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Alberio AMQ, Biagini Y, Di Gangi A, Pagnini I, Simonini G, Peroni D, Consolini R. Revising the value of Antistreptolysin O titre in childhood and its interpretation in the diagnostic approach of rheumatic diseases. Eur J Pediatr 2024; 183:835-842. [PMID: 38038770 DOI: 10.1007/s00431-023-05269-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 12/02/2023]
Abstract
The burden of group A streptococcus (GAS) infection and its rheumatic sequelae remains dramatically high, especially in low-income countries. Recently, an increased number of Acute Rheumatic Fever (ARF) cases was documented in many regions of Italy. The diagnosis of rheumatic sequelae relies on clinical signs and on the evaluation of the Antistreptolysin O titre (ASO), whose variations are globally reported. To re-examine the standard reference value of ASO titre, by measuring either its upper limit of normal (ULN) in a population of healthy children (HC) or comparing these values with streptococcal antibodies registered in a cohort of patients affected by the rheumatic sequelae of GAS infection. We performed a multicenter retrospective study. We enrolled 125 HC, aged 2-17 years, and a total of 181 patients affected by ARF, acute streptococcal pharyngitis, post-streptococcal arthritis, Henoch-Schönlein purpura and erythema nodosum, divided into four groups. The levels of ASO and anti-deoxyribonuclease B (anti-DNase B) titres were analyzed and compared among the various groups. Moreover, the 80th percentile value was calculated and established as the ULN for ASO titre in HC group. The ULN for ASO titre in overall HC group was 515 IU/mL, resulting in higher than used in the routine investigation. The ASO titre was significantly higher in patients with rheumatic sequelae compared with HC group, with a peak in the age between 5 and 15 years. Conclusion: Our study established a new ULN normal value of streptococcal serology in a childhood and adolescent population of Italy, suggesting the need to extend this revaluation to the critical areas, in order to avoid underestimating ARF diagnosis. The correct interpretation of ASO and anti-DNase B values in the context of rheumatic diseases has been discussed. What is Known: • The global burden of disease caused by group A streptococcus is not known and remains an important cause of morbidity and mortality. Acute rheumatic fever continues to be a serious worldwide public health problem and a recent recurrence of group A streptococcus infection cases is observed. • The streptococcal sequelae requires evidence of preceding streptococcal infection, commonly elevated streptococcal antibody titre, but the upper limit for these titres varies considerably based on age group, region, and origin. What is New: • This study provides population-specific values for streptococcal antibody titres in Italy. • Interpret the results of group A streptococcal antibody tests within the clinical context.
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Affiliation(s)
| | - Ylenia Biagini
- Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Di Gangi
- Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Diego Peroni
- Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, 56126, Italy.
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Elbendary A, Youssef R, Abdel-Halim MRE, Abdel Halim D, El Sharkawy DA, Alfishawy M, Gad MA, Gad A, Elmasry MF. Role of streptococcal infection in the etiopathogenesis of pityriasis lichenoides chronica and the therapeutic efficacy of azithromycin: a randomized controlled trial. Arch Dermatol Res 2023; 315:521-530. [PMID: 36129521 PMCID: PMC10020249 DOI: 10.1007/s00403-022-02398-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/02/2021] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
The exact aetiology of pityriasis lichenoides chronica (PLC) remains unknown. While phototherapy is the most investigated therapeutic modality, azithromycin has been used scarcely. The aim of this study is to evaluate the therapeutic efficacy of azithromycin in the treatment of PLC compared to NB-UVB and evaluating the presence of streptococcal infection as a possible etiological factor in PLC patients. The study was designed as a randomised controlled trial. Twenty-four patients with PLC were randomly allocated into either azithromycin (n = 13, standard dose every 10 days) or NB-UVB (n = 11, thrice weekly) groups. End of study (EOS) was either complete clearance of lesions or a maximum of 8 weeks. Therapeutic efficacy was defined as percent reduction in lesions and was calculated for the rash as a whole, erythematous papules alone, and hypopigmented lesions alone and graded into complete, very-good, good, poor or no response. Anti-streptolysin O titre (ASOT), anti-deoxyribonuclease B titre (anti-DNaseB) and throat culture were evaluated at day 0. No significant difference existed between both groups as regards therapeutic efficacy. At EOS, NB-UVB achieved significantly more percent reduction in the extent of hypopigmented lesions and consequently in the rash as a whole (p = 0.001, p = 0.034, respectively). The extent of the rash as a whole was significantly less in the NB-UVB at EOS (p = 0.029, respectively). The effect of NB-UVB on hypopigmented lesions appeared early at week 4 of treatment. Only two patients, one from each group, relapsed during the 3 month follow-up. Evidence of recent streptococcal infection was present in 79% of the cases, mainly in the form of elevated ASOT (94.7%). It was significantly more encountered in young children (< 13 years) (p = 0.03) and was associated with more extent of erythematous papules and consequently with more extent of the rash as a whole (p = 0.05 and p = 0.01, respectively). It did not affect outcome of therapy at EOS. Azithromycin did not show more favorable response in patients with recent streptococcal infection. Therapeutic efficacy of azithromycin is comparable to NB-UVB in treatment of PLC; however, NB-UVB is superior in management of hypopigmented lesions. It is highly suggested that PLC could be a post streptococcal immune mediated disorder.Registration number: ClinicalTrials.gov, NCT03831269.
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Affiliation(s)
- Amira Elbendary
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt.
| | - Randa Youssef
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt
| | - Mona R E Abdel-Halim
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt
| | - Dalia Abdel Halim
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt
| | - Dina Ahmed El Sharkawy
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt
| | - Mostafa Alfishawy
- Infectious Diseases Consultants and Academic Researchers of Egypt (IDCARE), Cairo, Egypt
| | - Maha A Gad
- Clinical Pathology Department, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abdallah Gad
- Lowell General Hospital, Lowell, MA, USA
- Biostatistics and Cancer Epidemiology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Maha Fathy Elmasry
- Dermatology Department, Kasr Alainy Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo, 11562, Egypt
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3
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Saha SK, Choudhury KN, Zareen S, Mousum S, Mamun MAA, Haque MA. Study of streptococcal antibody (anti-streptolysin O) among healthy children in Bangladesh. SAGE Open Med 2022; 10:20503121221108558. [PMID: 35784665 PMCID: PMC9244936 DOI: 10.1177/20503121221108558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/03/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: The standard reference value of anti-streptolysin O (ASO) titre for diagnosing acute rheumatic fever (RF) in children is yet to be determined in Bangladesh. We aimed to measure the upper limit of the normal (ULN) of ASO titre among healthy children to determine the cut-off value for the diagnosis of RF in Bangladesh. Methods: A total of 400 healthy children aged 5–15 years with no history of fever, sore throat and impetigo during the last 8 weeks of the study were enrolled. The respondents were randomly selected from an urban non-slum area, an urban slum area and a rural area of Bangladesh. ASO titre was measured using a turbidimetric immunoassay based on the principle of an agglutination reaction. The 80th percentile value was considered as the ULN of ASO titre. Results: Approximately 55% of the children were male. The mean (SD) age of children was 9.1 (2.7) years. The ULN of ASO titre for 5–15 years aged children was 217.4 IU/mL. Conclusion: Our reference value of ASO titre at the 80th percentile will be an essential guide for clinicians to diagnose acute RF.
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Affiliation(s)
- Santosh Kumar Saha
- National Institute of Cardiovascular Diseases and Hospital, Dhaka, Bangladesh
| | | | - Salma Zareen
- National Center for Control of Rheumatic Fever and Heart Disease, Dhaka, Bangladesh
| | - Sabrina Mousum
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - M Atiqul Haque
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade's achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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Mukohda M, Nakamura S, Takeya K, Matsuda A, Yano T, Seki M, Mizuno R, Ozaki H. Streptococcal Exotoxin Streptolysin O Causes Vascular Endothelial Dysfunction Through PKCβ Activation. J Pharmacol Exp Ther 2021; 379:117-124. [PMID: 34389653 DOI: 10.1124/jpet.121.000752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/10/2021] [Indexed: 11/22/2022] Open
Abstract
Streptolysin O (SLO) is produced by common hemolytic streptococci that cause a wide range of diseases from pharyngitis to life-threatening necrotizing fasciitis and toxic shock syndrome. While the importance of SLO in invasive hemolytic streptococcus infection has been well demonstrated, the role of circulating SLO in non-invasive infection remains unclear. The aim of this study was to characterize the pharmacological effect of SLO on vascular functions, focusing on cellular signaling pathways. In control Wistar rats, SLO treatment (1-1000 ng/mL) impaired acetylcholine-induced endothelial-dependent relaxation in the aorta and second-order mesenteric artery in a dose-dependent manner, without any effects on sodium nitroprusside-induced endothelium-independent relaxation or agonist-induced contractions. SLO also increased phosphorylation of the endothelial NO synthase (eNOS) inhibitory site at Thr495 in the aorta. Pharmacological analysis indicated that either endothelial dysfunction or eNOS phosphorylation was mediated by protein kinase Cβ (PKCβ), but not by the p38 mitogen-activated protein kinase (MAPK) pathway. Consistent with this, SLO increased phosphorylation levels of PKC substrates in the aorta. In vivo study of control Wistar rats indicated that intravenous administration of SLO did not change basal blood pressure, but significantly counteracted the acetylcholine-induced decrease in blood pressure. Interestingly, plasma anti-SLO IgG levels were significantly higher in 10- to 15-week-old spontaneously hypertensive rats compared to age-matched control rats (P<0.05). These findings demonstrated that SLO causes vascular endothelial dysfunction, which is mediated by PKCβ-induced phosphorylation of the eNOS inhibitory site. Significance Statement This study showed for the first time, that in vitro exposure of vascular tissues to SLO impairs endothelial function, an effect that is mediated by PKCb-induced phosphorylation of the eNOS inhibitory site. Intravenous administration of SLO in control and hypertensive rats blunted the ACh-induced decrease in blood pressure, providing evidence for a possible role of SLO in dysregulation of blood pressure.
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Affiliation(s)
| | - Sho Nakamura
- Faculty of Veterinary Medicine, Okayama University of Science, Japan
| | - Kosuke Takeya
- Faculty of Veterinary Medicine, Okayama University of Science, Japan
| | - Akira Matsuda
- Faculty of Veterinary Medicine, Okayama University of Science, Japan
| | - Takanori Yano
- Faculty of Science, Okayama University of Science, Japan
| | | | - Risuke Mizuno
- Faculty of Veterinary Medicine, Okayama University of Science, Japan
| | - Hiroshi Ozaki
- Faculty of Veterinary Medicine, Okayama University of Science, Japan
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Salie MT, Rampersadh K, Muhamed B, Engel KC, Zühlke LJ, Dale JB, Engel ME. Utility of Human Immune Responses to GAS Antigens as a Diagnostic Indicator for ARF: A Systematic Review. Front Cardiovasc Med 2021; 8:691646. [PMID: 34355030 PMCID: PMC8329041 DOI: 10.3389/fcvm.2021.691646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have established that streptococcal antibody titer is correlated with a diagnosis of acute rheumatic fever (ARF). However, results vary in the usefulness of GAS antibodies, particularly anti-streptolysin-O (ASO) and anti-DNase B, in confirming a recent GAS infection. Therefore, we sought to provide, from published studies, an evidence-based synthesis of the correlation of streptococcal serology to establish the usefulness of immunological data in aiding the diagnosis of ARF. These findings are anticipated to have implications where echocardiography is not freely available, especially where ARF is rampant. Methods: We conducted a comprehensive search across a number of databases. Applying a priori criteria, we selected articles reporting on studies, regardless of study design, that evaluate the levels of antibodies against GAS-specific antigens in ARF subjects against control values or a published standard. Data were extracted onto data extraction forms, captured electronically, and analyzed using Stata software. Risk of bias was assessed in included studies using the Newcastle-Ottawa Scale (NOS). Results and Conclusion: The search strategy yielded 534 studies, from which 24 met the inclusion criteria, reporting on evaluation of titers for SLO (n = 10), DNase B (n = 9), anti-streptokinase (ASK) (n = 3) amongst others. Elevation in titers was determined by comparison with controls and upper limit of normal (ULN) antibody values as determined in healthy individuals. Meta-analysis of case-controlled studies revealed moderate odds ratio (OR) correlations between ARF diagnosis and elevated titers for SLO (OR = 10.57; 95% CI, 3.36-33.29; 10 studies) and DNAse B (OR = 6.97; 95% CI, 2.99-16.27; 7 studies). While providing support for incorporating SLO and DNase B in the diagnosis of ARF, we present the following reflections: an elevation in SLO and DNase B levels are not consistently associated with an ARF diagnosis; increasing the number of GAS proteins in the test is warranted to improve sensitivity; paired (acute and convalescent) samples could provide a more accurate indication of a rising titer. Use of community-based controls as a standard is not a reliable marker by which to gauge recent GAS infection.
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Affiliation(s)
- M Taariq Salie
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kimona Rampersadh
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Babu Muhamed
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, Children's National Health System, Washington, DC, United States
| | - Kélin C Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Liesl J Zühlke
- Children's Heart Disease Research Unit, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - James B Dale
- Division of Infectious Diseases, University of Tennessee Health Science Center (UTHSC), Memphis, TN, United States
| | - Mark E Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Okello E, Murali M, Rwebembera J, Atala J, Bowen AC, Harik N, Kaudha G, Kitooleko S, Longenecker C, Ndagire E, Omara IO, Oyella LM, Parks T, Pulle J, Sable C, Sarnacki R, Stein E, Zimmerman M, de Klerk N, Carapetis J, Beaton A. Cross-sectional study of population-specific streptococcal antibody titres in Uganda. Arch Dis Child 2020; 105:825-829. [PMID: 32601082 PMCID: PMC11149943 DOI: 10.1136/archdischild-2020-318859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/09/2020] [Accepted: 05/30/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Despite substantial variation of streptococcal antibody titres among global populations, there is no data on normal values in sub-Saharan Africa. The objective of this study was to establish normal values for antistreptolysin O (ASO) and antideoxyribonuclease B (ADB) antibodies in Uganda. DESIGN This was an observational cross-sectional study. SETTING This study was conducted at Mulago National Referral Hospital, which is located in the capital city, Kampala, and includes the Uganda Heart Institute. PATIENTS Participants (aged 0-50 years) were recruited. Of 428 participants, 22 were excluded from analysis, and 183 (44.4%) of the remaining were children aged 5-15 years. MAIN OUTCOME MEASURES ASO was measured in-country by nephelometric technique. ADB samples were sent to Australia (PathWest) for analysis by enzyme inhibition assay: 80% upper limit values were established. RESULTS The median ASO titre in this age group was 220 IU/mL, with the 80th percentile value of 389 IU/mL. The median ADB titre in this age group was 375 IU/mL, with the 80th percentile value of 568 IU/mL. CONCLUSIONS The estimated Ugandan paediatric population standardised 80% upper-limit-of-normal ASO and ADB titres is higher than many global populations. Appropriateness of using population-specific antibody cutoffs is yet to be determined and has important implications for the sensitivity and specificity of rheumatic fever diagnosis.
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Affiliation(s)
| | - Meghna Murali
- Children's National Health System, Washington, District of Columbia, USA
| | | | | | - Asha C Bowen
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- University of Western Australia, Crawley, Western Australia, Australia
| | - Nada Harik
- Children's National Health System, Washington, District of Columbia, USA
| | | | | | - Chris Longenecker
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | | | | | | | - Tom Parks
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Craig Sable
- Children's National Health System, Washington, District of Columbia, USA
| | - Rachel Sarnacki
- Children's National Health System, Washington, District of Columbia, USA
| | - Elizabeth Stein
- University of Washington School of Medicine, Seattle, Washington, United States
| | - Meghan Zimmerman
- Dartmouth-Hitchcock School of Medicine, Dartmouth, New Hampshire, United States
| | - Nicholas de Klerk
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
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8
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Ghamrawy A, Ibrahim NN, Abd El-Wahab EW. How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018). PLoS Negl Trop Dis 2020; 14:e0008558. [PMID: 32804953 PMCID: PMC7451991 DOI: 10.1371/journal.pntd.0008558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/27/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.
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Affiliation(s)
- Alaa Ghamrawy
- Department of Non-Communicable Diseases, Ministry of Health and Population, Cairo, Egypt
| | - Nermeen N. Ibrahim
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Ekram W. Abd El-Wahab
- Department of Tropical Health, High Institute of Public Health, Alexandria University, Alexandria, Egypt
- * E-mail:
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Lamb CL, Price E, Field KP, Dayton C, McIndoo ER, Katahira EJ, Stevens DL, Hobdey SE. Enrichment of Antigen-Specific Class-Switched B Cells from Individuals Naturally Immunized by Infection with Group A Streptococcus. mSphere 2019; 4:e00598-19. [PMID: 31694896 PMCID: PMC6835209 DOI: 10.1128/msphere.00598-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/17/2019] [Indexed: 01/17/2023] Open
Abstract
The low frequency of circulating antigen-specific memory B cells is a considerable obstacle in the discovery and development of human monoclonal antibodies for therapeutic application. Here, we evaluate two solid-phase isolation methods to enrich the number of antigen-specific B cells from individuals naturally immunized against streptolysin O (SLO), a key virulence factor and known immunogen of group A streptococcus (GAS). Class-switched B cells obtained from individuals with a history of GAS infection were separated from peripheral blood mononuclear cells (PBMCs) by immunomagnetic methods. SLO-specific B cells were further enriched directly by binding to SLO monomers and captured by streptavidin-coated magnetic microbeads or indirectly by binding a fluorescently labeled SLO-streptavidin tetramer and captured by anti-fluorophore immunomagnetic microbeads. SLO-bound B cells were quantitated by flow cytometry and/or expanded in batch culture to determine IgG specificity. From individuals who have suffered a GAS infection ≥2 years prior, only the direct method enriched SLO-specific B cells, as determined by flow cytometry. Likewise, in batch culture, B cells isolated by the direct method resulted in an average of 375-fold enrichment in anti-SLO IgG, while no enrichment was observed for B cells isolated by the indirect method. The direct method established here provides a simple approach to increase low-frequency antigen-specific B cell populations supporting many downstream applications, such as immortalization of B cells, cloning of immunoglobulin genes, or purification of antibodies from supernatant for future study. Overall, this process is efficient, is inexpensive, and can be applied to many naturally immunogenic antigens.IMPORTANCE Bacteria called group A streptococci can cause a variety of skin and soft tissue infections ranging from mild pharyngitis ("strep throat") to deadly necrotizing fasciitis (sometimes called "flesh-eating" disease). In each case, the development of disease and the degree of tissue damage are mediated by toxins released from the bacteria during infection. Consequently, novel therapies aimed at clearing bacterial toxins are greatly needed. One promising new treatment is the utilization of monoclonal antibodies delivered as an immunotherapeutic for toxin neutralization. However, current methods of antibody development are laborious and costly. Here, we report a method to enrich and increase the detection of highly desirable antigen-specific memory B cells from individuals previously exposed to GAS using a cost-effective and less-time-intensive strategy. We envision that this method will be incorporated into many applications supporting the development of immunotherapeutics.
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Affiliation(s)
- Cheri L Lamb
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Emily Price
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Kevin P Field
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Christopher Dayton
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Eric R McIndoo
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
| | - Eva J Katahira
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
| | - Dennis L Stevens
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah E Hobdey
- Infectious Diseases Section, Veteran Affairs Medical Center, Boise, Idaho, USA
- Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
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10
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Saini N, Kumar D, Swarnim S, Bhatt D, Kishore S. Comparison of antistreptolysin O and anti-deoxyribonucleic B titers in healthy children to those with acute pharyngitis, acute rheumatic fever, and rheumatic heart disease aged 5-15 years. Ann Pediatr Cardiol 2019; 12:195-200. [PMID: 31516274 PMCID: PMC6716311 DOI: 10.4103/apc.apc_60_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Acute rheumatic fever (ARF) affects millions of children in the third world countries like India. The diagnosis of rheumatic fever is based on the Jones criteria with serological titers, antistreptolysin O titer (ASO), and anti-deoxyribonucleic B (ADB), taken as evidence of recent streptococci infection. There is a lack of recent data available on ASO and ADB titers in children from the Delhi/NCR and thus adequate geographical area-specific cutoffs for the region are not available. AIMS AND OBJECTIVES The aim of this study is to determine and compare the ASO and ADB antibody titers in children with acute pharyngitis, ARF, rheumatic heart disease (RHD), and in healthy children of the Delhi/NCR region. MATERIALS AND METHODS Twenty-six cases of ARF, 51 cases of RHD, 50 cases of acute pharyngitis, and 84 healthy normal children were included in the study. A single ASO and ADB titer measurement was done in these children. RESULTS The ASO titers was raised in acute pharyngitis - 303 IU/ml (interquartile range [IQR], 142-520 IU/ml) and ARF - 347.5 IU/ml (IQR, 125-686 IU/ml) children in comparison to healthy controls - 163.5 IU/ml (IQR, 133-246.5 IU/ml) and RHD patients - 163 IU/ml (IQR, 98.250-324.500). The ADB titers were highest in ARF patients - 570.5 IU/ml (IQR, 276-922 IU/ml) followed with RHD - 205 IU/ml (IQR, 113.6-456.5), healthy controls - 78.25 IU/ml (IQR, 53.39-128.15 IU/ml), and acute pharyngitis - 75.12 IU/ml (IQR, 64.5-136 IU/ml). The upper limit of normal (ULN) values of ASO and ADB computed from normal healthy children were 262.4 IU/ml and 134.44 IU/ml, respectively, and these can be used as cutoff values for recent streptococcal infection in this geographical area. CONCLUSIONS The median ASO titers in acute pharyngitis group and ARF were significantly raised compared to that of the control group. The ADB titers were raised in ARF and RHD patients albeit the levels were higher in ARF patients. The derived ULN values can be used as cutoff reference.
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Affiliation(s)
- Navjot Saini
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Dinesh Kumar
- Division of Paediatric Cardiology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Swarnim Swarnim
- Division of Paediatric Cardiology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Dheeraj Bhatt
- Division of Paediatric Cardiology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sunil Kishore
- Division of Paediatric Cardiology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
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11
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Dan JM, Silva Enciso J, Lund LH, Aslam S. Heart transplantation outcomes for rheumatic heart disease: Analysis of international registry data. Clin Transplant 2018; 32:e13439. [PMID: 30383907 DOI: 10.1111/ctr.13439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rheumatic heart disease (RHD), an autoimmune sequela of Group A streptococcal infection, is a chronic valvular disease affecting 32 million people worldwide, predominantly in developing nations. As the predisposition to autoimmune sequela still remains post transplantation, our primary objective was to assess if there were differences in mortality and rejection rates. METHODS AND RESULTS Using the International Society for Heart and Lung Transplantation (ISHLT) adult heart transplant registry, we identified 42 RHD patients who had undergone heart transplantation between 1988 and 2014. We matched the 42 RHD recipients by transplant year, age, and gender to 420 dilated cardiomyopathy (DCM) recipients. One-year mortality in the RHD group was 17.95% vs. 7.92% in the DCM group (P = 0.07). Survival was significantly reduced in the RHD group vs. the DCM group via Kaplan Meier curves (P = 0.04). In a multivariate model, RHD status (OR 3.19, 95% CI 1.15-8.83, P = 0.025) and serum creatinine (OR 1.41, 95% CI 1.09-1.82, P = 0.009) were associated with an increased odds of one-year mortality (P = 0.0013). CONCLUSIONS At one year post transplantation, RHD recipients had a significantly lower survival than DCM recipients. RHD status was also an independent predictor of mortality at 1 year post transplantation.
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Affiliation(s)
- Jennifer M Dan
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, California.,La Jolla Institute for Immunology, La Jolla, California
| | - Jorge Silva Enciso
- Division of Cardiovascular Medicine, University of California, San Diego, California
| | - Lars H Lund
- Departments of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Solna, Sweden
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, California
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12
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Zegeye N, Asrat D, Woldeamanuel Y, Habte A, Gedlu E, Tønjum T, Aseffa A. Throat culture positivity rate and antibiotic susceptibility pattern of beta-hemolytic streptococci in children on secondary prophylaxis for rheumatic heart disease. BMC Infect Dis 2016; 16:510. [PMID: 27663649 PMCID: PMC5035452 DOI: 10.1186/s12879-016-1841-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background Among children diagnosed to have chronic rheumatic valvular heart disease (RHD) in Ethiopia, many have been observed to develop recurrence of rheumatic fever (RF) despite secondary prophylaxis. This study determined the throat culture positivity rate and drug susceptibility pattern of beta hemolytic streptococci (BHS) isolated from children attending a specialized cardiac clinic in Ethiopia. Methods Throat swabs were collected from 233 children receiving benzathine penicillin injection as secondary prophylaxis for RHD and cultured. The bacterial isolates were characterized using Matrix Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) mass spectrometry. Drug susceptibility was tested with the Kirby Bauer disc diffusion method. Anti-streptolysin O (ASO) titers were determined using ASO latex reagents. Results The throat culture positivity rate for BHS was 24 % (56/233). Among the BHS bacterial strains isolated, four were characterized as S. pyogenes and another four as S. dysgalactiae subsp. equisimilis (Lancefield group A, C and G). All BHS were susceptible to penicillin except one isolate of S. agalactiae. Among 233 children enrolled, 46(19.7 %) showed increased ASO titer. Children who received antibiotic prophylaxis within 2-weeks of last injection had significantly lower BHS throat culture positivity rate than those injected every 4-weeks (p = 0.02). Children who missed at least one prophylaxis within the last 6 months had a higher BHS culture positivity rate than those who did not miss any (p = 0.0003). Conclusions The presence of groups A, C and G streptococci in the throat of children under secondary prophylaxis for RHD and increased ASO titer suggests failure of the regimen. This calls for further investigation into the causes of inadequate prophylaxis (including bioavailability of drugs used, optimal duration and patient compliance) and intervention.
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Affiliation(s)
- Nigus Zegeye
- Department of Medicine, DebreBerhan University, P. O. Box: 445, DebreBerhan, Ethiopia. .,Armauer Hansen Research Institute, Jimma Road, PO Box 1005, Addis Ababa, Ethiopia. .,Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Daniel Asrat
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebe Habte
- Armauer Hansen Research Institute, Jimma Road, PO Box 1005, Addis Ababa, Ethiopia
| | - Etsegenet Gedlu
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tone Tønjum
- Department of Microbiology, Oslo University Hospital, Oslo, Norway.,Department of Microbiology, University of Oslo, Oslo, Norway
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Jimma Road, PO Box 1005, Addis Ababa, Ethiopia
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13
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Karpishchenko SA, Lavrenova GV, Baranskaya SV. [Tonsillitis and tonsillogenic conditions]. Vestn Otorinolaringol 2016. [PMID: 28635792 DOI: 10.17116/otorino201681469-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of the present study was to analyze and summarize the literature publications concerning tonsillitis and related (tonsillogenic) pathological conditions. The retrospective analysis of these materials made it possible to collect and summarize information about the influence of palatine tonsillar pathology (chronic tonsillitis) on the function of various organs and their systems. It has been shown that pathogenesis of a great variety of disease is underlain by pathology of palatine tonsils. Also, the possibility to stabilize the pathological processes in certain organs and systems by the conservative and/or surgical treatment of chronic tonsillitis has been demonstrated. It is concluded that the patients presenting with chronic tonsillitis make up a group of risk of development of many serious somatic diseases and require enhanced attention not only of otorhinolaryngologists but also specialists representing other medical disciplines. The multidisciplinary approach to the management of such patients is the sole way to reduce the frequency ofgeneral complications in the patients with chronic tonsillitis.
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Affiliation(s)
- S A Karpishchenko
- I.P. Pavlov Saint-Petersburg First State Medical University, Russian Ministry of Health, Saint-Petersburg, Russia, 197022
| | - G V Lavrenova
- I.P. Pavlov Saint-Petersburg First State Medical University, Russian Ministry of Health, Saint-Petersburg, Russia, 197022
| | - S V Baranskaya
- I.P. Pavlov Saint-Petersburg First State Medical University, Russian Ministry of Health, Saint-Petersburg, Russia, 197022
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14
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Abstract
Group A streptococcus (GAS) is the cause of a wide range of acute suppurative and, following a latent period, non-suppurative diseases such as rheumatic fever and poststreptococcal glomerulonephritis. Diagnosis of the latter group requires evidence of preceding GAS infection. The bacteria produce a range of extracellular antigens, including streptolysin O, which induce an antibody response in the host. A rise in antistreptolysin O titre (ASOT) is indicative of preceding GAS infection. In clinical practice, often only a single ASOT measurement is available and its timing in relation to a possible GAS infection is unknown. Interpretation of the result in this context is liable to misdiagnosis. In order to optimise diagnosis of preceding GAS infection, at least two sequential ASOT measurements, together with simultaneous assay for anti-DNase B, a second antistreptococcal antibody, is recommended.
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Affiliation(s)
- E S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
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15
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Merlini AB, Stocco CS, Schafranski MD, Arruda P, Bail L, Borges CL, Dornelles CF. Prevalence of group a Beta-hemolytic streptococcus oropharyngeal colonization in children and therapeutic regimen based on antistreptolysin levels: data from a city from southern Brazil. Open Rheumatol J 2014; 8:13-7. [PMID: 25136388 PMCID: PMC4136371 DOI: 10.2174/1874312901408010013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 06/24/2014] [Accepted: 07/02/2014] [Indexed: 11/30/2022] Open
Abstract
The aim of this study is to determinate the prevalence of oropharyngeal colonization by group A beta-hemolytic Streptococcus (GABHS) in pediatric population of Ponta Grossa, a midsize city of southern Brazil; estimate the effectiveness of antistreptolysin-O (ASO), compared to culture, in presence of infection; and design an unpublished investigative algorithm of rheumatic fever's suspicion, based on needs identified in worldwide consensus. It is an epidemiologic, observational and transversal study, involving 180 children younger than 12 years. Secretion of posterior oropharynx was collected for culture; and peripheral blood for determination of ASO. Student-t and chi-square tests, with Yates correction, were performed for statistical analysis. The ASO cutoff was determined by Receiver Operating Characteristic (ROC) curve. The prevalence encountered was 3.9%, and 25.5% of the children showed reagent ASO. This serological test demonstrated quantitatively and qualitatively significant associations to the GABHS presence (p=0.0001 for both associations) throughout the ROC curve, 200 U Todd was the value that resulted in the best accuracy, demonstrating 100% of sensibility and 80% of specificity in the GAS infection documentation. Also, it was found that the value of 1.200 U represents a specificity of 100%. The results emphasize the need for similar studies in other populations, to provide better targeting of the diagnosis and treatment of oropharyngitis by GABHS, which in turn can prevent up to 80% the cases of rheumatic fever, and consequently, the chronic rheumatic heart disease.
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Affiliation(s)
| | - Carolina S Stocco
- Department of Medicine, State University of Ponta Grossa, Paraná, Brazil
| | | | - Polliane Arruda
- Department of Medicine, State University of Ponta Grossa, Paraná, Brazil
| | - Larissa Bail
- Department of Microbiology, State University of Ponta Grossa, Paraná, Brazil
| | - Celso L Borges
- Department of Immunology, State University of Ponta Grossa, Paraná, Brazil
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