Recurrent Streptococcal Pharyngitis Research Articles

IgA-dominant infection-associated glomerulonephritis in the pediatric population.

IgA-dominant infection-associated glomerulonephritis is well-documented in adults but has not been studied in depth in children. We assessed the incidence of pediatric IgA-dominant infection-associated glomerulonephritis and clinical and kidney biopsy findings. Pediatric native kidney biopsies over a 10-year period with IgA dominance, strong C3, and findings indicative of infection-associated etiology were identified. We identified 9 cases of IgA-dominant infection-associated glomerulonephritis, 0.8% of pediatric native kidney biopsies. Seven patients presented with elevated creatinine. All had hematuria and proteinuria. Eight patients had clinical evidence of infection: one each with central port infection by methicillin-sensitive Staphylococcus aureus, recurrent streptococcalpharyngitis and recent otitis media, streptococcalpharyngitis demonstrated 8months after biopsy, suspected streptococcalscalded skin syndrome, and viral gastroenteritis, and three with serologic evidence of Streptococcal infection but no identified site of infection. All but one patient experienced short-term normalization of creatinine and resolution of proteinuria, though two eventually progressed to kidney failure: one 3years later due to progressive disease and one 11years later due to focal segmental glomerulosclerosis without concurrent immune deposits. Pediatric IgA-dominant infection-associated glomerulonephritis is rare, and generally has a favorable prognosis, contrasting that seen in adults with severe comorbidities. A higher resolution version of the Graphical abstract is available as Supplementary.

Case 292.

History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed (Figs 1, 2).

Clinical evaluation of the oral probiotic Streptococcus salivarius K12 in the prevention of recurrent pharyngitis and/or tonsillitis caused by Streptococcus pyogenes in adults

Background: Streptococcus salivarius K12 has been shown to inhibit the growth of Streptococcus pyogenes due to bacteriocins release. Because of its ability to colonize the oral cavity, we have tested the strain K12 for its efficacy in preventing streptococcal pharyngitis and/or tonsillitis in adults.Methods: Forty adults with a diagnosis of recurrent oral streptococcal pharyngitis were enrolled in the study. Twenty of these subjects took for 90 days a tablet containing Streptococcus salivarius K12 (Bactoblis®). The other 20 subjects served as untreated controls. A 6-month follow-up was included to evaluate any persistent protective role.Results: The 20 adults who completed the 90-day course of Bactoblis® showed a reduction in their episodes of streptococcal pharyngeal infection (about 80%). The 90 days treatment was also associated with an approximately 60% reduction in the incidence of reported pharyngitis in the 6-month period following use of the product. The product was well tolerated by the subjects with no treatment-related side effects or drop-outs reported.Conclusion: Prophylactic administration of Streptococcus salivarius K12 to adults having a history of recurrent oral streptococcal pathology reduced the number of episodes of streptococcal pharyngeal infections and/or tonsillitis.

Biofilm formation or internalization into epithelial cells enable Streptococcus pyogenes to evade antibiotic eradication in patients with pharyngitis

Streptococcus pyogenes is the bacterium most frequently isolated from patients with pharyngitis. Although various antibiotics including penicillin are effective, antibiotic treatment failure in cases of streptococcal pharyngitis have been reported. Herein, we investigated mechanisms associated with recurrent streptococcal pharyngitis. Clinically isolated S. pyogenes strains showed serotype-specific features, with emm12 strains most frequently detected and emm6 strains more likely to produce biofilm. The architectures of formed biofilms were observed using a fluorescence microscope with Live/Dead staining. Furthermore, various cationic antimicrobial peptides were tested to evaluate their inhibitory activities toward biofilms formed by S. pyogenes. After treatments with high concentrations of antibiotics, S. pyogenes survived in biofilm even when dead bacterial cells covered the surface. Other findings demonstrated that some antimicrobial peptides have inhibitory effects on forming and formed biofilm. Moreover, emm4, emm6, and emm75 strains showed significantly higher levels of invasion capacity into Detroit 562 cells than strains with other genotypes. Additionally, more than half of the strains temporarily escaped killing by penicillin alone by internalization into epithelial cells, even when the antibiotic concentration used was greater than the 10-fold minimum inhibitory concentration (MIC) for planktonic S. pyogenes. Also, combined administrations of multiple antibiotics were more effective to eradicate strains more likely to be internalized. Finally, flow cytometric analyses demonstrated that emm12 strains with higher invasive capabilities expressed PrtF1 protein on the bacterial surface. These findings suggest that S. pyogenes isolated from patients with recurrent streptococcal pharyngitis have emm type-specific features that allow escape from eradication by antibiotics.

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial

Efficacy of Powered Intracapsular Tonsillectomy and Adenoidectomy

We sought to determine the effectiveness of powered intracapsular tonsillectomy and adenoidectomy (PITA) in the treatment of children with moderately severe obstructive sleep apnea and to measure changes in quality of life that occur with such treatment. Prospective, nonrandomized clinical trial in an academic pediatric otolaryngology practice. Convenience sample of children ages 3 to 12 years diagnosed with obstructive sleep apnea of moderate severity, defined as an apnea-hypopnea index (AHI) between 5 and 20 on polysomnography. Children with recurrent streptococcal pharyngitis, chromosomal abnormalities, craniofacial abnormalities, neuromotor disease, sickle cell disease, obesity, or coagulopathy were excluded. PITA was performed by using the microdebrider. Polysomnography was performed before surgery and repeated 4 to 8 weeks after surgery. The Obstructive Sleep Apnea (OSA)-18 questionnaire was completed at surgery and at the time of postoperative polysomnography to assess quality of life changes. The main outcome measure was cure of obstructive sleep apnea, as defined by a postoperative AHI of 1 or less for complete cure and less than 5 for partial cure. Improvements in quality of life were assessed by changes in the OSA-18 questionnaire. Nineteen children underwent PITA for moderate obstructive sleep apnea syndrome (OSAS), and 14 completed postoperative polysomnography. All 14 subjects who completed the study achieved at least partial cure. Thirteen of 14 (93%) subjects had a complete cure of OSAS after PITA. The median preoperative AHI was 7.9, and the median AHI after surgery was 0.1. The mean number of arousals per hour before surgery was 9.5, and this was reduced to a mean of 5.6 after surgery. Quality of life measures on OSA-18 also improved, with large improvements in total quality of life scores and in all five domains seen after surgery. PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short-term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA-18, were seen in all children as well.

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial

Objective To determine the short term efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. Design Randomised controlled trial. Setting Academic referral centre in Finland. Participants 70 adults with documented recurrent episodes of streptococcal group A pharyngitis. Intervention Instant tonsillectomy (n=36) or remaining on waiting list as control (n=34). Main outcome measures Percentage change in the risk of an episode of streptococcal pharyngitis at 90 days. Rates of all episodes of pharyngitis and days with symptoms and adverse effects. Results The mean (SD) follow-up was 164 (63) days in the control group and 170 (12) days in the tonsillectomy group. At 90 days, streptococcal pharyngitis had recurred in 24% (8/34) in the control group and 3% (1/36) in the tonsillectomy group (difference 21%; 95% confidence interval 6% to 36%). The number needed to undergo tonsillectomy to prevent one recurrence was 5 (3 to 16). During the whole follow-up, the rates of other episodes of pharyngitis and days with throat pain and fever were significantly lower in the tonsillectomy group than in the control group. The most common morbidity related to tonsillectomy was postoperative throat pain (mean length 13 days, SD 4). Conclusions Adults with a history of documented recurrent episodes of streptococcal pharyngitis were less likely to have further streptococcal or other throat infections or days with throat pain if they had their tonsils removed. Trial registration Clinical Trials NCT00136877.

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial

Objective To determine the short term efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults.Design Randomised controlled trial.Setting Academic referral centre in Finland.Participants 70 adults with documented recurrent...

Recurrent Streptococcal Pharyngitis–Reply–I

We thank Dr Hoover for his interest in our article. His family's experience sounds similar to that reported in 1983 in the journal Postgraduate Medicine. In that report, Mayer and Van Ore1Mayer G Van Ore S Recurrent pharyngitis in family of four: household pet as reservoir of group A streptococci.Postgrad Med. 1983; 74: 277-279PubMed Google Scholar described similar difficulties in eradicating group A β-hemolytic streptococcal infection in a family of 4 individuals.1Mayer G Van Ore S Recurrent pharyngitis in family of four: household pet as reservoir of group A streptococci.Postgrad Med. 1983; 74: 277-279PubMed Google Scholar On discovering that the family dog carried group A streptococcus, the entire family, including the dog, was treated concurrently, and no streptococcus episodes followed treatment. However, other investigators have subsequently published reports indicating that the transmission of group A streptococcus from pets to families is probably rare. Wilson et al2Wilson KS Maroney SA Gander RM The family pet as an unlikely source of group A beta-hemolytic streptococcal infection in humans.Pediatr Infect Dis J. 1995; 14: 372-375Crossref PubMed Scopus (32) Google Scholar cultured specimens obtained from animals owned by families with children who had acute streptococcal pharyngitis, from pets of families with children who did not have streptococcal pharyngitis, and from dogs and cats from a local veterinary hospital. None of the animals in which culture studies were performed carried β-hemolytic streptococcus. Falck3Falck G Group A streptococci in household pets' eyes—a source of infection in humans?.Scand J Infect Dis. 1997; 29: 469-471Crossref PubMed Scopus (8) Google Scholar examined cultures from 61 pets belonging to children with acute infection and found group A streptococcus in the eye secretions of only 2 of the pets. He noted that “transmission of group A streptococci from humans to pets and vice versa can probably occur, but is uncommon.” On the basis of these more recent studies, we expect that the presence of a household pet as a streptococcus carrier is unlikely to play a role in most cases of recurrent streptococcal pharyngitis. Recurrent Streptococcal PharyngitisMayo Clinic ProceedingsVol. 82Issue 1PreviewTo the Editor: The article by St. Sauver et al1 on the prevalence of recurrent episodes of streptococcal pharyngitis in children prompted me to share a personal experience with this problem. Years ago when our children were preschool age and stayed at home, they experienced a series of recurrent bouts of streptococcal pharyngitis. Their pediatrician treated them on multiple occasions. Because the recurrent infections persisted even when all 3 children were treated at the same time and their mother and I had negative culture results, I decided there had to be another cause. Full-Text PDF

Recurrent Streptococcal Pharyngitis

To the Editor: The article by St. Sauver et al1St. Sauver JL Weaver AL Orvidas LJ Jacobson RM Jacobsen SJ Population-based prevalence of repeated group A ß-hemolytic streptococcal pharyngitis episodes.Mayo Clin Proc. 2006; 81: 1172-1176Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar on the prevalence of recurrent episodes of streptococcal pharyngitis in children prompted me to share a personal experience with this problem. Years ago when our children were preschool age and stayed at home, they experienced a series of recurrent bouts of streptococcal pharyngitis. Their pediatrician treated them on multiple occasions. Because the recurrent infections persisted even when all 3 children were treated at the same time and their mother and I had negative culture results, I decided there had to be another cause. We took our cat to the veterinarian, who documented the presence of streptococcal pharyngitis in our pet. When the cat and our children were all treated at the same time, there was no further recurrence of streptococcal pharyngitis. Certainly, the possibility of a pet harboring the infection should be considered as a cause of recurrent streptococcal pharyngitis. Recurrent Streptococcal Pharyngitis–Reply–IMayo Clinic ProceedingsVol. 82Issue 1PreviewWe thank Dr Hoover for his interest in our article. His family's experience sounds similar to that reported in 1983 in the journal Postgraduate Medicine. In that report, Mayer and Van Ore1 described similar difficulties in eradicating group A β-hemolytic streptococcal infection in a family of 4 individuals.1 On discovering that the family dog carried group A streptococcus, the entire family, including the dog, was treated concurrently, and no streptococcus episodes followed treatment. Full-Text PDF

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

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

Group A streptococcal pharyngitis

The group A Streptococcus is the most common bacterial cause of pharyngitis. Although most cases of streptococcal pharyngitis are managed by primary care providers, the otolaryngologist is often consulted to assist in the management of patients with persistent sore throat, chronic streptococcal carriage, recurrent streptococcal pharyngitis, or complications of streptococcal infection. This article reviews recent advances in diagnosis and management of individual episodes of streptococcal pharyngitis, the clinical approach to the streptococcal carrier, and the role of tonsillectomy in the management of recurrent pharyngotonsillitis.

A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis.

Guttate psoriasis is closely associated with preceding or concurrent streptococcal infection. Some authorities have claimed that chronic plaque psoriasis may also be made worse by infection. In view of this many dermatologists have recommended using antibiotics for psoriasis, particularly guttate type. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal pharyngitis. This review aims to assess the evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis. Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms (STREPTOCOCC* or ANTIBIOTIC* or TONSIL*) and PSORIASIS using the Cochrane Skin Group search strategy. Only one trial met the selection criteria. This compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonization. Either rifampicin or placebo was added to the end of a standard course of phenoxymethylpenicillin or erythromycin. No patient in either arm of the study improved during the observation period. No randomized trials of tonsillectomy for psoriasis were identified. Although both antibiotics and tonsillectomy have frequently been advocated both for patients with guttate psoriasis and for selected patients with chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.

A Role for Tonsillectomy in the Treatment of Psoriasis?

Our objective was to determine whether tonsillectomy is beneficial in the treatment of recurrent childhood guttate psoriasis that is associated with recurrent streptococcal pharyngitis and tonsillitis. We retrospectively reviewed the cases of two children who were referred to our facility for treatment of repeated exacerbations of psoriasis and recurrent streptococcal pharyngotonsillitis. Both patients experienced a significant improvement in their psoriasis after undergoing adenotonsillectomy, and both were completely free of psoriatic outbreaks after 16 months of follow-up. We conclude that tonsillectomy appears to be of benefit in the treatment of children with recurrent guttate psoriasis and recurrent streptococcal pharyngotonsillitis, and we hope that further investigation will be undertaken.

Strategies for managing group A streptococcal pharyngitis. A survey of board-certified pediatricians.

To assess the management strategies and knowledge of board-certified pediatricians regarding group A beta-hemolytic streptococcal (GABHS) pharyngitis. Survey of 1000 US pediatricians in 1991, chosen randomly from the membership of the American Academy of Pediatrics. The survey included questions related to 2 clinical scenarios, respondent demographics, and knowledge of streptococcal pharyngitis. Pediatricians who treated patients with pharyngitis. Of the 690 surveys that were returned, 510 pediatricians treated patients with pharyngitis and were included in the data analysis. Data were analyzed using Chi 2 statistics for categorical data and the Student t test for continuous variables. Antigen detection tests (ADTs) were used by 64% of the pediatricians; 85% used throat cultures. Strategies for diagnosing streptococcal pharyngitis were throat culture alone (38%), consider positive ADTs definitive and use throat culture when ADTs are negative (42%), ADT alone (13%), ADT and throat culture for all patients with pharyngitis (5%), and no tests for GABHS performed (2%). Thirty-one percent usually or always treated with antibiotics before test results were available. Only 29% of these "early treaters" always discontinued antibiotics when tests did not confirm the presence of group A streptococci. The drug of choice for treatment was penicillin (73%); another 26% preferred a derivative of penicillin, particularly amoxicillin. Many pediatricians altered their management when a patient had recurrent streptococcal pharyngitis. Nearly half of the respondents would use a different antibiotic than they used for routine acute streptococcal pharyngitis. They most often changed to erythromycin (25%), cefadroxil (23%), or amoxicillin-clavulanate (20%). Follow-up throat culture was obtained by 51% of pediatricians after treatment of recurrent streptococcal pharyngitis. A patient with chronic carriage of GABHS and symptoms of pharyngitis would be treated with an antibiotic by 84%; most (62%) would use a penicillin. Other choices were cephalosporins (19%), erythromycin (12%), clindamycin (3%), or rifampin plus penicillin (3%). Tonsillectomy was recommended for symptomatic carriers by 31% of respondents. Carriers without symptoms were less likely to be treated with antibiotics (23%) or referred for tonsillectomy (21%). Most surveyed board-certified pediatricians managed acute GABHS pharyngitis appropriately, but 15% to 20% used diagnostic or treatment strategies that are not recommended. There was lack of a consensus about the management of recurrent GABHS pharyngitis and chronic carriage of GABHS.

Anal Carrier Rate of Group A Beta-Hemolytic Streptococci in Children With Streptococcal Pharyngitis

A study was carried out to determine the frequency of anal cultures positive for group A beta-hemolytic streptococci in children with acute pharyngitis whose throat cultures were positive for group A beta-hemolytic streptococci. Only 6% of the patients screened had positive anal cultures and none of these children had a history of recurrent streptococcal pharyngitis. This rate does not warrant routinely obtaining anal cultures from children with group A beta-hemolytic streptococcal pharyngitis.

Unsuspected Bacterial Interference with Antibiotic Therapy

The problem of the recurrent streptococcal pharyngitis after apparently adequate antibiotic (especially penicillin) therapy has been a thorny problem which often plagues those in clinical medicine. Dr. Simon and Sakai are certainly to be congratulated for the very interesting paper on "Staphylococcal Antagonism to Penicillin Therapy Streptococcal Infection" (Pediatrics, 31:463, 1963). Perhaps this will help to solve this problem in clinical medicine. I wish to point out that this may not be an isolated instance of staphylococcal interference with antibiotic therapy for what should be nonresistant organisms.