strain contained M protein of provisional type Schoenborn isolated from pyoderma in Red Lake, Minnesota. It also contained a second antigen found in some type 41 strains of streptococci. Studies of temperate bacteriophage related to these strains suggested a possible association with nephritis in a negative way. With one exception, streptococci strains from nephritic patients were not lysogenic, while antiphage activity was observed in sera from 72 per cent of 50 patients. Moreover, 33 per cent of 86 strains from school children in areas where nephritis was occurring were lysogenic, while only 3 of 46 strains from areas without nephritis contained bacteriophage.(AU)

Recurrent epidemic nephritis in South Trinidad

An unusually large epidemic of acute glomerulonephritis occurred in Trinidad, the third outbreak on that island in fifteen years. Clinical and laboratory observations on 681 cases in South Trinidad are presented in this report. These data indicated that the majority of cases were poststreptococcal acute glomerulonephritis, associated with impetiginous sores, which are common among children in Trinidad. (AU)