Hemolytic Streptococcal Infections Research Articles

#2864 IgA dominant post-infectious glomerulonephritis secondary to the infected left ankle joint in a non-diabetic patient, a case report

Abstract Introduction Post-infectious glomerulonephritis (PIGN) is an immune complex glomerulonephritis that commonly affects children and young adults following beta haemolytic Streptococcal throat or skin infections. Kidney biopsy is characterised by Segmental or global endocapillary hypercellularity, and crescents may be present. In immunofluorescence, post-infectious glomerulonephritis typically shows IgG and C3 deposition. A rare type of PIGN is IgA-dominant post-infection glomerulonephritis. It commonly occurs in the setting of active infection. It usually presents in patients > 60 years old with diabetes mellitus, alcohol consumption, and Staphylococcal infections. It can present with RPGN, AKI, and nephrotic syndrome. Hypocomplementemia can be present, and immunofluorescence is characterised by IgA dominance with C3 co-dominance and no IgG. Despite the strong association with Staph aureus, however, it has been reported with other types of infections. The main line of treatment is antibiotic eradication of the infection. Steroids can be used based on the severity of the lesion and the presence of crescents. Its prognosis is worse than that of the traditional PIGN. In this case, we report a case of IgA-dominant post-infectious glomerulonephritis secondary to left ankle osteomyelitis with Staph aureus infection. Case Presentation A 65-year-old lady had open reduction and internal fixation of a left trimalleolar ankle fracture in June 2023 at a district general hospital. Unfortunately, the post-operative course was complicated by wound infection. The wound swab showed Heavy growth of Staphylococcus aureus. This was followed by Acute Kidney Injury (AKI) stage 3; therefore, she was transferred from her hospital to our renal ward. On admission to the ward, her creatinine was 388 μmol/L(baseline creatinine was 73 μmol/L one month before admission), urine dipstick was positive for blood and protein, and urine protein creatinine ratio was 480 mg/mmol. She had only a medical background of bronchial asthma for which she was only on Inhalers (Beta Agonist) as a regular medication. CT scan of the left ankle revealed appearances consistent with osteomyelitis of both the lateral and medial malleoli. This finding was discussed with microbiology and orthopaedic teams, and the patient was started on intravenous antibiotics (Vancomycin followed by doxycycline). A kidney biopsy was done. Mesangial electron-dense deposits were identified. Immunohistochemistry revealed IgA dominant, predominantly mesangial positivity, with associated C3. The picture was consistent with IgA acute glomerulonephritis associated with S. aureus, which is a post-infectious Glomerulonephritis with dominant IgA staining (rather than conventional IgA nephropathy). With proper intravenous hydration and antibiotics, her inflammatory markers started to improve, and her renal chemistry followed the inflammatory markers, and her last creatinine improved to 146 μmol/L, eGFR 31 ml/min and UPCR was 40 mg/mmol. Discussion IgA-dominant post-infectious glomerulonephritis is now a distinct form of PIGN, which usually presents with acute kidney injury, haematuria, and proteinuria and is typically related to Staph aureus infection. In contrast to typical IgA nephropathy, there is no role for steroid or immunosuppression in the treatment of IgA-dominant post-infectious glomerulonephritis, and the treatment is mainly dependent on the treatment of infection.

Sudan's rheumatic fever and rheumatic heart disease guidelines: a simplified approach in an endemic country.

Rheumatic heart disease (RHD) is a preventable sequelae of group A beta hemolytic streptococcal infection leading to an immune reaction: acute rheumatic fever (ARF) and progressive heart valve dysfunction. RHD is the leading cause of acquired heart disease in children and young adults in Sudan and many low/middle-income countries. In 2018, the World Health Organization (WHO) issued a resolution for RHD mandating that each country adopt updated guidelines for ARF and RHD management. These current guidelines are mainly directed to primary healthcare workers. Sudan's Federal Ministry of Health (FMOH) in collaboration with the WHO East Mediterranean Regional Office (EMRO) assembled a committee for updating RHD guidelines. We conducted a systematic literature search from 2000 to 2022 in National Institute of Health Database (PubMed) under the following titles: streptococcal pharyngitis, acute rheumatic fever, rheumatic heart disease, benzathine penicillin. Best available, evidence-based practices for diagnosis and management of ARF/RHD were selected and adapted to Sudan's situation. The guidelines were critically appraised by the committee then endorsed to the FMOH and WHO EMRO Noncommunicable Disease Departments in January 2023. This paper describes the updated guidelines. Simplified algorithms are provided for diagnosis of bacterial pharyngitis including two clinical criteria: sore throat and the absence of viral symptoms in the target age group. A simplified algorithm for diagnosis and management of ARF is adopted using two levels of diagnosis: suspected case at primary level where penicillin prophylaxis is started and secondary/tertiary care where echocardiography is performed and diagnosis confirmed or excluded. Echocardiography screening is recognized as the standard method for early diagnosis of RHD; however, due to the anticipated limitations, its implementation was not adopted at this time. Streptococcal skin infection is included as a precursor of ARF and a detailed protocol for benzathine penicillin administration is described. The Sudan guidelines for ARF/RHD management were updated. Endorsement of these guidelines to FMOH and WHO EMRO is expected to improve control of RHD in the region.

Exploring the association between alpha hemolytic streptococcal infection and intensive treatment outcomes in acute myeloid leukemia.

Objective: To assess the prevalence of alpha hemolytic streptococcal (AHS) infections and related risk factors in patients with newly diagnosed acute myeloid leukemia (AML) undergoing consistent treatment. Study Design: Prospective study. Setting: Jinnah Teaching Hospital and DHQ Charsadda undergoing treatment from Hayatabad Medical Complex Peshawar. Period: June 2022 to February 2023. Material & Methods: AML patients were recruited and algorithmically followed for AHS infections. Core symptoms, diagnostic workups, differential diagnoses, and relevant treatments were assessed in this manner. Results: AHS caused 22% of bacteremic infections in 22% of patients, mostly by blood transmission (87%). After treatment, 32% recurred. AHS had a 60% mortality rate (P < 0.002). Age, precise induction timing, and high-dose cytarabine significantly enhanced AHS incidence (OR 2.0, 1.8–1.9, and 3.8, respectively). AHS infections increased hospital stays (P < 0.0002) and decreased long-term survival (OR 2.8; P < 0.001) and disease-free survival (OR 2.1; P 0.008) in bone marrow transplant patients. Conclusion: The first prospective study investigating AHS frequency in consistently treated individuals revealed increased rates with intensified AML therapy. AHS bacteremia is particularly likely in adults with prior cases and high-dose cytarabine usage.

A fatal case of fulminant group: a streptococcal infection in a neonate

BackgroundFulminant hemolytic streptococcal infection is a condition of sudden onset and rapidly progressing septic shock caused by Streptococcus pyogenes. It causes beta (complete) hemolysis. Although type A Streptococcus occurs more frequently, all streptococci that cause beta-hemolysis are eligible as causes. This report describes a rare autopsy case of fulminant group A streptococcal infection in a neonate.Case presentationA 16-day-old girl, 3300 g, born by spontaneous delivery at 41 weeks 1 day, experienced a 1-day history of low-grade fever, malaise, and a few hours of cyanosis and anuria, prompting her parents to bring her to the hospital. Her eldest brother, who lived with her, had been infected with Streptococcus approximately one month earlier, and had been treated with ten days of antibiotics. The infant died three hours after presentation. Autopsy findings indicated her to be 52 cm in length, weighing 3585 g, with medium build and normal nutrition. Her lungs were slightly oligemic with decreased volumes. The liver and kidneys were mildly enlarged. The spleen was markedly enlarged. The adrenal glands showed diffuse cortical hemorrhage (Fig. 1). There was some thymic atrophy (thymus weight 7.4 g, < 1 SD below the mean). Histopathological findings included chronic and neutrophilic infiltration of the tonsils and multiple septic emboli containing cocci in the lungs. Perivascular inflammatory cell infiltrates were observed in the lungs, myocardium, kidneys, adrenal glands, brain, meninges, and liver, with micro-necrotic changes in the kidneys and liver. Fibrin thrombi were observed in multiple renal glomeruli. Hemophagocytosis by macrophages was observed in the spleen, liver, lymph nodes, bone marrow, and adrenal glands. Immunostaining showed positive results for group A Streptococcus antibody in the tonsils, with bacterial masses. Blood cultures were positive for group A Streptococcus pyogenes.ConclusionsBecause of the lower respiratory tract infection and suspected sibling transmission, in addition to the adrenal hemorrhages, a diagnosis of fulminant sepsis with group A Streptococcus pyogenes with associated Waterhouse–Friderichsen syndrome was made.

Accuracy of Centor scoring system in diagnosing group a-beta haemolytic streptococcal (GABHS) infection

ABSTRACTBackground: At present, the standard examination for diagnosing streptococcal upper respiratory tract infection is throat culture. As throat culture is time-consuming and relatively expensive, efforts are made to develop certain criteria that will still lead to proper diagnosis and rational use of antibiotics, that is Centor score. Even so, the accuracy of Centor score is still debatable. Purpose: To provide evidence on the accuracy of Centor scoring system compared to throat culture in diagnosing GABHS upper respiratory tract infection. Case Report: A 25-years old male came to primary health care with primary complain of sore throat. Centor score was used to diagnose GABHS infection and as a guide to give antibiotics. Clinical question: “In patients with sore throat, how accurate is the Centor score compared to throat culture in diagnosing Group A Beta-Haemolytic Streptococcal (GABHS) Infection?” Methods: Literature searching was conducted through 4 databases. Critical appraisal based on the Centre of Evidence-Based Medicine (CEBM)-University of Oxford University, Diagnostic Critical Appraisal Sheet and Systematic Review Sheet. Results: All the selected studies were considered valid. They revealed a high specificity, low sensitivity, high negative predictive value (NPV), and low positive predictive value (PPV) in the importance aspect assessment. The Centor scoring system was applicable to our patient. It was available, affordable, and accurate in adult patients, yet less accurate in children. Conclusion: In conclusion,Patient with sore throat and suspicion of GABHS infection could be diagnosed with Centor scoring system as the first line diagnosis in primary care and as a guide to whether to give giving antibiotics or not.ABSTRAKLatar belakang: Saat ini, kultur tenggorok merupakan pemeriksaan baku emas yang digunakan untukmendiagnosis infeksi saluran napas atas yang disebabkan oleh bakteri Streptococcus. Namun, kulturtenggorok merupakan pemeriksaan yang mahal dan hasilnya memakan waktu yang lama, sehinggaberbagai kriteria dikeluarkan untuk dapat dipakai sebagai alat diagnostik dan sebagai panduanpenggunaan antibiotik yang rasional pada kasus infeksi saluran napas atas. Salah satunya yaitu Centorscore, tetapi akurasinya masih kontroversial. Tujuan: Menyediakan laporan kasus berbasis buktiterhadap akurasi dari Centor score sebagai alat diagnostik infeksi saluran napas atas yang disebabkanoleh bakteri Streptococcus dibandingkan dengan pemeriksaan kultur tenggorok. Laporan kasus: Seorang laki-laki berusia 25 tahun datang ke fasilitas kesehatan tingkat pertama dengan keluhan utama nyeri tenggorokan. Centor score digunakan untuk mendiagnosis pasien ini dan sebagai panduan pemberian antibiotik. Pertanyaan klinis: Pada pasien dengan radang tenggorok,seberapa akurat Centor score dibandingkan dengan kultur tenggorok dalam diagnosis GABHS? Metode: Pencarian literatur dilakukan melalui 4 database dan telaah kritis literatur menggunakan tilikan dari CEBM, University of Oxford University. Hasil: Seluruh studi yang ditelaah valid. Seluruh studi menunjukkan spesifisitas dan negative predictive value (NPV) yang tinggi, serta sensitivitas dan positive predictive value (PPV) yang rendah. Centor score dapat diaplikasikan untuk pasien pada skenario klinis karena bersifat mudah digunakan, biaya yang dikeluarkan terjangkau, dan akurat khususnya pada pasien dewasa. Kesimpulan: Pasien dengan nyeri tenggorok yang dicurigai memiliki infeksi saluran napas atas yang disebabkan oleh bakteri Streptococcus dapat ditegakkan diagnosisnya melalui penilaian Centor score di fasilitas layanan tingkat pertama, serta dapat menjadi panduan dalam pemberian antibiotik.

Correlation between McIssac Score and Throat Swab Culture in Patient Presenting with Acute Tonsillitis

Introduction: Tonsillitis is inflammation of tonsils which is characterized by various signs and symptoms with sore throat being the most consistent symptom. The condition is mostly caused by bacterial infection with Streptococci being the most common bacteria. McIssac scoring technique is clinical symptoms based scoring method designed for diagnosing streptococcal tonsillitis. Aims: To find out the association between McIssac Score and beta hemolytic streptococcal infection in acute tonsillitis. Methods: This hospital based, prospective study was carried out in the Department of ENT, Nepalgunj Medical College from July 2020 to June 2021. Patients were scored as per McIssac score. The specimens were collected from the tonsillar surface using sterile cotton swabs and subjected for culture and sensitivity. Results:The most common affected age group was 21 to 30 years (46%). Females were affected more commonly (57%). The most common organism isolated in the study was Group A beta hemolyticn Streptococcus (48%), followed by Pseudomonas (10%), Enterococcus (9%) and Klebsiella (8%) and no organisms were isolated in 25% of the patients. It was observed that high McIssac score was associated with higher chance of having positive beta hemolytic streptococcal infection. Out of 48 group A beta hemolytic streptococci culture positive patients 18(37.5%) patients scored 3, 9 (18.75%) patients scored 4 and 7(14.5%) patients scored 5.The most common antibiotic effective against group A beta hemolytic srtreptococci was ceftriaxone in 25(72.9%), followed by amoxyclavulinic acid in 20 isolates (41.6%) and amikacin in seventeen (35.4%) isolates. Conclusion: The correlation between throat swab culture and McIssac score emphasized that this clinical scoring system aid in early diagnosis of group A beta hemolytic streptococci tonsillitis.

Streptococcal Exotoxin Streptolysin O Causes Vascular Endothelial Dysfunction Through PKCβ Activation.

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. Although the importance of SLO in invasive hemolytic streptococcus infection has been well demonstrated, the role of circulating SLO in noninvasive 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 pathway. Consistent with this, SLO increased phosphorylation levels of protein kinase C 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 with 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 protein kinase C β-induced phosphorylation of the endothelial NO synthase inhibitory site. Intravenous administration of SLO in control and hypertensive rats blunted the acetylcholine-induced decrease in blood pressure, providing evidence for a possible role of SLO in dysregulation of blood pressure.

Isolated Acute Rheumatic Pancreatitis—A Case Report

Aim: To emphasize the role of antibiotics in acute pancreatitis as prophylactic and therapeutic benefits. Case Report: A 32-year-old obese male was admitted with acute abdomen in the emergency room. He was supported with intravenous fluids and the blood chemistry revealed elevated amylase and lipase levels, raised ESR and a positive ASO titer test. CT abdomen suggested interstitial edematous pancreatitis (IEP) and no fluid collection. Patient was treated with IV cefotaxime and IV metronidazole, his condition remarkably improved with therapy, blood parameters returned normal at the end of 4 weeks, and follow-up CT revealed no abnormal findings and symptom free thereafter. Conclusion: Acute pancreatitis is usually a sterile inflammatory process caused by chemical autodigestion of pancreas. The edematous form of acute pancreatitis needs to correct its etiological factor to avoid recurrence. It is observed as an initial manifestation of group A beta hemolytic streptococcal infection in this patient and antibiotics play a role as curative and prophylactic in selected cases.

Assessment of Group a Streptococcus and Antimicrobial Resistance Pattern in School Going Children in Morang District, Nepal

Introduction: Group A hemolytic Streptococcal infections has worldwide distribution among children and it poses an important problem globally. There is lack of baseline information regarding Group A hemolytic streptococci in school going children in the eastern part of Nepal.&#x0D; Objective: The study was conducted for assessing the carrier rate of Group A hemolytic streptococci in school going children in eastern part of Nepal.&#x0D; Methodology: This study was community based cross-sectional study. During the study of 9 months, a total of 518 patients (school-going children) from different school who were symptomatic as well as asymptomatic were enrolled. All samples were collected by rubbing quickly and thoroughly over either tonsils (or tonsillar fossa) and over the posterior wall of the pharynx using light pressure and were subjected to microbial analysis in the clinical Microbiology Laboratory. The specimens were inoculated immediately into Blood agar (BA) and MacConkey agar (MA) and were incubated at 37°C aerobically and were checked for growth after overnight incubation. The identification of bacterial isolates was carried out by Clinical and Laboratory Standards Institute (CLSI) guidelines with colonial morphology and staining reactions. Biochemical tests such as catalase, bacitracin sensitivity test (0.004 units) and Lancefield grouping (PastorexTM Strep) were performed. All the identified S. pyogenes isolates thus obtained were subjected to in vitro antibiotics sensitivity testing by using Kirby-Bauer disc- diffusion method as recommended by CLSI (2014).&#x0D; Results: During 9 months period total 518 throat swabs (303 male and 215 female)from school going children attending government and private school were collected after taking verbal consent and were cultured on blood agar and MacConkey agar.Streptococcus pyogenes was identified by using standard microbiological procedures. Antimicrobial susceptibility testing of the isolates was performed by Kirby Bauer disc diffusion method. Group A streptococci (GAS) was isolated from 28 (5.4%) school going children, of which 15 (5%) were male and 13 (7%) were female. There was no significant sex difference in colonization of GAS (p&gt;0.05). Majority of cases were asymptomatic. In this study it was observed that the sensitive drugs for GAS were Penicillin and their deravatives (100%), Ciproflocaxin (100%) and Azithromycin (100%) followed by Erythromycin (75%) and Cotrimoxazole (71.4%) (Table 9,10).&#x0D; Conclusion: The present preliminary study provides the base-line information on the GAS carriage rate and resistance trend among healthy school children. The present study showed that Penicillin and its derivatives should be used to treat a case of GAS pharyngitis and Azithromycin for those who are allergic to Penicillin. The present study also showed that Staphylococcus aureus as an equally important agent of pharyngitis and hence throat swab culture should be requested for appropriate therapy.

Activation of activin/Smad2 and 3 signaling pathway and the&amp;nbsp;potential involvement of endothelial‑mesenchymal transition in the valvular damage due to rheumatic heart disease

Rheumatic heart disease (RHD) is an autoimmune disease caused by rheumatic fever following group A hemolytic streptococcal infection and primarily affects the mitral valve. RHD is currently a major global health problem. However, the exact pathological mechanisms associated with RHD-induced cardiac valve damage remain to be elucidated. The endothelial-mesenchymal transition (EndMT) serves a key role in a number of diseases with an important role in cardiac fibrosis and the activin/Smad2 and 3 signaling pathway is involved in regulating the EndMT. Nevertheless, there are no studies to date, to the best of the authors' knowledge, investigating the association between RHD and EndMT. Thus, the aim of the current study was to investigate the potential role of EndMT in cardiac valve damage and assess whether activin/Smad2 and 3 signaling was activated during RHD-induced valvular injury in a rat model of RHD induced by inactivated Group A streptococci and complete Freund's adjuvant. Inflammation and fibrosis were assessed by hematoxylin and eosin and Sirius red staining. Serum cytokine and rheumatoid factor levels were measured using ELISA kits. Expression levels of activin/Smad2 and 3 signaling pathway-related factors [activin A, Smad2, Smad3, phosphorylated (p-)Smad2 and p-Smad3], EndMT-related factors [lymphoid enhancer factor-1 (LEF-1), Snail1, TWIST, zinc finger E-box-binding homeobox (ZEB)1, ZEB2, α smooth muscle actin (α-SMA) and type I collagen α 1 (COL1A1)], apoptosis-related markers (BAX and cleaved caspase-3) and valvular inflammation markers (NF-κB and p-NF-κB) were detected using reverse transcription-quantitative PCR and western blot analyses. Compared with the control group, the degree of valvular inflammation and fibrosis, serum levels of IL-6, IL-17, TNF-α and expression of apoptosis-related markers (BAX and cleaved caspase-3) and valvular inflammation marker (p-NF-κB), activin/Smad2 and 3 signaling pathway-related factors (activin A, p-Smad2 and p-Smad3), EndMT-related factors (LEF-1, Snail1, TWIST, ZEB 1, ZEB2, α-SMA and COL1A1) were significantly increased in the RHD group. These results suggested that the activin/Smad2 and 3 signaling pathway was activated during the development of valvular damage caused by RHD and that the EndMT is involved in RHD-induced cardiac valve damage.

Evaluation of Xpert® Xpress Strep A Test for detection of Group A streptococcus in throat swabs

Background Streptococcus pyogenes (Group A β -hemolytic Streptococcus) infections in humans range from mild pharyngitis to life-threatening infections such as septicaemia and necrotizing fasciitis. We assessed the diagnostic accuracy of the Xpert® Xpress Strep A Assay, a new automated real-time polymerase chain reaction (PCR) that can detect this pathogen. Methods We evaluated the diagnostic accuracy (sensitivity, specificity PPV and NPV) of Xpert® Xpress Strep A Test (Cepheid, Maurens-Scopont, France) for the detection of Group A Streptococcus in throat swabs using Copan virus transport medium at Ninewells Hospital &amp; Medical School (Dundee, Scotland, UK). The performance of Xpert t® Xpress Strep A Assay was compared with routine culture (gold standard method). Results A total of 323 clinical throat swab samples were tested. The sensitivity of Xpert ® Xpress Strep A Assay was found to be 95% (95% CI, 75.13% -99.87); specificity 96.5% (95% CI 93.83% -98.36%);PPV 65.5% (95% CI 50.61% -77.89%); and NPV 99%(95% CI 97.68% -99.95%). Overall, there were eleven discrepant results, of these 10 were positive by PCR and not confirmed by culture and one sample was recorded positive by culture and negative by PCR. The turnaround time (TAT) was 24 minutes for negative samples and 18 minutes for positive samples. Conclusion The Xpert® Xpress Strep A Assay for detection of Streptococcus pyogenes in throat swabs had high sensitivity, specificity and rapid TAT. Use of this technology as a point-of-care test could be explored further to assess its impact on antimicrobial prescribing and infection prevention and control measures.

P3132Methylenetetrahydrofolate reductase A1298C as a risk factor for rheumatic heart disease in indonesian population

Abstract Introduction Rheumatic heart disease (RHD) is a chronic condition causing damage in cardiac valvular tissues due to acute rheumatic fever (ARF) post Streptococcus pyogenes or Group A β hemolytic Streptococcus (GABHS) infection. The damage to the valve tissue within the heart can lead to congestive heart failure, strokes, endocarditis, and death. However, only 3–6% of post-streptococcal infection individuals develop ARF, suggesting host susceptibility in the pathogenesis of ARF. Polymorphisms of methylenetetrahydrofolate reductase (MTHFR) may be linked to the genetic susceptibility of the host that results in abnormal autoimmune response to the infection. Purpose This study aims to look at MTHFR A1298C polymorphism as a risk factor for rheumatic heart disease in Indonesian population. Methods This was an observational analytical study with case control approach. Blood samples were obtained from 36 Indonesian RHD patients with confirmed diagnosis of RHD using echocardiography and 36 healthy controls. Patients DNA were isolated and then amplified using polymerase chain reaction followed by restriction fragment length polymorphism analysis using MboII restriction enzyme. Results We observed a significant difference between genotypic distribution between cases and controls (OR = 4.6, 95% CI = 1.697–12.469, p=0.002). The genotype frequency of MTHFR A1298C AA (wild type) was 36.1%, heterozygous AC was 47.2%, and 16.7% of CC in the cases group. In the control group, the genotype frequency of the wild type AA was 72.2%, AC was 27.8%, and homozygous CC was 2.8%. Conclusion Compared with the CC frequency in the control population, the frequency of MTHFR CC was 5 times higher in individuals with rheumatic heart disease (p=0.002), suggesting that MTHFR A1298C gene variant may contribute to the pathogenesis of RHD. Individuals with MTHFR 1298C have a risk of 4.6 times higher to develop ARF post streptococcal infection.

MON-046 POST-STREPTOCOCCAL ACUTE PULMONARY RENAL SYNDROME

Pulmonary renal syndrome is a group of disorders where we see rapidly progressive glomerulonephritis and diffuse alveolar syndrome. We present a case of post streptococcal pulmonary renal syndrome A 45 year old Sri Lankan Male, dairy farmer by occupation, presented with hemoptysis and increasing shortness of breath for 2 days. His history included a recent travel to Sri Lanka, where he had been unwell 2 weeks preceding the admission with upper respiratory tract symptoms and was given a course of antibiotics. At the time of presentation, his oxygen saturation was low and hence he was started on non-invasive ventilation. His renal function was impaired and urine microscopy showed dysmorphic red cells. Serology for HIV, Hepatitis B and C and Leptospirosis and cultures for TB were all negative. Because of recent history of upper respiratory tract infection, streptococcal antibody titres were done which was significantly positive for both antistreptolysin O titer and Anti DNAase –B, which would be consistent with recent streptococcus pyogenes infection. Antibody screen for anti GBM, ANCA and ANA were negative. CT scan of the chest showed changes consistent with diffuse alveolar haemorrhage and this was confirmed with bronchoscopy ( see below). He underwent a renal biopsy, which was consistent with Post infectious glomerulonephritis (histology below). Given his presentation and worsening respiratory status, Plasma exchange was performed and he was started on pulse methylprednisone. Patient was switched to oral prednisone, which was slowly weaned over 8 weeks and patient made completely recovery both from a respiratory and renal perspective. Discussion: This is an extremely rare case of pulmonary renal syndrome in the setting of post streptococcal pharyngitis. So far, only 5 such cases have been reported. Post streptococcal glomerulonephritis develops approximately 10 days to 2 weeks after streptococcal pharyngitis. It presents with oliguric renal failure, hematuria and hypertension, however most patients present with mild disease. It is very unusual to develop diffuse alveolar haemorrhage to develop in association with PSGN. Mechanism of diffuse alveolar haemorrhage in relation to streptococcal infection is not clear. Possible theory is patients with haemolytic streptococcal infection, the released nephritogenic antigen include nephritis associated plasmin receptor and streptococcal pyrogenic exotoxin B. These antigens accumulate in the glomeruli, trap and maintain the activity of plasmin and induce the degranulation of glomerular basement membrane. The host immunity generates antibody and there is deposition of immune complexes in the sub-epithelial space. A similar process may occur in lung tissue causing diffuse alveolar haemorrhage. Diffuse Alveolar Haemorrhage is a life threatening condition. When pulmonary capillaritis is the pathology of haemorrhage, as in pauci-immune glomerulonephritis or Good Pastures disease, it responds to plasma exchange and pulse intravenous steroids followed by oral steroids. Consistent with this, our patients hemoptysis and respiratory distress completely resolved and renal impairment improved back to normal levels after therapy. Acute pulmonary renal syndrome can occur in the post streptococcal glomerulonephritis. Timely therapy with Plasma exchange and steroids helps in complete resolution.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluation of Symptoms and Findings in Children with Tonsillopharyngitis Reflecting The Presence of Beta Hemolytic Streptococcal Infection

Amac : Streptokoksik tonsillofarenjitte erken ve uygun antibiyotik tedavisi semptomlari azaltip bulasicilik suresinin kisaltilmasinda, akut glomerulonefrit ve akut romatizmal ates gibi poststreptokokkal komplikasyonlarin onlenmesinde onemlidir. Oyku ve fizik muayene bulgularindan etiyolojiye isik tutanlarin belirlenmesi tedavinin erken ve uygun antibiyotikle baslanmasini saglayabilir. Materyal ve Metot: Bu calismada ust solunum yolu enfeksiyonu belirtileri ile basvuran ve klinik olarak akut tonsillofarenjit tanisi alan 300 vaka prospektif olarak degerlendirildi. Hastalarin yas ortalamasi 67,70 ± 40 ay (14-168 ay) olup 136’si (% 45,33) kiz; 164’u (% 54,66) erkekti. Hastalar yas, akut bogaz agrisi, ates, basagrisi, yutma guclugu, myalji, dokuntu, karin agrisi, bulanti, kusma, aile oykusu, evdeki fert sayisi, basvuru oncesi hastalik suresi acisindan sorgulandi, fizik muayenedeki tonsil hipertrofisi, kript, servikal lenf bezi hassasiyeti kaydedildi. Tum hastalardan bogaz kulturu alindi. Bulgular : Bogaz kulturu sonuclarina gore 60(%20) hastada beta hemolitik streptokok(BHS) izole edilirken, bunlardan 50(%83,33)’si A grubu olarak gruplandi. BHS izole edilen ve BHS izole edilmeyen vakalar karsilastirildiginda yas ortalamalari BHS grubunda 85,81±39, BHS uremeyen grupta 63,13±39 ay(p<0,001) bulundu. Oykude basagrisi(p<0,001), myalji(p<0,001), yutma guclugu (p=0,040) ve dokuntu(p=0,011) varligi ile BHS izolasyonu arasinda istatistiksel olarak anlamli bir iliski bulundu. Diger veriler anlamli degildi. Sonuc : Hastalarin bakteriyolojik olarak degerlendirilmesinin mumkun olmadigi durumlarda oyku ve klinik bulgulardan spesifik olanlarin degerlendirilmesi cocuk hastalarda gelisene tonsillofarenjitin ampirik tedavisinde yol gosterici olacaktir.

Screening for group B hemolytic streptococcal infection in pregnancy in a low-resourced country

Objectives: The objectives of this study conducted in a low-resourced country were to determine the feasibility and acceptability among pregnant women of universal screening for group B streptococcus (GBS), the prevalence of GBS, to calculate the risk of vertical transmission, and to study the neonatal outcome of early onset group B streptococcus disease (EOGBSD). Materials and Methods: All pregnant women between 35-37 weeks of gestation who attended the Port-of-Spain General Hospital during a six-month interval were enrolled in a study involving universal screening for group B streptococcus from vaginal and ano-rectal swabs. After appropriate laboratory preparation, inspection of the plate for GBS was performed. Patients found to be GBS screen-positive received intrapartum antibiotic prophylaxis (IAP). Results: Among the 420 eligible patients, 341 women (81.2%) agreed to participate. A total of 52 maternities (15.2%) were confirmed as GBS screen-positive. The highest rate of positive results were observed in Afro-Caribbean women, although this difference was not statistically significant (p &gt; 0.05). Intrapartum antibiotic prophylaxis (IAP) was administered to 37 patients (71.1%). Conclusion: This study reveals that despite the relatively low prevalence rate of GBS, a policy of universal screening and IAP in low-resourced countries, it is possible to address the major burden of EOGBSD.

Group A ?-Hemolytic Streptococci Infection among Children in Primary School in Samarra City

Group A ?-Hemolytic Streptococci Infection among Children in Primary School in Samarra City

Knowledge, awareness, and attitude of Saudi population toward rheumatic fever

Background: Rheumatic fever (RF) is an autoimmune disease associated with group A-&amp;#946;-hemolytic streptococcal infection, in the course of which the patient develops carditis, arthritis, chorea, subcutaneous nodules, and erythema marginatum. The present study aims to evaluate knowledge, awareness, and attitude of the Saudi population toward RF. Methodology: A questionnaire-based cross-sectional study was conducted from October 2016 to May 2017. The questionnaire included a total of 19 questions. Sixteen were close-ended questions and 3 were openended questions. After excluding incomplete questionnaires, data of 1,596 participants were obtained and entered into the Statistical Package for Social Sciences (SPSS) statistical software version 22. Results: A total of 1,596 respondents completed the questionnaire. The respondents were from all the regions of Saudi Arabia. Regarding age, the participants were classified into four groups, most of them (60.7%) were aged between 18 and 30 years. More than half of them (55.8%) were females. Regarding occupation; 38% of participants were educated. The knowledge and attitude about RF among our participants was 70%. The statistical analysis showed a significant correlation between; knowledge regarding age, gender, occupation, and attitude regarding age, gender, and accommodation and practice regarding age and occupation. Conclusion: Levels of knowledge, attitude, and awareness of RF were high when compared with other studies reported. Age, gender, and occupation were significant factors for knowledge, attitude, and awareness regarding RF.

SOMANZ Guidelines for the Investigation and Management of Sepsis in Pregnancy

(Aust N Z J Obstet Gynaecol 2017;57:540–551) Sepsis, caused by Group A beta hemolytic streptococcal (GAS) infection, is an increasing cause of maternal mortality in both Australia and the United Kingdom. Sepsis can lead to insufficiency in maternal circulation, leading to compromised fetal perfusion and fetal distress. The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) has designed evidence-based guidelines for the effective investigation and management of sepsis in pregnant and postpartum women.

Immune deficiency derive a favorable response to IVIg in PANDAS

For two decades, pediatric autoimmune neuropsychiatric disorder associated with group a beta hemolytic streptococcal infection (PANDAS) has been treated with high-dose intravenous immune globulin (IVIg) therapy based upon the understanding that the disorder is partly due to post-infectious dysimmunity.

Tonsillitis exacerbates renal injury in IgA nephropathy through promoting Th22 cells chemotaxis.

Tonsillitis can promote the progression of IgA nephropathy (IgAN) by aggravating immunopathologic response. Th22 cell disorder is involved in the pathogenesis of IgAN with tonsillitis. This study was determined to explore the possible mechanism of IgAN with tonsillitis underlying Th22 cell chemotaxis response to the effect of CCL20, CCL22, and CCL27. This research was conducted on 65 subjects including 16 healthy controls (HCgroup), 5 patients with renal carcinoma (HTC group) and 44 patients with IgAN between 2015 and 2016. According to clinical symptoms and results of throat swab culture, patients with IgAN were divided into two groups: IgAN with tonsillitis (IgAN+tonsillitis, n=14) and IgANpatientswithout tonsillitis (IgAN, n=30). Distribution of Th22 cells in IgAN patients was determined. The expression of CCL20, CCL22, and CCL27 in both peripheral blood and kidneys of IgAN patients was investigated. Severity of pathological lesions in IgAN patients was analyzed. Coculture assay and transwell assay were performed to explore the impacts of human mesangial cells (HMC) on Th22 cell chemotaxis and Th22 cell local accumulation under hemolytic streptococcus (HS) infection. Th22 cell percentages in IgAN patients increased compared with healthy controls. This increased Th22 cell percentage was positively correlated with the renal lesions of IgAN patients. Correspondingly, the expression of CCL20, CCL22, and CCL27 in renal tissue increased in IgAN patients. Tonsillitis exacerbated these overrepresentations of Th22 cells and chemokines. It was found that HMC could produce CCL20, CCL22, and CCL27. The supernatant of HMC was chemotactic for Th22 cells. This activity of HMC was stimulated by HS infection, whereas treatment of anti-CCL20, anti-CCL22, and anti-CCL27 antibodies partly blocked this chemoattractant effect of HMC. Tonsil infection may aggravate the renal pathological lesions of IgAN by exacerbating Th22 cell accumulation. Our data suggested a collaboration between HMC and Th22 cells in IgAN with tonsillitis underlying the effects of CCL20, CCL22, and CCL27.