Case study: acute basal ganglia enlargement and obsessive-compulsive symptoms in an adolescent boy

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAs) may arise when antibodies directed against invading bacteria cross-react with basal ganglia structures, resulting in exacerbations of obsessive-compulsive disorder (OCD) or tic disorders. This is a report of severe worsening of obsessive-compulsive symptoms in an adolescent boy following infection with group A beta-hemolytic streptococci for whom serial magnetic resonance imaging scans of the brain were acquired to assess the relationship between basal ganglia size, symptom severity, and treatment with plasmapheresis. These data provide further support for basal ganglia-mediated dysfunction in OCD and the potential for immunological treatments in PANDAs patients.

[Reliability of the rapid Streptococcus A test]

The results of three second-generation immune assays for direct detection of group A streptococcus were compared in 65 patients with acute pharyngitis. The assays included Strep A Plus, (Abbott), Concise Strep A (Hybritech) and Cards Plus (Pacific Biotech). A standard culture was used as reference. Additionally a nucleic acid hybridization assay (Gen-Probe) was applied after enhanced broth culturing. The sensitivities and specificities of the three immunoassays were similar and showed that Strep A Plus had an 84.2% sensitivity and 88.9% specificity, Concise Strep A an 82.4% sensitivity and 92.3% specificity, and Cards Plus an 84.2% specificity and 90.7% sensitivity. The Concise Strep A had significantly more doubtful results in comparison with the two other rapid immune assays (9.7% versus 2.3%, P = 0.034. The standard culture and the DNA probe test gave the same results in 94% of cases. Clinical parameters were found to be unreliable for the diagnosis of group A streptococcal pharyngitis. However, findings show that when the rapid immune assay is positive, it is reasonable to start antibiotic treatment without performing a bacterial culture. In cases with a negative assay, management is best tailored to clinical symptoms and laboratory examinations.

Transient hemorrhagic diathesis associated with an inhibitor of prothrombin with lupus anticoagulant in a 1 1/2-year-old girl: report of a case and review of the literature

Acquired inhibitors of coagulation causing bleeding manifestations are rare in children, particularly without an associated underlying disorder such as autoimmune disease. We describe an otherwise healthy 1 1/2-year-old girl who had extensive spontaneous bruising and prolonged bleeding from venipuncture sites. Prothrombin time (PT) and activated partial thromboplastin time (APTT) were prolonged, with evidence of an immediate-acting inhibitor. Thrombin clotting time, fibrinogen, and platelets were normal. Biologic assay of factors II, V, VII, and X were all low, with increasing values at higher dilutions. However, by immunoassay and/or chromogenic assays, only factor II was reduced. An antibody which failed to neutralize prothrombin activity in vitro was detected against radiolabeled prothrombin. Coagulation studies normalized in parallel with clinical recovery and disappearance of the antibody. This case demonstrates acute hypoprothrombinemia-lupus anticoagulant syndrome as a rare presentation of bleeding diathesis in a healthy young child.

Optical immunoassay for rapid detection of group A beta-hemolytic streptococci. Should culture be replaced?

OBJECTIVE

To evaluate an optical immunoassay rapid antigen test to detect group A beta-hemolytic streptococci directly from throat swab specimens.

DESIGN

Criterion standard with "blinded" comparison. Double-swab pharyngeal samples were obtained; one swab was cultured and the other was used for the rapid antigen test.

SETTING

Microbiology laboratory in a primary care center at a university teaching hospital.

PATIENTS

Two hundred sixty-two outpatients with pharyngitis.

MAIN OUTCOME MEASURE

The results of the optical immunoassay rapid antigen test were compared with results of standard aerobic culture.

RESULTS

Sixty-two (24%) of 262 samples were culture-positive; 48 of these 62 were positive by the optical immunoassay rapid test (sensitivity, 77%). Of the 200 culture-negative samples, seven (4%) were positive by the rapid test (specificity, 96%).

CONCLUSION

The optical immunoassay performed well, but like other rapid tests, is not sensitive enough to replace standard culture for detection of group A beta-hemolytic streptococci.

Mitral regurgitation may be related with previous streptococcal infection

We measured anti M protein antibody (AMPA) titres in children with idiopathic mitral regurgitation (MR), streptococcal infection, rheumatic fever (RF), post-streptococcal acute glomerulonephritis (AGN) and normal healthy children. We investigated the association of MR with streptococcal infection and whether high AMPA titres can be used as persisting evidence of previous streptococcal infection. AMPA titres were measured with an enzyme-linked immunosorbent assay. We found significantly higher antibody titres in patients with MR and in streptococcal infection, RF, and AGN than in healthy controls. In the MR group (n = 15), 54% patients had AMPA titres above the 90th percentile value that was found in normal controls. An elevated AMPA titre persisted for a long period even when the anti-streptolysin O titres had declined to normal in RF patients. Our data suggest that the high AMPA titres in MR should be further investigated to clarify the probable association with previous streptococcal infection.

CONCLUSION

High AMPA titre is a risk factor for developing complications after streptococcal infection. Our serological evidence suggests that in some patients, MR may be related to previous streptococcal infection.

Streptococcal toxic shock syndrome associated with marked gamma delta T cell expansion: case report

Streptococcal toxic shock syndrome (strepTSS) has been associated with various streptococcal soft-tissue infections including cellulitis, necrotizing fasciitis, and peritonitis in adults. We describe a 40-year-old patient with pharyngitis and strepTSS. Throat swab cultures yielded a strain of Streptococcus pyogenes that produced large amounts of erythrogenic toxin A. Fluorescence-activated cell sorter analysis of the patient's peripheral blood lymphocytes revealed generally enhanced expression of the T cell activity markers CD25 and human leukocyte antigen-DR and a marked increase in the number of gamma delta T cells, largely of the V delta 1-bearing subpopulation. Two more analyses, which were performed 2 weeks and 9 months later, respectively, documented the course of normalization after the acute episode of strepTSS. The T cells of this patient were stimulated in vitro with supernatants of his streptococcal isolate, and they proliferated in a dose-dependent manner. These proliferating T cells were mainly alpha beta T cells.

Retrograde axonal cytokine transport: a pathway for immunostimulation in the brain inducing hypoxia and sudden infant death?

The etiology and pathogenesis of sudden infant death syndrome (SIDS) remain unknown. A hypothesis for SIDS should explain three characteristic findings: (a) an age distribution peaking at 2-4 months; (b) frequent association with respiratory tract infections; and (c) occurrence during sleep. The diagnosis of SIDS is applied when death cannot be explained, and this syndrome therefore probably includes various underlying causes. Based on recent observations, however, we suggest a pathogenic pathway that might be common to most SIDS victims.

[Diagnosis of sore throat. A multipractice study of 3 different ways of antigenic determination for detection of group A streptococci in throat swabs]

During five months in the winter of 1992/1993, 34 general practitioners (GPs) from 18 offices participated in a clinical testing of three group A streptococcal antigen detection test (ADT) kits (Abbott TestPack Strep A Plus (Abbott), Concise Strep A, Hybritech (Concise) and Kodak SureCell Strep A (Kodak)). The GPs obtained duplicate throat swabs, one for processing with the ADT kit, the other for culture reference at The Streptococcus Laboratory (Bacteriological Department, Statens Seruminstitut, Copenhagen). A total of 1389 patients were enrolled in the study, thirty percent of whom were infected by group A streptococci. The following results were obtained: Abbott: Sensitivity: 76%, specificity: 99%, positive predictive value: 97%, negative predictive value: 91%. Concise: Sensitivity: 82%, specificity: 95%, positive predictive value: 86%, negative predictive value: 92%. Kodak: Sensitivity: 84%, specificity: 87%, positive predictive value: 73%, negative predictive value: 93%. As a follow-up to the main study, each GP filled in a questionnaire, stating his opinion about the investigated ADT kit. Considering the practical handiness, Concise scored higher than Abbott, which in turn scored higher than Kodak. In conclusion, Abbott and Concise are recommended for the diagnosis of group A streptococcal pharyngotonsillitis in general practice.

Role of adenotonsillectomy in the management of pediatric ear, nose and throat infections

Tonsil and adenoid diseases in children continue to result in considerable morbidity despite the age of antibiotics. Immunologic studies have thus far shown no adverse effects as a result of adenoidectomy or tonsillectomy. However, because the indications for surgery remain controversial, each child must be considered on a case-by-case basis.

Mycoplasma pulmonis infection of the murine oropharynx protects against subsequent vaginal colonization

Intranasal inoculation of 12 young adult mice (strain TO) with Mycoplasma pulmonis protected all of them against vaginal colonization when they were challenged intravaginally 60 days later with the same mycoplasmal strain. In contrast, all 15 mice without a respiratory infection became colonized vaginally (geometric mean titre [GMT] 4.6 x 10(6) colour-changing units [c.c.u.]) when challenged in the same way. The GMT of serum antibody, measured by a microimmunofluorescence technique, prior to challenge was 200 and 8 for the oropharyngeally infected and unexposed mice, respectively. The GMT of antibody in vaginal washings from the two groups was 6 and 3, respectively. All four nude BALB/c mice were susceptible to vaginal colonization (GMT 5.6 x 10(6) c.c.u.) after oropharyngeal infection (GMT 5.1 x 10(4) c.c.u.) resulting from intranasal inoculation, as were all six nude mice (vaginal GMT 1.4 x 10(7) c.c.u.) that had not been inoculated intranasally. In contrast, all ten of their immunocompetent counterparts were resistant to vaginal colonization after oropharyngeal infection (GMT 1.3 x 10(3) c.c.u.), whereas all nine such mice that had not been infected oropharyngeally were susceptible to vaginal colonization (GMT 7.6 x 10(6) c.c.u.). These results show the important role that a respiratory infection has in protecting the vagina against colonization and that protection is dependent on a functioning T-lymphocyte system.

[Autoimmune reactions in diseases of streptococcal etiology]

In this work 98 cases of streptococcal tonsillitis and 361 cases of erysipelas were studied. As revealed in this study, in relapsing forms of streptococcal infection antibodies to cross-reacting antigens of the infective agent appear in the blood. The synthesis of antibodies to the basal layers of skin epithelium was accompanied by an increase in the concentration of medium-size immune complexes, 0-cell population and by a decrease in the number of T suppressors. The mechanism of the development of the autoimmune process in relapsing forms of streptococcal infection is discussed.

[An explosive outbreak of strep throat morbidity in an adult organized collective]

Altogether 162 cases of tonsillitis were registered in two military units during the period of May 11-16. The disease took an acute course with short-time fever, symptoms of acute intoxication, sore throat, pronounced inflammatory changes in tonsils and swelling of regional (submaxillary and anterocervical) lymph nodes. In some of the patients (1.1%) sickness and vomiting and in 0.2% diarrhea were registered. In 6.7% of the patients scarlatiniform eruptions were observed on days 2-3 of the disease. In the course of the bacteriological examination of the patients group A streptococci, serovar T II, were isolated. The dynamic study of paired sera showed a considerable increase in the number of patients with a high level of antibodies to streptolysin 0 and group A polysaccharide. All patients were fed at the same canteen. The factor of the transmission of this infection could be butter, stored without observation of the required temperature conditions and apportioned by the soldiers of the kitchen police. Experimental study revealed that group A streptococci are capable for proliferation and accumulation in butter.

The relationship between SIgA and chronic granular pharyngitis

A survey of the SIgA content in saliva, serum and pharyngeal mucosa with lymphoid tissue (PMLT) of chronic granular pharyngitis patients was conducted by a double antibody PEG radio-immune method. These data were compared with those from a healthy control group. Result shows that SIgA in patients with chronic granular pharyngitis had dissociation of saliva, serum and PMLY. There was low salivary SIgA level but higher levels in serum and PMLT. These data suggest that the saliva and serum immunoglobulin pools are under separate regulation.

Development and evaluation of capture enzyme-linked immunosorbent assays for detection of immunoglobulin G and M antibodies to group A streptococcal antigens

Capture enzyme-linked immunosorbent assays (ELISAs) were developed to detect immunoglobulin G and M antibodies to group A streptococcal (GAS) antigens, streptolysin O, streptokinase, and group A carbohydrate. The sensitivities and the specificities of the IgM capture ELISAs to each GAS antigen were high enough to distinguish the patients with GAS infections (diagnosed as GAS pharyngitis or scarlet fever) from the control groups (healthy people and patients with pharyngitis from whom GAS could not be isolated). On the other hand, the specificities of the IgG capture ELISAs were not very effective in diagnosis of GAS infections. When the capture ELISA and an indirect ELISA detecting IgM antibodies to group A carbohydrate were compared, false-positive reactions due to rheumatoid factor occurred in the indirect ELISA, but did not occur in the capture ELISA. These results indicate that the capture ELISA works better than the indirect ELISA in detecting the IgM antibody, and that the IgM capture ELISA to GAS antigen provides a rapid and highly reliable serodiagnosis for GAS infections employing only a single serum.

Enhancement of IL-1, IL-2 production and IL-2 receptor generation in patients with acute rheumatic fever and active rheumatic heart disease; a prospective study

In a prospective study, patients with quiescent rheumatic heart disease (CRHD), streptococcal pharyngitis (SP) and healthy normal subjects produced comparable amounts of IL-1 and IL-2, but acute rheumatic fever (ARF) patients produced significantly elevated amounts of IL-1 and IL-2 at all intervals up to 48 weeks. In active rheumatic heart disease (ARHD), IL-1 activity returned to within normal range at 48 weeks, but IL-2 activity remained persistently elevated compared with CRHD, SP and healthy age- and sex-matched volunteers. CD4+ T lymphocytes were significantly increased in the peripheral blood of ARF and ARHD patients. The amount of IL-2 produced by ARF and ARHD patients correlated with the percentage of helper T lymphocytes (CD4+ cells) but not with the percentage of suppressor/cytotoxic T lymphocytes (CD8+ cells). Moreover, pre- and post-phytohaemagglutinin (PHA)-stimulated peripheral blood mononuclear cell (PBMC) cultures from ARF and ARHD patients contained higher proportions of IL-2R+ (CD25+) cells than those from patients with SP, CRHD and normal individuals, which persisted up to 48 weeks. The percentage of CD25+ cells in both types of PBMC cultures directly correlated with the percentage of CD4+ cells and not with CD8+ cells in active rheumatic patients only. These findings indicate that the immune response in ARF and ARHD patients is skewed to produce activated helper T cells that release IL-2 which drives the accumulation of more T helper cells. The result is an undamped helper T cell response in the peripheral blood of these patients.

Serum immunoglobulin changes in relation to tonsil and adenoid surgery

In the course of clinical trials of tonsillectomy, adenoidectomy, and adenotonsillectomy, we measured serum levels of immunoglobulins G, A, and M by rate nephelometry in 268 subjects at baseline and at intervals after receipt or nonreceipt of surgery. Up to 30 months after baseline we observed a consistent pattern of change only in levels of immunoglobulin G, decreases in which tended to occur more commonly and be of greater magnitude in subjects who received tonsillectomy or adenotonsillectomy than in corresponding control subjects. However, in both surgical and control subjects the subsequent incidence of throat infection showed no relationship to either contemporaneous immunoglobulin levels or changes from baseline levels. A decline in serum immunoglobulins following tonsillectomy appears not to be a risk factor for developing throat infection, and may reflect a reduction in antigenic stimulation.

[The immunomodulating action of vilozen and splenin in angina patients against a background of chronic bronchitis]

Immunological indices were compared in 138 patients with angina and concomitant bronchitis; 86 of them received antibiotics, splenin and vylosen; 52 received routine treatment. It was established that use of a combination of splenin and vylosen produces a pronounced immunodulating effect in primary immunodeficiency states due to recurrences of angina and concomitant pathology of the bronchopulmonary in workers of a large industrial enterprise. Immunomodulators are indicated in the treatment of repeat and relapsing angina, especially in the presence of concomitant bronchitis.

[Use of vilozen and ketotifen combination for increasing the effectiveness and prevention of complications of antibiotic therapy of streptococcal infections]

The clinical efficacy of a vilozen and ketotifen (zaditen) combination in the treatment of streptococcal infections along with the routine therapy was studied. The use of the combination was shown advisable in the complex therapy and prevention of relapses in patients with streptococcal infections. The combined pharmacotherapy promoted better clinical indices, normalization of the immune status and a reduction in the incidence of allergic reactions to antibiotics and a decrease in sensitization to bacterial allergens.