Some problems in long-term prevention of streptococcal infection among children with rheumatic heart disease in Taiwan

In Taiwan, rheumatic fever (RF) and rheumatic heart disease (RHD) remain widespread and constituting a health problem. The long-term prevention of streptococcal infections among rheumatic children has also failed to prevail, and yet has seldom been emphasized. Therefore, recurrence of RF remained prevalent. For an appraisal of the difficulties in the administration of long-term medication prophylaxis, a prospective study was started in 1967. One hundred and five consecutive cases of RF and RHD were followed up for more than 1 year to 6 years with an average of 4.4 years. One hundred and two cases received monthly injections of benzathine penicillin G for 6 months to 6 years, of whom 10 were switched to daily sulfa drugs; 1 case had oral penicillin daily for 6 years; in 12 cases, sulfa drugs were given for 6 months to 5 years. Fifty-one cases (48.6 %) stayed well in the program; 22 (21.0 %) stayed but were not compliant; 32 (30.4 %) dropped out soon or after staying in for more than 1 year. Major risk factors leading to non-compliance are; 1) apparent recovery from the illness or resumption of the normal activity; 2) cram session at school; 3) lack of easy medical care system; and 4) shortage of active participation by the health workers and general practitioners. The present study confirmed that the long-term prevention of streptococcal infection was effective and contributed to the decline of RF recurrence rate from more than 30 % down to 6%. Our study implicates that this important preventive program can not be achieved just only by the hospital staff, but should be approached jointly by all doctors, health and social workers, school teachers and the parents.     

Group A streptococcal infections as related to rheumatic fever

Beta-hemolytic streptococci were recovered frequently, particularly from the throats of children, and the same type of group A strains was isolated from both throats and tonsils. A significant antibody response to streptolysin O was observed in 44.8 to 43.5 % of the children whom group A streptococci were recovered. It is considered that these children had the definite evidence of acute streptococcal infections, and administration of josamycin, penicillin G, and benzyl penicillin V benzathine decreases the frequency of recovery of beta-hemolytic streptococci and prevents rheumatic fever.     

The effect of prevention and other factors in the decrease in rheumatic fever

933 children with rheumatic fever hospitalised in Clinic in the period of 40 years (from 1995 to the end of 1994) were analysed in order to establish the fluctuation of patients number and changes in clinical appearance. Patients were divided in 4 groups: I. the patients hospitalised from 1955-1964 (472 patients), II. from 1965-1974 (307), III. from 1975-1984 (135), IV. from 1985-1994 (19). The data for Republic Croatia show the steady fall of the number of hospitalised children with rheumatic fever. Carditis with polyarthritis were present in the largest part of our patients (446 namely 47.8%). The number of recurrences fell equally with the number of patients with rheumatic fever. However, ratio between the number of patients with rheumatic fever and the number of recurrences did not change essentially, that was 11-15.85% in the periods considered. The percent of hospitalised children with fixed rheumatic heart disease was 4.23% in the I. period to as much as 15.5% in the III. period from totally hospitalised children with rheumatic fever. In the last time the disease became mild in its development. All children with suspicion on rheumatic fever should be hospitalised. The prophylaxis, primary or secondary, should be carried out intramusculary with benzithine penicillin G, as proved as the best, in order to ensure that the child virtually received the prophylaxis.     

Chorea in fifty consecutive patients with rheumatic fever

Envenomation by the brown recluse spider (Loxosceles reclusa) is associated with shock, significant hemolysis, renal insufficiency, and disseminated intravascular coagulation (DIC). Shock has never been associated with envenomation by L arizonica, a related species indigenous to Arizona, southern California, and northwestern Mexico. We report the case of a 13-year-old girl, bitten by a specimen of L arizonica (the spider was identified by an entomologist), in whom shock and a typical cutaneous lesion developed. She did not experience renal insufficiency or disseminated intravascular coagulation. Infectious causes of shock were excluded. She recovered completely with supportive care.     

Persistent elevation of immunoglobulin G titer against the C region of recombinant group A streptococcal M protein in patients with rheumatic fever

To analyze the immune response to the C region of group A streptococcal M protein in patients with rheumatic fever (RF), we cloned the structural gene for the C region of type 12 M protein and produced recombinant C region of M protein. IgG titers against the C region of M protein were measured by ELISA from sera of patients with RF (n = 10), uncomplicated streptococcal pharyngitis (n = 26), and age-matched controls (n = 49). IgG titers against the C region were significantly higher in patients with RF than in controls or patients with uncomplicated streptococcal pharyngitis (43 versus 1.5 or 1.8 micrograms/mL, p < 0.01). Studies using overlapping synthetic peptides of the C region demonstrated that increased IgG reactivity was observed against the amino-terminal halves of the C repeat blocks (C1, C2) in RF, indicating that these domains are the main immunodominant epitopes in the C region.     

Prevalence of rheumatic fever in children from a public high school in Belo Horizonte

Genetic studies have suggested homogeneity between the Baltic-type and Mediterranean-type progressive myoclonic epilepsy. Magnetoencephalography was applied to elucidate the mechanism underlying the giant evoked responses in cortical reflex myoclonus. A new concept of negative myoclonus mediated by cortical reflex mechanism was proposed. Cortical myoclonus was demonstrated in various neurodegenerative or metabolic disorders, such as presenile or senile dementia, olivopontocerebellar atrophy, and myoclonus epilepsy associated with ragged-red fibres. Myoclonus in corticobasal degeneration is especially noteworthy because it has clinical and electrophysiological features of cortical reflex myoclonus, but its latency is shorter compared with the conventional cortical reflex myoclonus. Clinical features of 'palatal myoclonus' were reported by the name of 'palatal tremor'.     

Perianal streptococcal dermatitis in children

Perianal dermatitis caused by Streptococcus pyogenes (beta-haemolytic Lance-field group A) was diagnosed in four children, three boys aged I, 6 and 8 years and a girl aged 2 years. Perianal itching in children is most frequently attributed to enterobiasis (Enterobius vermicularis); fissures due to scratching can complicate this situation. Perianal streptococcal dermatitis can effectively be treated with oral penicillin, in combination with local antibiotic application (fucidin, mupirocin).     

Autoimmune rheumatic diseases associated with HIV infection and its pathogenesis

In autoimmune rheumatic diseases, retroviruses have been repeatedly discussed as important etiologic factors. However, despite a considerable amount of indirect evidence that retroviruses might indeed be involved in triggering or initiating autoimmune rheumatic diseases, clear cut direct evidence is still missing. Studies on autoimmune or rheumatic disorders associated with HTLV-I or HIV-I infection as well as new data from the autoimmune rheumatic mouse (MLR/1pr mouse) model might help to answer the questions how and what mechanisms retroviral infection may lead to autoimmune rheumatic diseases. From data obtained in patients with HIV-I infection, apoptosis and molecular mimicry to autoantigens opens new approaches to the study of rheumatic disease pathogenesis.     

Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever

BACKGROUND: The incidence of acute rheumatic fever in New Zealand remains relatively high. Reliable early diagnosis of carditis is difficult and important in management. AIM: To determine if Doppler echocardiography contributed to the early diagnosis of carditis in acute rheumatic fever. METHODS: Forty-seven patients admitted to hospital with suspected acute rheumatic fever and 19 control patients, with a febrile illness due to a documented non-cardiac bacterial infection, were assessed two days and two weeks following admission. Presence or absence of clinical carditis was determined by a cardiologist unaware of the suspected diagnosis, from clinical examination, chest radiograph, electrocardiogram (ECG) and two dimensional echocardiogram. Doppler echocardiography was then performed and interpreted by a second cardiologist unaware of the diagnosis. After completion of the study the Jones criteria were applied, to categorise the patients with suspected acute rheumatic fever into four groups for the final diagnosis: no acute rheumatic fever, possible acute rheumatic fever, definite acute rheumatic fever without carditis, and definite acute rheumatic fever with carditis. RESULTS: In 19 patients with a final diagnosis of acute rheumatic fever and carditis at the baseline assessment carditis was detected by clinical assessment in 15 patients, compared with 19 patients with evidence of significant valve regurgitation by Doppler echocardiography. Following the two week assessment, all 19 patients had both clinical and Doppler evidence of carditis. Five patients with a final clinical diagnosis of possible acute rheumatic fever or definite acute rheumatic fever without carditis, had a Doppler abnormality detected. There was no clinical or Doppler abnormality in the febrile controls. CONCLUSIONS: Doppler echocardiography is more sensitive than clinical assessment in the detection of carditis in acute rheumatic fever, and can contribute to earlier diagnosis.