Journal of the Korean Pediatric Society 1964;7(5):155-173.
Published online December 31, 1964.
Studies on Hemolytic Streptococcal Infections in Korean
Sang Jhoo Lee
Department of Pediatrics, Han-Il Hosptical.
韓國人의 落血性 連鎖狀球菌感染症에 關한 硏究
韓一 病院 小兒科
The Laneefield group A hemolytic streptococcus liberates, among other substances, a hemolyzing agent or streptolysin. Todd identified a streptolysin S and a much more antigenic streptolysin O. The antibody for streptolysin O (ASO) is readily measurable, and a specific antibody of the hemolytic streptococcus and according to Mote and Jones, is not increased in infection in which the streptococcus has been excluded. A rise in ASO titre can be interpreted as reliable evidence of a streptococcal infection and there has been great interest over the last decade in the measurement of ASO in the serum of human beings for the purpose of evaluatit^ the role of hemolytic streptococcal infection in various disease states. It has been observed that 85 to 90% of patients infected with group A hemolytic streptococcus responded with an increased streptolysin antibody index in convalescent period. The rise in ASO titer usually can be demonstrated during the second and third week following acute hemolytic streptococcal infection and a titer above 200 units generally has been considered as serological evidence of a recent infection with the hemolytic streptococcus. Because of the ubiquity of streptococcal infections and of the commonness of streptolysin 0 as an antigen of group A streptococci, sera from normal individuals generally show some antibody to streptolysin O, reflecting contact with the streptococcus at some time in the distant past. These low titers are ccmmonly found in school age children and young adults who have not had a recent streptococcal infection. The antibody is passively transferred to the fetus via the placental circulation, and present in the serum cf the new born infant in amounts approximating that of the mother but disappear rapidly. Consequently between 6 months and 2 years of age ASO titres are usually very low or not detectable. After infancy there is a progressive increase in the vigor of antibody production with advancing age through the early years of childhood which may well be associated with condition of the antibody forming organs by repeated contact with the hemolytic streptococcus. ASO reaches its peak concentration during late childhood and then declined gradually in later years as the frequency of streptococcal infection decreases. It has now been adequately documented that the prevention of the complication, particularly rheumatic fever and glomerulonephritis, is predicted upon the identification of infection with the hemolytic streptococcus and eradication of that organisms by adequate therapy. From the standpoint of preventive medicine, therefore, the challenge to the physician is to identify and treat adequately all hemolytic streptococcal infection. That such identification is subject to a considerable margin of error when based upon chinical manifestations alone has been demonstrated unless a critical evidence, such as subsequent evaluation of ASO, has been added to clinical observations. It was demonstrated that many patients with respiratory illness failed to develop antibodies against the hemolytic streptococcus even when the latter organism was found in the oropharynx, indicating that the mere finding of such organisms does not establish an etiological relationship to the illness. Under such circumstances the individual is a carrier of the organism. On the other hand, the group A beta-hemolytic streptococcus may be so easfly eradicated by antibiotic therapy or, even, without antibiotics, by the time rheumatic fever is suspected. Parker and many others suggested that the ASO titer determination might be a more sensitive test than a throat culture in identifying an inapparent streptococcal infection. In spite of the importance of the problems, little arno information is available as to the expected titers of the antibody in normal populations and in the disorders in Korea. For this reason the present study was undertaken in the hope of eliciting information on ASO titres in (a) a group df mothers and their respective infants with consideration given to the transplacental passage of ASO (b) a group of healthy infant and children and (c) a group of children with various states of streptococcal infection giving consideration to the relationship between age and the clinical patterns of diseases. Part. 1. Study on the transplacental passage of ASO 1) ASO. titration was done on 44 blood samples from 22 mothers and their respective infants. The mean ASO titers of mother bloods was 120.8 土 130.44 units and that of infants, 77.6± 68.23. 2)In 10 cases out of 22, ASO titers in the blood of infants were equal to those of respective mothers and in 12 remainders ASO titers of infants exceeded those of respective mothers. 3) 8 out of 12 cases in which infant’s bloods showed higher ASO titers than mother’s bloods, the degree of excess was 100 to 316% and in these cases the majority of mother's blood showed ASO titres of .50 units. Part. 2. ASO titres of healthy Korean infants and children in various age groups. 412 healthy children with the age range from the newborn to 15 years of age were engaged in this study. The children were selected partially from the out patient clinics who entered Han-il Hospital with the disorders other than streptococcal origin and spartialiy from other Hospital located in the centre area of Seoul city from June, 1962 to June, 1964. The following results were obtained. 1) Antistreptolysin passively transferred from mother to infant diminished Tapidly after birth and by the time of 3 months of age tire levels were very low. This low levels went on unchanged until die age of 2 years. After irifancy, With increasing age the average age ASO levels increased gradually reaching its peak in the group of 10 years ctf age. These declined slightly in later years. 2) The mean ASO levels of the several age groups were; 19.1+ 16.68 units in the group under 2 years of age, 68.1 ± 65.30 units in children from 3 to 5 years of age, 121.5±95.18 units from 6 to 7 years of age, 157.3± 102.34 units from 8 to 10 years of age, 160. l±103.89 units from 11 to 13 years of age, and 140.4土 73.06 units from 14 to 15 years of age. Highest normal level was 188.5± 124.22 units in the group of 10 years of age. 3) 362 (87.8%) out of 412 had a titer of 166 units or less and 392 (95.1%) out of 412 had a titre of 250 units or less. 50 (12.2%) out of 412 showed 250 units of ASO titer or more, and these relatively higher titers were mainly found in school age children above 6 years of age. 500 units of high titer occurred few in the older school children, 10 to 13 years of age. 4) It can be concluded that in the school age children in Korea a titer of 250 units or less may be considered normal. 3.ASO titers in a group of patients in various states of streptococcal infections and the relationship of age factor to the manner of expression of clinical patterns of the disease. The group under study consisted of 68 children aged 2 to 15 years. According to the clinical forms of disease these patients were grouped into; 32 cases of acute glomerulonephritis; 24 cases of uncomplicated acute upper respiratory infection with streptococcal origin; 7 cases with the presence of suppurative complications (otitis media, pyoderma, suppurative adenitis, pneumonia) and 5 cases of rheumatic fever or rheumatic heart disease. ASO, WBC cotmt, ESR and C-reactive prowsrn determinations and chest X-ray check were carried otit in all cases. ECG tracing was made upon some cases of children. The results were as follows; 1. ASO titers in patients with acute glomerulonephritis. 1 1) In 32 cases, the ASO titers ranged from 100 to 833 units with the mean value of 354.0± 130.48units. 20 (62.5%) out of 32 showed ASO titers higher than 250 units and 17 (53.1%) of 32 showed ASO titers higher than 333 units. 2) In all 10 cases in which ASO determinations were done during the first week after onset of clinical manifestations, the titers were less than 166 units. On the other hand, in 14 cases done during the second week, the titers showed 250 units or more in all. 3)On admission throat culture, 17 of 32 cases revealed positive for beta hemolytic streptococci and 15 negative. In the former the mean ASO titer was 347 .9+181.31 units and in the latter 360.9±288.65 units, 2. ASO titers in patients with streptococcal pharyngitis. 1)In 24 cases ASO titers determined during the first 4 weeks after onset (in 20 cases within 2 weeks) ranged from 12 to 833 units and the mean was 342. 9+98.81 units. 2) In 13 cases in which throat culure rendered positive for beta hemolytic streptococci the mean ASO titer was 305.8±233.04 units and in H cases negative for the organisms the mean was 372.6±218.61 units. 3. ASO titers in cases with the other streptococcal infections. 1) In 7 cases of suppurative complications ASO titers ranged from 12 to 333 units with the mean of 187.1 ±117.64 units. 2) In 5 cases of rheumatic fever or rheumatic heart disease ASO ranged from 166 to 625 units and the mean was 433.2±191.31 units. 4. Relationship of age factor to the manner of expression of clinical patterns of the disease. 1) The suppurative complications of streptococcal infection such as otitis media, suppurative adenitis, skin disease or pneumonia tend to occur more frequently in the younger age group less than 4 years of age and nonsuppurative complications such as rheumatic diseases or acute glomerulonephritis in the older age group. 2) A skin rash of the scarlatinal type was most frequently observed in the age group between 5 and 8 years. 3) Most frequently encountered manifestations were fever, elevated ESR and WBC count, usually combined, in all age groups. 4) The rate of recovery of beta hemolytic streptococci on throat culture was higher in younger age group. 5) The mean ASO titer was highest in the cases of the rheumatic fever or rheumatic heart disease and lowest in the presence of suppurative complications and intermediate in the cases of pharyngitis and glomerulonephritis. The mean age was also lowest in the groups of suppurative complication

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