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.

[The significance of antistreptolysin O characteristics for the determination of indications for tonsillectomy in the children]. / Znachenie pokazatelei antistreptolizina O pri opredelenii pokazanii k tonzilléktomii u detei.

The objective of the present work was to evaluate the diagnostic significance of the measurement of the antistreptolysin O (ASLO) titers in the children presenting with chronic tonsillitis for determining the indications for tonsillectomy. The study included 54 patients at the age varying from 4 to 17 years who had undergone bilateral tonsillectomy for the treatment of chronic tonsillitis. The diagnosis was confirmed by the results of the histological study of the removed amygdalae. Prior to surgery, all the patients had been subjected to the bacteriological investigation of the smears taken from the surface of the palatal tonsils. The titers of antistreptolysin O in the serum were determined with the use of the kinetic nephelometric technique before, 6 and 12 months after the surgical intervention. The results of the measurements were treated using the Statzilla software package (version 3.2, R Foundation for Statistical Computing, Vienna, Austria). Streptococcus pyogenes (group A) was identified only in 7 (13%) patients. The initially enhanced content of ASLO ranging from 273 to 1880 IU/ml was documented in 42 (77.7%) of the 54 patients. Twelve patients had the ASLO titers within the normal limits (from 13 to 124 IU/ml). The removal of palatal tonsils resulted in a significant decrease of the ASLO titers in the patients who had presented with the initially enhanced content of antistreptolysin O (p < 0.05); nevertheless, their ASLO titers remained higher than the normal values in 69% and 82% of the patients examined within 6 and 12 months after the surgical intervention, respectively. The patients who had exhibited the high levels of antistreptolysin O during the preoperative period did not experience normalization of this parameter after surgery. It is concluded, taking into account the absence of correlation between the enhancement of serum antistreptolysin O titers and the presence of group A beta-chemolytic Streptococci (BCSA), that the result of the measurement of ASLO titers can not be considered as a valid indication for tonsillectomy in the children.

Clinical value of antistreptolysin O levels in adult patients with tonsillitis: report I.

To assess the clinical value of antistreptolysin O (ASO) level in adult patients with acute tonsillitis of group A beta-hemolytic streptococcus (GABHS) etiology and its interaction with the Centor score and throat cultures data. ASO antibody titers and throat cultures were obtained from 260 adult patients with acute tonsillitis of GABHS etiology initially proven by the Centor score. The results were compared with the group of 100 adult patients with recurrent tonsillitis who underwent tonsillectomy and with the group of 100 healthy adults. Throat cultures revealed GABHS-positive results in 69 acute cases (26.5%) and in 24 recurrent cases (24%), i.e., with no significant differences between the groups (p = 0.845). There was no significant difference between cases with GABHS-positive and with GABHS-negative throat culture in ASO titers results (mean 250 and 280, respectively, p = 0.44) but these titers were significantly higher than established normative data (p < 0.01). For the group of recurrent tonsillitis cases, the mean ASO titer was 363 being significantly higher in comparison with acute cases (p = 0.015). The ASO antibody titers are significantly higher than normative ranges in cases of acute tonsillitis in adults. The detection of the elevated titers may lead to early antibiotherapy to tonsillitis. The Centor score is supported by the ASO data and less supported by throat cultures data. Further research should reveal if these titers might have predictive value for possible further recurrence or serve as an indicator for tonsillectomy in cases of recurrent tonsillitis.

Antibasal Ganglia Antibodies and Antistreptolysin O in Noncomorbid ADHD.

OBJECTIVE: An association between streptococcal infections, ABGA positivity, and no comorbidity ADHD (nc-ADHD) has been little investigated. The aim of this study was to evaluate the streptococcal infection frequency, defined entitled serum antistreptolysin O (ASO), and frequency of serum ABGA positivity in a sample of patients with nc-ADHD. METHOD: In all 40 participants were investigated the ASO titer and ABGA. RESULTS: The results showed that ABGA positivity was statistically significantly higher in patients affected by ADHD than in patients of a control group, and pathological values of ASO were statistically more frequent in the ADHD group than the control group. CONCLUSION: These data suggest that streptococcal infections and autoimmune reactions against the basal ganglia are more frequent in ADHD patients than patients in a control group.

Urticaria recurrente asociada a infección por Streptococcus pyogenes / Recurrent urticaria associated with group Streptococcus pyogenes infection

La mayoría de las urticarias crónicas o agudas recidivantes son idiopáticas. Presentamos un caso de urticaria aguda recidivante en una niña de tres años, en la que, tras el estudio realizado, solo se objetivó un valor elevado de anticuerpos antiestreptolisina O (ASLO). La desaparición de la urticaria tras el tratamiento con penicilina G-benzatina intramuscular, junto con la normalización de los ASLO, sugiere que la etiología de esta podría ser las infecciones recurrentes por el Streptococcus pyogenes. Destacar la importancia de incluir en el protocolo diagnóstico de la urticaria la determinación de los ASLO, lo cual permite el diagnóstico y tratamiento precoces de las infecciones por S. pyogenes (AU)

We present a case of relapsing acute urticaria in a three years old girl who after the study only showed a high value of ASLO (antistreptolysin O titer). The disappearance of urticaria after intramuscular penicillin G benzathine treatment, together with the ASLO normalization, suggested that the etiology of this could be recurrent Streptococcal infections. We conclude the importance of including ASLO determination in the diagnostic protocol of urticaria, allowing early diagnosis and treatment of Group A Streptococcus infections (AU)

Neutrophilic figurate erythema of infancy.

We report here a new case of neutrophilic figurate erythema of infancy in a 1-year and 9-month-old white boy. Neutrophilic figurate erythema of infancy is a rare inflammatory dermatosis which is part of the figurate inflammatory dermatoses of infancy and is considered a variant of annular erythema of infancy. The disease is clinically characterized by annular erythematous lesions, sometimes with a polycyclic configuration, and histologically by a dermal neutrophilic infiltration with leukocytoclasia. Differential diagnosis mainly includes clear-cut severe diseases with a well-known etiology, such as neonatal lupus erythematosus and its variant erythema gyratum atrophicans transiens neonatale, erythema chronicum migrans and erythema marginatum rheumaticum, and diseases of unknown origin and with less clear limits, such as erythema annulare centrifugum and its variant familial annular erythema. Anamnesis, laboratory findings, clinical features, and histology allow the correct diagnosis and therefore, having excluded severe diseases, parents should be reassured as neutrophilic figurate erythema of infancy, as the annular erythema of infancy, is a benign disease, in most cases unassociated with other conditions and usually self-limiting over a few months, even though a chronic course may rarely occur. Our case was characterized by a chronic persistent course and by a complete resolution of the lesions only during febrile episodes.

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.

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]. / Asymptomatische Myokarditis nach Infekt der oberen Luftwege.

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.

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.

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.

[Clinical immunological characteristics of the pathogenesis of catarrhal gingivitis (Communication 1)]. / Kliniko-immunologicheskie osobennosti patogeneza kataral'nogog gingivita (Soobshchenie 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.