Comparison of Two Rapid Tests for Detecting Group A Streptococcal Pharyngitis in the Pediatric Population at Wright-Patterson Air Force Base

This prospective cohort study compared two rapid antigen tests for group A streptococcus in an enrolled pediatric population of a busy Air Force clinic during the autumn of 2005. The study was performed to determine whether the Genzyme test was a more sensitive rapid test than the currently used Quidel test. A highly sensitive rapid test would eliminate the need to perform backup cultures, thus saving time and facilitating faster diagnosis and treatment. The study revealed that the Genzyme test was more sensitive (85.5%) than the Quidel test (79.5%). However, the difference was not statistically significant using the McNemar chi(2) tool and was attributable to random variability. Therefore, future comparative studies need to be performed to find a rapid antigen test with sensitivity comparable to that of throat culture, for use at the Wright-Patterson Air Force Base pediatric clinic.

Active and passive immunizations with the streptococcal esterase Sse protect mice against subcutaneous infection with group A streptococci

The human pathogen group A Streptococcus (GAS) produces many secreted proteins that play important roles in GAS pathogenesis, including hydrolases that degrade proteins and nucleic acids. This study targets another kind of hydrolase, carboxylic esterase, with the objectives of identifying GAS esterase and determining whether it is a protective antigen. The putative esterase gene SPy1718 was cloned, and the recombinant protein (Sse) was prepared. Sse was detected in GAS culture supernatant, and patients with streptococcal pharyngitis seroconverted to Sse, indicating that Sse was produced in vivo and in vitro. Sse hydrolyzes p-nitrophenyl butyrate, and the residue (178)Ser is critical for this esterase activity. There are two Sse variant complexes according to the available genome databases, consistent with the previous finding of two antigenic Sse variants. Complex I includes serotypes M1, M2, M3, M5, M6, M12, and M18, whereas M4, M28, and M49 belong to complex II. Sse variants share >98% identity in amino acid sequence within each complex but have about 37% variation between the two groups. Active immunization with M1 Sse significantly protects mice against lethal subcutaneous infection with virulent M1 and M3 strains and inhibits GAS invasion of mouse skin tissue. Passive immunization with anti-Sse antiserum also significantly protects mice against subcutaneous GAS infection, indicating that the protection is mediated by Sse-specific antibodies. The results suggest that Sse plays an important role in tissue invasion and is an antigen protective in subcutaneous infection against GAS strains of more than one serotype.

Immune function in sport and exercise

Regular moderate exercise is associated with a reduced incidence of infection compared with a completely sedentary state. However, prolonged bouts of strenuous exercise cause a temporary depression of various aspects of immune function (e.g., neutrophil respiratory burst, lymphocyte proliferation, monocyte antigen presentation) that usually lasts approximately 3-24 h after exercise, depending on the intensity and duration of the exercise bout. Postexercise immune function dysfunction is most pronounced when the exercise is continuous, prolonged (>1.5 h), of moderate to high intensity (55-75% maximum O(2) uptake), and performed without food intake. Periods of intensified training (overreaching) lasting 1 wk or more may result in longer lasting immune dysfunction. Although elite athletes are not clinically immune deficient, it is possible that the combined effects of small changes in several immune parameters may compromise resistance to common minor illnesses, such as upper respiratory tract infection. However, this may be a small price to pay as the anti-inflammatory effects of exercise mediated through cytokines and/or downregulation of toll-like receptor expression are likely mediators of many of the long-term health benefits of regular exercise.

Ribosomal therapy in the prophylaxis of recurrent pharyngotonsillitis in children

OBJECTIVE

Although much has been written on how to manage recurrent pharyngotonsillitis, it remains a controversial topic. The composition of normal commensal oropharynx bacteria may be disrupted by frequently using antimicrobials, by inhibiting sensitive organisms and by allowing resistant organisms to overgrowth. This may cause the recurrence of acute episodes. The aim of this study was to evaluate the efficacy of ribosomal immunotherapy in the prophylaxis of recurrent pharyngotonsillitis.

METHODS

A total of 160 children aged between 5 and 14 years with recurrent pharyngotonsillitis were ramdomized to receive either ribosomal immunotherapy (group A one tablet a day, 8 days a month for 3 months) or a placebo (group B same dosage for the same period).

RESULTS

At the end of the study, each patient treated with Immucytal presented a subjective decrease of symptoms. Compared with group B, group A experienced a significant improvement of some clinical parameters.

CONCLUSIONS

The results show that ribosomal immunotherapy causes a significant improvement of both specific and non-specific immunity and may be effective in the prophylaxis of recurrent pharyngotonsillitis and in preventing recurrences without entailing side effects or bacterial resistance.

Genetic susceptibility to rheumatic heart disease and streptococcal pharyngitis: association with HLA-DR alleles

Acute rheumatic fever (ARF) is a systemic inflammatory disease that develops as a consequence of an exaggerated immune response to group A beta-haemolytic streptococci, which causes pharyngitis. Major manifestations of ARF include carditis, arthritis and chorea. Several investigators have attempted to establish a relation between ARF and human leucocyte antigens (HLA). Heterogeneity in various studies has been found, although associations with certain antigens were reported. The aim of this study was to analyse whether HLA-DR alleles play a role in the resistance or susceptibility to streptococci-related disorders including rheumatic heart disease (RHD) as a sequela of ARF and recurrent streptococcal pharyngitis in Turkish patients. The study included 102 patients with RHD, 71 persons with recurrent streptococcal pharyngitis and 130 healthy controls. HLA-DR alleles were typed by using polymerase chain reaction (PCR)-sequence-specific primers. Positive association with HLA-DRB1*07 allele was found for RHD when compared with healthy controls [29.4% vs 13.1%; P < 0.01, P-corrected: P < 0.01, odds ratio (OR) 2.78, 95% confidence interval (CI) 1.43-5.26] and also for recurrent streptococcal pharyngitis (26.8% vs 13.1%; P < 0.05, P-corrected: P < 0.05, OR 2.44, 95% CI 1.17-3.56). The frequency of HLA-DRB1*11 allele was decreased in patients with RHD (23.5% vs 42.3%; P < 0.01, P-corrected: P < 0.01, OR 0.42, 95% CI 0.24-0.75). Data suggest that HLA-DRB1*07 allele may be a genetic factor in increasing the susceptibility to develop RHD and recurrent streptococcal pharyngitis. HLA-DRB1*11 allele seems to be a protective factor against RHD.

A study of the factors responsible for the development of allergic diseases in early life

In order to analyze the determinants involved in the development of allergic diseases early in infancy, we examined the environmental and genetic factors that might affect the induction of such diseases during infancy, using a questionnaire. Maternal pharyngitis during pregnancy was significantly related to the development of atopic dermatitis in their progeny. Moreover, the frequency of the maternal infection was associated with a significantly increased risk of allergy in their infants. The prevalence of post-delivery maternal allergy was positively linked to the allergic symptoms in their children while the likelihood of bearing allergic children was related to the numbers of allergic individuals within their family. These results suggested that pre- and post-natal maternal factors and any genetic predisposition might modify the development of allergy in infancy.

[Lymphocyte subsets in patients with recurrent upper airway infections]

The aim of our study was to evaluate the digressions of lymphocyte subsets in patients with recurrent upper airway infectious diseases.

METHODS

We studied 35 patients (mean of age 11.1+/-2.1 years) with recurrent upper airway infections. The first group consisted of patients, who had acute upper airway infections: rhinitis, pharyngitis, laryngitis and tracheitis more than 6 times per last year, sinusitis or otitis more than 4 times per last year. The control group comprised of 9 healthy subjects. Subsets of lymphocytes (CD3+, CD4+, CD8+, CD4+/CD8+, CD16+/56+ and CD19+) were detected by FACS Calibur cytometer.

RESULTS

We found a significantly lower count of CD4+ lymphocytes in the patients' group compared to the control group (37.5+/-1.2 vs 45.7+/-3.1% of total lymphocytes, p<0.01). We did not find any significant differences of other lymphocyte subsets between patients and control groups.

CONCLUSION

We propose that patients with recurrent upper airway infections have alterations of the cellular immunity -- decreased amount of CD4+ lymphocytes.

Which is the best method to trace group A streptococci in sore throat patients: culture or GAS antigen test?

OBJECTIVE

To compare an antigen detection test (GAS antigen test) with the results from combinations of two various bacteriological test media in general practice patients with sore throat. Furthermore to assess the diagnostic properties of the chosen GAS antigen test and to compare semi-quantitative results of this test with the bacterial load found in the throat culture.

SETTING

Two Norwegian general practices in Stokke and Kongsberg communities.

SUBJECTS

306 patients with sore throat lasting less than 7 days; 244 were adults, 62 were children under 10 years old, mean age 23.9 years (SD 15.0), 40% were men.

MAIN OUTCOME MEASURES

Results from GAS antigen test, and distribution of bacteriological findings in throat cultures, compared with the results of our GAS antigen test; semi-quantitative results of the GAS antigen test compared with the bacterial load by culture.

RESULTS

In the primary culture 110 patients harboured group A streptococci (GAS) infection, while the second culture identified another 17, giving a total of 127 patients. Some 33 patients harboured large-colony groups C and G. The GAS antigen test used had a sensitivity of 97% and specificity of 95% regarding GAS when compared with the two cultures. We found a significant correlation between the bacterial loads by culture and the semi-quantitative results of the GAS antigen test.

CONCLUSIONS

By using a second, different set of bacteriological media, we identified an additional 17 patients with GAS infections. This raises the question of validity of frequently used reference standards in studies related to streptococcal infections. Compared with the combined results of the two throat cultures, the GAS antigen test used showed high sensitivity and specificity. Semi-quantitative evaluations of the rapid immunological test may also be of clinical value.

D8/17 and CD19 expression on lymphocytes of patients with acute rheumatic fever and Tourette's disorder

D8/17, an alloantigen found on B lymphocytes, has been reported to be elevated in patients susceptible to rheumatic fever and may be associated with autoimmune types of neuropsychiatric disorders. The pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococci model is a putative model of pathogenesis for a group of children whose symptoms of obsessive-compulsive disorder and Tourette's disorder (TD) are abrupt and may be triggered by an infection with group A streptococci. As a test of this model, we have examined D8/17 levels on the B cells of patients with TD and acute rheumatic fever (ARF) along with those on the B cells of normal controls by flow cytometry. We have utilized several different preparations of D8/17 antibody along with a variety of secondary antibodies but have been unable to show an association with an elevated percentage of D8/17-positive, CD19-positive B cells in either ARF or TD. We did find, however, that the percentages of CD19-positive B cells in ARF and TD patients were significantly elevated compared to those in normal controls. Group A streptococcal pharyngitis patients also had an elevated percentage of CD19 B cells, however. These studies failed to confirm the utility of determining the percentage of B cells expressing the D8/17 alloantigen in ARF patients or our sample of TD patients. In contrast, the percentage of CD19-positive B cells was significantly elevated in ARF and TD patients, as well as group A streptococcal pharyngitis patients, suggesting a role for inflammation and/or autoimmunity in the pathogenesis of these disorders.

Reduced IFN-gamma responses associated with HLA-DR15 presentation of streptococcal cell wall proteins to dermal Th-1 cells in psoriasis

We have recently described a group A streptococcal (GAS)-reactive Th-1 subset specifically present in skin lesions of chronic plaque psoriasis. To investigate MHC presentation of GAS cell wall proteins, dermal T cell lines (TCL) cultured from the lesional skin of 39 HLA-typed psoriasis patients were stimulated with a cell wall extract, stained for intracellular IFN-gamma expression, and analyzed by flow cytometry. TCL from a further seven psoriasis patients were also tested with S. mutans extract. Eight TCL were tested in the presence of anti-Class II antibodies or allogeneic antigen-presenting cells. The dermal T cell IFN-gamma responses to the cell wall extract, which ranged from < 1 to 28%, were significantly higher than that to S. mutans extract (p = 0.0052) and were self-HLA-DR allele restricted. A significantly decreased response was observed in TCL from DR15+ (n = 13) versus DR15- (n = 26) patients (p = 0.0377). In addition, DR15+ patients had a later age of onset of disease and a decreased history of sore throats. In contrast, TCL from HLA-DR7+ (n = 23) patients responded similarly to those from individuals lacking the DR7 allele. However, DR7+ patients who coexpressed the MHC Class I antigen, Cw6 (n = 14) had a significantly higher IFN-gamma response than Cw6-, DR7+ patients (n = 7; p = 0.0288) whose responses were also significantly lower than those of patients expressing non-DR7 alleles (n = 16; p = 0.0302). This study has shown that HLA-DR15 expression is associated with a reduced dermal Th-1 response to GAS cell wall proteins in patients with psoriasis. It is proposed that HLA-DR allelic variation may contribute to disease phenotype via effects on the immune response to group A streptococci.

Analysis of Immune Activation and Clinical Events in Acute Infectious Mononucleosis

The symptoms of infectious mononucleosis (IM) are thought to be caused by T cell activation and cytokine production. Surface lymphocyte activation marker (SLAM)-associated protein (SAP) regulates lymphocyte activation via signals from cell-surface CD244 (2B4) and SLAM (CD150). We followed T cell activation via this SAP/SLAM/CD244 pathway in IM and analyzed whether the results were associated with clinical severity. At diagnosis, SAP, SLAM, and CD244 were significantly up-regulated on CD4 and CD8 T cells; expression decreased during IM, but CD244 and SLAM levels remained higher on CD8 cells 40 days later. There were significantly more lymphocytes expressing CD8 and CD244/CD8 in patients with severe sore throat. The expression of CD8 alone and CD244 on CD8 cells correlated with increased virus load. We suggest that T cells expressing CD244 and SLAM are responsible for the clinical features of IM but that the control of activation is maintained by parallel increased expression of SAP.

Immune response to group A streptococcal C5a peptidase in children: implications for vaccine development

The group A streptococcal C5a peptidase (SCPA) is a major surface virulence protein that facilitates the establishment of local infection by group A streptococci (GAS). We measured the human immune response to SCPA, using a standardized indirect enzyme-linked immunosorbent assay. Paired acute and convalescent serum samples from children with GAS-associated pharyngitis were assayed, and a strong immune response to SCPA was demonstrated that was independent of the infecting M type and the age of the patient. Western blot analysis of bacterial extracts revealed that all tested M types expressed SCPA. The immune response to SCPA correlated with the anti-streptolysin O and anti-DNase B responses. These data confirm the immunogenicity of SCPA in humans. Previous knowledge of SPCA's role in virulence, its highly conserved nature, and the results of mouse protection studies make SCPA an ideal vaccine candidate for the prevention of GAS disease.

Parkinsonian features after streptococcal pharyngitis

Bradykinesia and rigidity developed in a 10-year-old girl during an episode of Sydenham chorea. These parkinsonian features improved over 6 months. Serum analysis demonstrated elevated anti-streptolysin-O and anti-basal ganglia antibodies. We suggest that autoimmune antibodies may cause remitting parkinsonian signs subsequent to streptococcal tonsillitis as part of the spectrum of poststreptococcal CNS disease.

[Autoimmune reactions in chronic hypertrophic pharyngitis]

The aim of the study was to examine blood serum and oral liquid of patients with chronic pharyngitis (CF) for autoimmune reaction, i.e. the presence of pharynx-specific antigen (FSA), antibodies to it and complexes antigen-antibody. A total of 29 CF patients were examined and 18 healthy controls. Before the treatment, FSA was detected in the blood and oral liquid in 24.1 and 89.6%, respectively. The indices of the blood and oral liquid correlated. 30 days after conservative treatment the rate of the antigen detection was not less, while after cryosurgical treatment the antigen was not found. Autoantibodies to FSA occurred in the blood of the patients in 86.2%, in the oral liquid in 34.5%. Conservative treatment failed to reduce the antibodies frequency though cryosurgical treatment lowered this frequency to 5.9 and 17.6%, respectively. Immune complexes in the blood of CF patients were registered before the treatment in 10.3%, after conservative treatment in 9.1%, after cryosurgical treatment they were not found. The emergence of autoantibodies and immune complexes may be a normal reaction to introduction of tissue antigen of the affected organ. Detection of the antigen in the blood and oral liquid indicates destruction of the tissue and the test can be used for assessment of the destruction degree.

[Serological assessment of destructive processes in the pharynx in conservative and cryosurgical treatment of patients with chronic hypertrophic laryngitis]

The examination of 29 patients with chronic pharyngitis before the treatment, 10 and 30 days after treatment and 18 controls without ENT pathology revealed that the patients' blood and oral fluid contained the antigen inherent for pharyngeal tissue in 24.1 and 89.6% cases, respectively. This antigen was not found in the controls. The appearance of the tissue antigen in the blood and oral fluid may result from destruction of the inflammed tissue and may entail autoimmune reaction. 10 days after conservative anti-inflammatory treatment 12 patients exhibited a temporary clinical and serological effect--improvement of general condition, attenuation of destructive processes, blood and oral levels of the autoantigen and humoral autoimmune reaction to the tissue antigen. 20 days after the treatment clinical and laboratory manifestations renewed. 10 days after cryosurgery antigenemia and autoimmune reaction persisted but 30 days after the treatment the antigen was found neither in the blood nor in the oral fluid, autoimmune reaction declined. This indicates termination of the inflammation and correlates with clinical results.

[Clinico-immunological effects of cryosurgery in chronic hypertrophic pharyngitis]

The authors observed a clinico-immunological effect of cryosurgical treatment for chronic hypertrophic pharyngitis resistant to previous conservative therapy. Cryosurgery results in the patients' recovery with normalization of basic indices of local and systemic immune defense to day 30. Thus, cryosurgical treatment of patients with chronic hypertrophic pharyngitis has both clinical and immunological advantages over conservative treatment.

Post-streptococcal autoimmune dystonia with isolated bilateral striatal necrosis

Infantile bilateral striatal necrosis (IBSN) is characterized by a dystonic movement disorder and basal ganglia imaging abnormalities. Acute IBSN often occurs after upper respiratory tract infections although no specific micro-organism which may cause IBSN has been identified. We present 2 children (1 year 2 months and 4 years) with acute IBSN after clinical pharyngitis. Both IBSN patients had serological evidence of recent beta-haemolytic streptococcal infection. Due to the association of post-streptococcal disorders with anti-basal ganglia antibodies (ABGA), we examined both patients for anti-neuronal antibodies. For comparison, 20 children with dystonia (9 females, 11 males; mean age 4 years 1 month), and 20 children with uncomplicated streptococcal infection (12 females, 8 males; mean age 5 years 9 months) were examined. Both IBSN patients had antibodies reactive against basal ganglia constituents of molecular weight 40 kDa. Immunohistochemistry showed antibody reactivity against large striatal neurons only. Other anti-neuronal antibodies were negative, supporting striatal specificity. All controls were negative for ABGA. Acute IBSN is part of the poststreptococcal autoimmune neuropsychiatric spectrum. An autoimmune aetiology should be considered in this phenotype, as immunomodulatory therapies may reduce morbidity and mortality.

Post-streptococcal autoimmune neuropsychiatric disease presenting as paroxysmal dystonic choreoathetosis

Paroxysmal dystonic choreoathetosis (PDC) is an episodic, non-kinesogenic, extrapyramidal movement disorder. It is postulated that PDC is an ion channel disorder. We describe a sporadic case of paroxysmal dystonic choreoathetosis occurring after streptococcal pharyngitis. The episodes were characterized by abrupt-onset dystonic posturing, choreoathetosis, visual hallucinations and behavioral disturbance. Each episode lasted between 10 minutes and 4 hours, and occurred up to 4 times per day. In between attacks, examination was normal. The episodes waxed and waned in frequency during a 6-month illness. Magnetic resonance imaging of the brain was normal. Post-streptococcal neuropsychiatric disease has a proposed autoimmune etiology, which is supported by the presence of serum antibasal ganglia antibodies. Western immunoblotting of this case's serum demonstrated antibody binding to a basal ganglia antigens of molecular weight 80 kDa and 95 kDa. Immunohistochemistry examination demonstrated specific antibody binding to large striatal neurones. We propose that autoantibodies produced in post-streptococcal neuropsychiatric disease cause alteration in neurotransmission, possibly secondary to ion channel binding.

A link between parotid salivary Ig level and recurrent respiratory infections in young Down's syndrome patients

The purpose of the present investigation was to assess the correlation between recurrent respiratory infections and the levels of salivary Ig in a group of young Down's syndrome (DS) individuals. Twenty-three DS and 10 age- and sex-matched healthy individuals were included. DS individuals who had experienced three or more upper respiratory tract infections (n = 10) in the previous 12 months were compared to DS individuals who had not experienced recurrent respiratory infections (n = 13) and to healthy controls (n = 10). A statistically significant reduction in the Ig salivary secretion rate was recorded in the subgroup with recurrent respiratory infections. No significant differences were seen between the subgroup without recurrent respiratory infections and controls. It is suggested that the secretory immune system provides local immune protection against pathogens in the respiratory tract. Detection of salivary Ig levels may serve as a predictor of the susceptibility of DS individuals to recurrent respiratory tract infections.

A half-century of streptococcal research: then & now

Research on Group A streptococci (GAS) before 1950 paved the way for successful clinical trials to prevent acute rheumatic fever (ARF) by treating the prior streptococcal infection with penicillin. Prevention of ARF has led to almost complete disappearance of rheumatic heart disease in the industrialized world, but has yet to be accomplished in developing countries, where most of the world's populations reside. Twenty years of research beginning in 1918 by Lancefield and others delineated the modern classification of haemolytic streptococci and led to the recognition that only Group A is responsible for the pharyngitis that causes ARF. M-protein, identified as a major virulence factor, is a powerful inhibitor of phagocytosis, and antibodies to it promote type-specific phagocytosis and therefore type-specific immunity. Other virulent properties of GAS include a bulky capsule, as well as extracellular toxins such as streptolysins S and O and streptococcal proteinase. McCarty and others pursued the cell biology of GAS and identified the cellular localization of various antigenic components. The discovery of purified M-protein as a helical coiled-coiled fibrillar protein has sparked development of M-protein vaccine. US, UK, and Trinidad scientists described differences between streptococcal infections of the throat and skin and noted particularly that many of the GAS M-types that cause impetigo are less likely to cause pharyngitis. GAS impetigo may cause acute glomerulonephritis, but such infections do not result in ARF. The changing manifestations of disease over time and the evolution of microbes are common themes in medicine today. These themes are relevant to GAS pharyngitis and ARF, especially the decline in the incidence of severe ARF and the decrease in severity of GAS pharyngitis. Research on GAS bacteriophages led to the discovery of a relationship between lysogenic GAS and production of erythrogenic toxin and has broadened approaches to the molecular epidemiology of GAS virulence. The 21st century begins with determination of the complete genome sequence of M-1, M-18, and M-3 strains of GAS. These studies provide evidence for phage-encoded toxins, high-virulence phenotypes, and clone emergence. This research will reveal genetic processes at the molecular level that control the emergence and decline of streptococcal diseases in different places and times and the shifting patterns in clinical manifestations.

Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS)

BACKGROUND

The current diagnostic criteria for pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS) are pediatric onset, neuropsychiatric disorder (obsessive-compulsive disorder [OCD]) and/or tic disorder; abrupt onset and/or episodic course of symptoms; association with group A beta-hemolytic streptococcal (GABHS) infection; and association with neurological abnormalities (motoric hyperactivity or adventitious movements, including choreiform movements or tics).

OBJECTIVE

To assess new-onset PANDAS cases in relation to acute GABHS tonsillopharyngitis.

DESIGN

Prospective PANDAS case identification and follow-up.

RESULTS

Over a 3-year period (1998-2000), we identified 12 school-aged children with new-onset PANDAS. Each patient had the abrupt appearance of severe OCD behaviors, accompanied by mild symptoms and signs of acute GABHS tonsillopharyngitis. Throat swabs tested positive for GABHS by rapid antigen detection and/or were culture positive. The GABHS serologic tests, when performed (n = 3), showed very high antideoxyribonuclease antibody titers. Mean age at presentation was 7 years (age range, 5-11 years). In children treated with antibiotics effective in eradicating GABHS infection at the sentinel episode, OCD symptoms promptly disappeared. Follow-up throat cultures negative for GABHS were obtained prospectively after the first PANDAS episode. Recurrence of OCD symptoms was seen in 6 patients; each recurrence was associated with evidence of acute GABHS infection and responded to antibiotic therapy, supporting the premise that these patients were not GABHS carriers. The OCD behaviors exhibited included hand washing and preoccupation with germs, but daytime urinary urgency and frequency without dysuria, fever, or incontinence were the most notable symptoms in our series (58% of patients). Symptoms disappeared at night, and urinalysis and urine cultures were negative.

CONCLUSION

To our knowledge, this is the first prospective study to confirm that PANDAS is associated with acute GABHS tonsillopharyngitis and responds to appropriate antibiotic therapy at the sentinel episode.

Primary role for CD4(+) T lymphocytes in recovery from oropharyngeal candidiasis

Oropharyngeal candidiasis is associated with defects in cell-mediated immunity and is commonly seen in human immunodeficiency virus positive individuals and AIDS patients. A model for oral candidiasis in T-cell-deficient BALB/c and CBA/CaH nu/nu mice was established. After inoculation with 10(8) Candida albicans yeasts, these mice displayed increased levels of oral colonization compared to euthymic control mice and developed a chronic oropharyngeal infection. Histopathological examination of nu/nu oral tissues revealed extensive hyphae penetrating the epithelium, with polymorphonuclear leukocyte microabscess formation. Adoptive transfer of either naive or immune lymphocytes into immunodeficient mice resulted in the recovery of these animals from the oral infection. Reconstitution of immunodeficient mice with naive CD4(+) but not CD8(+) T cells significantly decreased oral colonization compared to controls. Interleukin-12 and gamma interferon were detected in the draining lymph nodes of immunodeficient mice following reconstitution with naive lymphocytes. This study demonstrates the direct requirement for T lymphocytes in recovery from oral candidiasis and suggests that this is associated with the production of cytokines by CD4(+) T helper cells.

[Inflammation and acute pharyngo-tonsillitis]

1.

FACTS

Despite several studies, it has been impossible to establish a correlation between bacteriological and clinical findings in erythematous pultaceous sore throat. 2.

A RULE

Antibiotics should be prescribed for group A streptococcal sore throat alone. 3.

INFLAMMATION AND INFECTION

In acute tonsilitis, inflammation is perfectly proportional to infection; 4.

INFLAMMATORY CYTOKINES

Their extremely important role in the pathogenesis of different inflammatory processes has been demonstrated in acute tonsilitis. 5.

RECOMMENDATION

Based on the fact that no clinical argument can confirm or infirm the streptococcal cause, it is recommended to use a rapid diagnostic test in all adults or children with sore throat. 6.

A QUESTION

No data are available demonstrating the benefit of non-steroidal antiinflammatory drugs at antiinflammatory doses or of general corticosteroid treatment of acute sore throat. Nevertheless, in non-A hemolytic streptococcal where antibiotic treatment is not indicated, wouldn't it be useful to prescribe symptomatic antiinflammatory treatment?

The relationship between the clinical features of pharyngitis and the sensitivity of a rapid antigen test: evidence of spectrum bias

STUDY OBJECTIVE

We evaluate the test characteristics and test for spectrum bias of a rapid antigen test for group A beta-hemolytic streptococcal (GABHS) pharyngitis among adults.

METHODS

Medical record and laboratory results of consecutive adult patients receiving a rapid antigen test for GABHS in the emergency department or urgent care clinic of an urban teaching hospital between August 1999 and December 1999 were analyzed. Patients were stratified according to the number of clinical features present using the following modified Centor criteria: history of fever, absence of cough, presence of pharyngeal exudate, and cervical lymphadenopathy. The sensitivity of the rapid antigen test was defined as the number of patients with positive rapid antigen test results divided by the number of patients with either positive rapid antigen test results or negative rapid antigen test results and positive throat culture results.

RESULTS

In the study sample of 498 patient visits, the prevalence of GABHS pharyngitis was 28% (95% confidence interval [CI] 24% to 32%). The prevalence of GABHS pharyngitis increased as modified Centor scores increased: 0 or 1=14%, 2=20%, 3=43%, and 4=52%. An increased number of modified Centor criteria (0 or 1, 2, 3, 4) was associated with increased rapid antigen test sensitivity (61%, 76%, 90%, and 97%, respectively) (Mantel-Haenszel trend test; P =.001).

CONCLUSION

The sensitivity of the rapid antigen test for GABHS is not a fixed value but varies with the spectrum of disease. Among adults with 3 or 4 clinical criteria for GABHS pharyngitis, further study may reveal that culture confirmation of negative rapid antigen test results are not necessary.