Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression / Parâmetros indicativos de persistência de patologia valvular no diagnóstico inicial de cardite reumática aguda: o papel da albumina e da expressão de CD19

Abstract Objective: The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC). Methods: Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement. Results: During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6 ± 0.48 g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1. Conclusion: The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.

Resumo Objetivo: Definir os preditores da cardite crônica em pacientes com cardite reumática aguda (CRA). Métodos: Os pacientes diagnosticados com CRA entre maio de 2010 e maio de 2011 foram incluídos no estudo. Foram feitos os testes de ecocardiografia, eletrocardiograma, uma análise do subgrupo de linfócitos, provas de fase aguda, níveis de albumina plasmática, antiestreptolisina-O (ASO) na manifestação inicial. As avaliações ecocardiográficas foram repetidas no 6º mês de acompanhamento. Os pacientes foram divididos em dois grupos de acordo com a persistência da patologia valvular no 6º mês como Grupo 1 e Grupo 2 e todos os parâmetros clínicos e laboratoriais na internação foram comparados entre dois grupos de comprometimento valvular. Resultados: Durante o período do estudo de um ano, 22 pacientes apresentaram doença valvular; 17 (77,2%) apresentaram regressão da patologia valvular. Houve desaparecimento de regurgitação moderada inicial em oito pacientes (36,3%). Entre sete (31,8%) pacientes com regurgitação moderada inicialmente, a regurgitação desapareceu em três e quatro apresentaram melhoria para regurgitação leve. Dois pacientes com regurgitação grave inicialmente apresentaram melhoria para regurgitação moderada (9,1%). Em cinco (22,8%) pacientes o grau de regurgitação (regurgitação moderada em um [4,6%] e regurgitação grave em quatro [18,2]) continuou inalterado. O nível de albumina foi significativamente menor no diagnóstico no Grupo 2 (2,6 ± 0,48 gr/dL). A análise do subgrupo de linfócitos mostrou uma redução significativa no percentual de CD8 e um aumento significativo no percentual de CD19 no Grupo 2 em comparação com o Grupo 1. Conclusão: O nível de albumina no sangue e o percentual de linfócitos CD8 e CD19 (+) no diagnóstico podem ajudar a prever risco de doença valvular crônica em pacientes com cardite reumática aguda.

Association between antistreptolysin-O serum level and chronic plaque psoriasis in Iraqi patients

Objective: Psoriasis is a disease characterised by T-cell-mediated hyperproliferation of keratinocytes initiated by antigen-presenting cells on the skin. Environmental factors including streptococcus infections and multiple genetic components may be responsible for the pathogenesis of the disease. This study was performed to assess the association between antistreptolysin-O [ASO] serum level and chronic plaque psoriasis

Methods: Serum level of ASO was measured in 45 doctor-diagnosed psoriatic patients with an age range of 10-50 years attending the dermatology outpatient clinic in Al-Hussein Medical City in Kerbala Province - Iraq during the period from March 2014 through July 2015. Psoriatic patients with chronic plaque type were selectively recruited to the study. Another 20 age- and gender-matched persons were chosen as healthy control group. Serum level of ASO was estimated in all patients and control group using enzyme-linked immunosorbent assay [ELISA]

Findings: Data revealed a significantly increased serum ASO level in the chronic plaque-type psoriatic patients compared to the healthy control group [P-value < 0.05]

Conclusion: The present study suggests that serum ASO level could be associated with the immunopathogenesis and/or susceptibility to this type of psoriasis

Valores referenciales de antiestreptolisina O y portadores asintomáticos de estreptococos β-hemolíticos en adolescentes y adultos del Municipio Francisco Linares Alcántara, Venezuela / Reference valúes antistreptolysin O and asymptomatic carriers of β-hemolytic streptococci in adolescents and adults at Municipality Francisco Linares Alcántara, Venezuela

Introduction: β-hemolytic streptococci (Streptococcus pyogenes) groups A, C or G, secretes streptolysin O, toxin which causes in the infected individual an adaptive humoral immune response with production of serum antibodies called anti-streptolysin O (ASO). Objectives: To determine the reference value of ASO in a sample of 159 individuals aged 16-72 years from municipality Francisco Linares Alcántara, Aragua state, applying indirect (passive) agglutination test. By using a throat swab sample which was sown in blood agar 5% the frequency of asymptomatic carriers of β-hemolytic streptococci was also determined. Results and Discussion: As reference value for determining ASO by agglutination method a title of up to 200 IU/mL was obtained, this reference value differs from that recommended by the commercial equipment. Asymptomatic carriers frequency was 21.2% (n = 34). The distribution of β-hemolytic streptococci isolated were: group A (17.6%), group B (32.3%), group C (20.5%), group D (2.9%), group F (8.8%), group G (14.7%) and unclusterable (2.9%). Conclusions: The new ASO reference value for teens and adults of the mentioned municipality is up to 200 IU/mL. β-hemolytic Streptococcus group B was the most frequently isolated.

Introducción: Los estreptococos β-hemolíticos del grupo A (Streptococcus pyogenes), C o G, secretan estreptolisina O, toxina que causa en el individuo infectado una respuesta inmune adaptativa humoral con producción de anticuerpos séricos denominados antiestreptolisina O (ASO). Objetivos: Determinar el valor referencial de ASO en una muestra poblacional de 159 individuos con edades comprendidas entre 16 y 72 años del municipio Francisco Linares Alcántara, estado Aragua mediante aglutinación (pasiva) indirecta. También se determinó la frecuencia de portadores asintomáticos de estreptococos β-hemolíticos utilizando una muestra de exudado faríngeo que se sembró en agar sangre de cordero al 5%. Resultados y Discusión: Como valor referencial para la determinación de ASO por el método de aglutinación se obtuvo un título de hasta 200 UI/mL, valor que difiere del recomendado por el kit comercial. La frecuencia de portadores fue 21,2% (n = 34). La distribución de los estreptococos β-hemolíticos aislados fue: grupo A (17,6%), grupo B (32,3%), grupo C (20,5%), grupo D (2,9%), grupo F (8,8%), grupo G (14,7%) y no agrupable (2,9%). Conclusiones: El nuevo valor referencial de ASO para adolescentes y adultos del municipio mencionado es hasta 200 UI/mL. Streptococcus β-hemolítico del grupo B fue el grupo más frecuentemente aislado.

Subclinical involvement of cardiovascular system in juvenile collagen diseases

Cardiovascular lesions are commonly found in children and adolescence with different collagen diseases with relevant implication in mortality and morbidity. The purpose of the study was to verify whether there is any sign of cardiovascular involvement in juvenile collagen diseases using electrocardiography [ECG] and echocardiography [ECHO]. The study was carried out on 77 patients, 52 juvenile idiopathic arthritis [JIA], 20 systemic lupus erythematosus [SLE], 3 spondylarthropathy [SPA] and 2 juvenile dermatomyositis [JDM]. They were free of any clinically evident of cardiac manifestations. Thirty six healthy children were enrolled as control group All subjects underwent complete history and physical examinations, x ray chest, ECG and two dimensional, M mode, continuous wave [CW], pulse wave [PW] and color flow Doppler examinations. The following investigations were done erythrocyte sedimentation. rate[ESR], antistreptolysin O titre [ASOT], C reactive protein[CRP], rheumatoid factor[RF], antinuclear antibodies[ANA] and anti double stranded DNA[anti ds DNA]. Minor ECG changes were detected in 3 SLE and 2 JDM. ECHO showed pericardial effusion in 2 [3.3%] JIA and 3[15%] SLE. Aortic insufficiency was detected in 5[9.6%] JIA, 4 [20%] SLE. Mitral regurge was found in 7[13.4%] JIA, 5 [25%] SLE. Mild tricuspid regurge was detected in 3[15%] SLE. Mild pulmonary hypertension was found in 4[20%] SLE. Significant systolic dysfunction was elicited in JIA in form of increased left ventricular end diastolic diameter [LVEDD], left ventricular end systolic diameter[LVESD], left ventricular end diastolic volume[LVEDV] and left ventricular end systolic volume[LVESV] and reduction of ejection fraction [EF] and fractional shortening [FS]. In SLE .there was significant reduction, of EF and FS. Significant diastolic dysfunction was manifested in JIA by decreased peak early [E], E acceleration time [Eat], E duration [Edur], Total duration [Tdur], [E/A] ratio and A acceleration time [Aat] and increased peak atrial filling velocity [A], E deceleration time [Edt], isovolumic relaxation time [IVRT] and A deceleration time [Adt] and in SLE by decreased [E] and [E/A] ratio and increased [Edt] and in JDM by decreased [E] and [E/A] ratio and increased [IVRT]. In JIA, there was a positive correlation between age and [LVEDD] and disease duration with both [LVEDD] and [LVESD] and negative correlation between disease duration and EF. Cardiovascular involvement in juvenile collagen diseases is common. Regular cardiac evaluation using [ECG] and [ECHO] is recommended for early diagnosis of cardiac involvement. Key words: Cardiovascular-juvenile-collagen diseases

Determinação de anti-estreptolisina "O" e proteína C reativa entre escolares do município de Laranjal, PR / Determination of antistreptolysin \"O\" and C-reactive protein among school children of Laranjal, PR

Para a determinação de anti-estreptolisina "O" e proteína C reativa, no município de Laranjal-PR, foram analisados soros de 411 escolares, entre 5 a 16 anos. Para anti-estreptolisina "O", 13,6 por cento tiveram títulos elevados e 5,1 por cento foram reativos para proteína C reativa. Não foram observadas diferenças em relação ao sexo e faixa etária.

Evaluation of antibiotics used for treating acute attacks of recurrent tonsillitis in children

The often-indiscriminate use of antimicrobial agents has led to increased bacterial resistance over the past years. This phenomenon is not only evident in nosocomial environments but also at a community level. It is therefore important that, in addition to the rational use of antibiotics, an accurate prophylaxis is performed which includes the correct use of antimicrobials. Eighty children aged up to 10 years old, with a history of recurrent attacks of tonsillitis were included in this study. They were classified according to the frequency of occurrence of tonsillitis/year into the following groups: Group 1,40 children with a history of recurrent tonsillitis less than 4 attacks per year and group 2,40 children with a history of recurrent tonsillitis, 4 attacks or more per year. Blood samples were taken from each child for leukocytic count and measurement of erythrocytic sedimentation rate [ESR], antistreptolysin O titer [ASO], and C-reactive protein [CRP]. Throat swabs for microbiological examination were collected. Antibiotic sensitivity testing was done using antimicrobial discs of penicillin, cephradine, cefotaxime, ofloxacin, ciprofloxacin, ampicillin-sulbactam, gentamicin, ampicillin-cloxacillin 1:1, amoxicillin-clavulanic acid 2:1, cefuroxime and erythromycin. The isolates from group I were Streptococcus pyogenes [50%], Staphylococcus aureus [15%], Hemophilus infiuenzae [15%], Staphylococcus epidermidis [10%], Streptococcus agalactiae [5%] and Streptococcus pneumoniae [5%]. While the isolates from group 2 patients were Streptococcus pyogenes [15%], Staphylococcus aureus [20%], Neisseria and Streptococcus agalactiae [each 5%]. Mixed infection with Streptococcus pyogenes and Streptococcus pneumoniae constituted the majority of isolations among group 2 children [22 children, 55%]. This is in contrast to group I, where mixed infection was not reported at all. This difference was statistically significant. There was a significant difference between the 2 groups as regards the type of antibiotic used by each group where group I used all types of antibiotics. The use of antibiotic for the first time was also different where group 1 used more antibiotics than group 2

Interleukin-2 and Anticardiolipin antibodies in children with acute rheumatic fever and chronic rheumatic heart disease

The pathogenesis of rheumatic fever involves an interaction between the group A streptococcus and the immune system. Although an old disease the exact immunopathogenesis still unclear, so our aim is to determine whether interleukin-2 [IL-2] and anticardiolipin antibodies [aCL ab] have a role in immunopathogenesis of rheumatic fever or not. The work was carried out on 60 patients, 30 patients with acute rheumatic fever ARF [group I], 10 of them with rheumatic arthritis and 20 of them with rheumatic carditis and 30 patients with well documented chronic rheumatic heart disease CRHD [group II]. Twenty apparently healthy children were taken as control [group III]. All patients [group I and II] and control group [group III] were subjected to careful history taking, thorough clinical examination, laboratory investigations: Complete blood picture [CBC], Erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], Antistreptolysin-O titre [ASOT], Serum IL-2 and aCL Ab. Furthermore, patients with ARE and CRUD were sitbjected to: Plain X-ray chest and heart, ECG and Echocardiography. Our results showed that: IL-2 was significantly increased in cases of ARF [both in arthritis and carditis] than in patients with CRHD and normal control. No significant difference in IL-2 was found between cases of arthritis and carditis. Although IL-2 increases in rheumatic carditis, it has no relation to severity of carditis or to degree of ESR elevation. There was significant postive correlation between IL-2 and ASOT and CRP. Anti CL Ab was increased significantly in cases of rheumatic carditis [but not in cases of arthritis] than in patients with CRHD and normal control. A direct relationship was found between aCL Ab and the severity of carditis and ESR. There was significant positive correlation between aCL Ab and ESR, TLC and ASOT. So we suggest, the use of IL-2 [although non specific] to confirm the diagnosis of ARF as well as aCL Ab for the diagnosis of rheumatic carditis and a marker of its severity

Anti-streptolysin O titers in normal healthy children of 5-15 years.

Antistreptolysin O (ASO) levels vary with age group of the study population and geographical locations. The present study was undertaken to determine the upper limit of normal of ASO in 200 normal children of 5-15 years of age with no history of recent sore throat infection. The standard tube dilution method (WHO) was used for estimating ASO titers. It was found that 239 IU was the upper limit of normal in the study population, which can be considered as the baseline ASO titer. This can provide useful guidelines for physicians in the interpretation of elevated ASO titers in cases of suspected acute rheumatic fever.

Humoral immune response in a sample of Bangladeshi children with rheumatic fever.

Several researchers have investigated cellular response, and antibody response to different antigens of group A beta-haemolytic streptococci, cardiac tissues and B cell alloantigen in rheumatic fever (RF). However, immunoglobulins (Ig) which may indicate general immune status did not receive attention. This study was done in the outpatient clinic of the National Center for Control of Rheumatic Fever and Heart Diseases, Dhaka, to compare Ig levels in subjects with and without RF who have had recent group A beta-haemolytic streptococcal infections. We have recruited 44 RF cases aged 5 to 20 years, and 44 subjects without RF were randomly matched for age and sex as controls. Convalescent blood samples were used to measure antistreptolysin O and IgG, IgM, and IgA levels. The cases, as compared with the controls, had significantly higher levels of antistreptolysin O (mean 399 versus 321 IU/ml), IgG (mean 2386 versus 1885 mg/dl), IgM (mean 286 versus 222 mg/dl) and IgA (mean 258 versus 184 mg/dl). It is not clearly known why the immune response is higher in the RF cases. We have to elucidate factors responsible for higher immune response in children with RF.

Correlation between the severity of carditis and the level of acute phase reactants and anti-streptolysin O titer in acute rheumatic fever: a Retrospective study in Shiraz

In order to find the correlation between the severity of carditis in acute rheumatic fever [ARF] and the erythrocyte sedimentation rate [ESR], C-reactive protein [CRP] and anti-streptolysin O [ASO] titers, we performed a retrospective study in Shiraz on one-hundred and four patients. The mean age of the patients was 11 years. Fever was seen in 85.5%, arthralgia in 95.2%, arthritis in 81.7%, carditis in 82.5%, chorea in 3:8%, and subcutaneous nodules in 0.9% of patients. Mitral regurgitation was the most frequent valvar involvement [79.6%]. Sixteen patients [15.4%] had severe carditis. The ESR level was >/= 20 Wintrobe units in 98.0%, the CRP was elevated in 83.0%, and the ASO titer was >/= 400 Todd units in 91.0% of patients. There was no significant statistical difference between those patients with mild and severe carditis concerning the level of ESR, CRP, and ASO titers. There was also no significant statistical difference between the level of these parameters and the presence or absence of carditis, and the patient's age [8 years old]

Improvement of the indirect hemagglutination test for the detection of antibodies to Streptococcus pyogenes

An indirect hemagglutination test for a seroepidemiological survery of Streptococcus pyogenes infection was standardized. This is an improved modification of the indirect hemagglutination test which utilizes an unstable reagent prepared with fresh blood cells. Two types of bacterial antigens represented by extracellular products and purified streptolysin O were assayed but only the former antigen gave good results. Pretreatment of the bacterial antigen with 0.15 M NaOH and neutralization to pH 5.5, as well as postfixation of sensitized red cells with 0.1 per cent glutaraldehyde at 56 degrees Celsius for 30 min were found to be essential to give long stability to the reagent in liquid suspension, at least 9 months at 4 degrees Celsius. A total of 564 serum samples with high, moderate and low anti-streptolysin 0 antibodies as determined by the neutralization assay were studied by the indirect hemagglutination test using the new reagent. The sensitivity, specificity, efficiency, positive predictive value and negative predictive value of the test in relation to the neutralization assay were 0.950, 0.975, 0.963, 0.973, and 0.955, respectively. The kappa agreement index between the two techniques was high (0.926) and ranked as "almost perfect". Antibody levels detected by both techniques also presented a high positive correlation (r(s)=0.726). Five reagent batches sucessively produced proved to be reproducible. Thus, the improved indirect hemagglutination test seems to be useful for public health laboratories.

Febre reumática: manifestaçöes articulares atípicas / Rheumatic fever: atypical articular manifestations

O diagnóstico de febre reumática (FR) continua sendo um dos mais difíceis em pediatria, devido ao polimorfismo do seu quadro e à falta de exames laboratoriais específicos ou patognomônicos da doença. Este trabalho aborda o critério diagnóstico mais freqüente e menos específico, a artrite. Foram estudadas 93 crianças (117 surtos) acompanhadas no setor de Reumatologia Pediátrica do Departamento de Pediatria da Escolar Paulista de Medicina, sendo critério de inclusäo a presença de artrite. O diagnóstico foi baseado na história clínica, exame físico e exames complementares, tendo sido considerados os critérios de Jones modificados. Em 45// observamos artrite e cardite, em 7// artrite e coréia e em 4// artrite, cardite e coréia. A artrite foi migratória em 75 surtos (64// e aditiva em 42 (32//), poliarticular em 64// e pauciarticular em 36//. Monoartrite foi encontrada em 3//. Em 5// foi observada artrite de coxofemoral como manifestaçäo inicial da doença. O tempo de duraçäo da artrite foi igual ou maior a seis semanas em 5// dos surtos. O diagnóstico definitivo de FR nos casos com manifestaçöes articulares atípicas só foi possível com a presença de cardite ou coréia. Os autores chamam a atençäo para o diagnóstico diferencial da FR com outras doenças, principalmente quando a artrite é o único critério maior encontrado

Estreptococos beta-hemolíticos e níveis de antiestreptolisina "O" em escolares do 1§ grau da regiäo do Vale do Ribeira - SP / Beta hemolytics streptococci and levels of antiestreptolysin-O in schoolchildren from the fifth to ninth grade living in the Vale do Ribeira - Säo Paulo

Realizou-se a pesquisa de Estreptococos beta-hemolíticos, com material das fossas nasais e orofaringeano e dos níveis séricos de antiestreptolisina "O" (ASO), em escolares da zona urbana e rural de dois municípios da regiäo do Vale do Ribeira, SP. Examinou-se 588 escolares, encontrando-se 99 (16,8 por cento) portadores de Estreptococos beta-hemolíticos, assim distribuídos: 92 (92,9 por cento) do grupo A; 5 (5,1 por cento) do grupo G e 2 (2,0 por cento) do grupo C. No município A, distante do mar e com maior atençäo à saúde do menor, encontrou-se 24,2 por cento de Estreptococos beta-hemolíticos, enquanto no B, próximo ao mar, 75,8 por cento. Quanto aos níveis séricos, observou-se títulos considerados como indicativos de risco para Doença Reumática em número maior (45,6 por cento) para o Município B e 38,4 por cento para o Município A. Näo houve diferenciaçäo entre escolares de zona urbana e rural

Estreptococos beta-hemolíticos e níveis séricos de antiestreptolisina O em uma populaçäo adulta / Beta-hemolytic streptococci and serum levels of antistreptolysin O in an adult population

Verificou-se a incidência de Estreptococos beta-hemolíticos e os níveis séricos de ASO em uma populaçäo adulta residente no município de Araraquara. Entre 279 indivíduos, isolaram 30 portadores com 8 (25,8%) amostras do grupo A; 7 (22,6%) do grupo C; 15 (48,4%) do grupo G. Em 267 coletas de sangue, na primeira investigaçäo , 43 (16,1%) apresentaram níveis de ASO entre 250 e 333 UT; 13 (4,9%) acima de 500 UT e os demais dentro da normalidade. Reexaminados 6 meses após, dois apresentaram níveis de ASO mais elevados e 13 permaneceram como estavam. Dos cinco jovens que apresentavam processo infeccioso de vias respiratórias e a ASO se encontrava dentro da normalidade, na segunda avaliaçäo dois deles apresentaram títulos bem elevados e säo exatamente aqueles dos quais se isolaram Estreptococos beta-hemolíticos do grupo A