Björn Eriksson

Epidemiological and Clinical Aspects of Invasive Group A Streptococcal Infections and the Streptococcal Toxic Shock Syndrome

In a retrospective study of invasive infections due to group A Streptococcus (GAS) in Stockholm during 1987 to 1995, the average incidence per 100,000 residents per year was 2.3, varying between 3.7 per 100,000 (in 1988) and 1.3 per 100,000 (in 1993). Incidence was 1.8 in the age group of 0-4 years but otherwise increased by age, from 0.48 in the age group of 5-14 years to 6.1 among those over 65 years of age. A review of 151 invasive episodes occurring in 1983-1995 showed cyclic increases of infections due to T1M1-serotype strains during 1986-1990 and 1993-1995. The T1M1 serotype accounted for 27 (20%) of 135 available GAS strains. Streptococcal toxic shock syndrome (STSS) developed in 19 (13%) of the 151 episodes. The case fatality rate was 11% overall but 47% among patients with STSS. In a multivariate logistic regression model, STSS was associated with a history of alcohol abuse (odds ratio [OR], 6.3; P = .004) and infection with a T1M1 strain (OR, 6.7; P = .007). Case fatality was associated with age (OR, 14.5; P = .08), immunosuppression (OR, 4.7; P = .02), and STSS (OR, 21.5; P < .0001) but not with T1M1 infection. Hypotension was significantly associated with a fatal outcome, regardless of whether STSS developed (P < .0001).

Invasive Group A Streptococcal Infections: T1M1 Isolates Expressing Pyrogenic Exotoxins A and B in Combination with Selective Lack of Toxin-Neutralizing Antibodies Are Associated with Increased Risk of Streptococcal Toxic Shock Syndrome

Analysis of 132 group A streptococcal (GAS) isolates from 151 invasive episodes, including streptococcal toxic shock syndrome (STSS), from 1983 to 1995 showed great genetic variation by use of T serotyping in combination with restriction fragment length polymorphism. In contrast, genetically homogenous T1M1 isolates appeared in epidemic patterns with significantly increased risk of STSS. The speA gene, with the allelic variants speA2 and speA3 carried by the T1M1 and T3M3 serotypes, respectively, was strongly associated with STSS. Infection with a GAS isolate carrying speA, alcohol abuse, and malignancy recently treated with cytostatic drugs were factors independently related to STSS. Neutralization of SpeA lymphocyte mitogenicity was totally absent in sera from patients with STSS and low in sera from persons with uncomplicated bacteremia compared with levels in sera from uncomplicated erysipelas. Neutralization of SpeB was significantly lower in sera of patients with STSS than in sera from persons with bacteremia or erysipelas.

Group A Streptococcal Infections in Sweden: A Comparative Study of Invasive and Noninvasive Infections and Analysis of Dominant T28 emm28 Isolates

Surveillance of group A streptococcus (GAS) infections in Sweden during 1996-1997 indicated that T28 isolates were dominant, whereas T1M1 infections were uncommon. Circulating T28 isolates were nearly all emm28, MLST52, and these clones had also been prevalent 10 years earlier. Isolates from invasive and noninvasive infections were of similar types and prevalences. The average national incidence of invasive episodes was 2.9/100,000 population but varied between 0 and 8.3/100,000 population in different counties. It increased markedly with age, reaching 22.9 episodes/100,000 among people aged > or =90 years. The incidence of puerperal sepsis was higher than expected (22.4/100,000 of those at risk), with 1 death. Overall mortality was 16% and was associated with preexisting chronic disease (P=.002). Streptococcal toxic shock syndrome (STSS) developed in approximately 15% of patients with invasive episodes, with a mortality rate of 45%. The use of nonsteroidal anti-inflammatory drugs was not found to be associated with the development of STSS.

Effect of epinephrine infusion on chest pain in syndrome X in the absence of signs of myocardial ischemia

Eight female patients (aged 51 to 65 years) with New York Heart Association class II angina pectoris, normal coronary angiograms, normal hyperventilation, and abnormal exercise stress tests (chest pain and ST depression), and 5 sex- and age-matched controls participated in this study. Epinephrine was given intravenously to both patients and controls at 5-minute intervals in doses of 0.1, 0.2, 0.3, 0.4, and 0.6 nmol/kg/min. After rest (15 minutes), the alpha-adrenoceptor antagonist phentolamine or placebo was administered intravenously to patients in a double-blind, crossover study on 2 separate occasions in doses of 250 micrograms/min for 5 minutes and 500 micrograms/min for the next 10 minutes; the epinephrine infusion was repeated. Blood pressure, heart rate, and electrocardiogram were monitored continuously and pain was estimated on the Borg CR-10 scale. On a third occasion, chest pain was induced in patients using the same epinephrine protocol during echocardiographic monitoring. In the control group, all patients received the maximal epinephrine dose. No chest discomfort or pain developed. In the patient group, the maximal tolerable epinephrine dose (0.39 +/- 0.19 nmol/kg/min) decreased diastolic pressure (-14 +/- 9 mm Hg, p < 0.01) and increased heart rate (+24 +/- 10 beats/min, p < 0.01), not statistically different from the control group. Pulse pressure increased in the patient group (27 +/- 17 mm Hg, p < 0.01) but not in the controls. Left ventricular ejection fraction at baseline was within reference limits (58% to 75%) and did not change during epinephrine infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Anal Colonization of Group G β-Hemolytic Streptococci in Relapsing Erysipelas of the Lower Extremity

Four patients who had frequent relapses of erysipelas but no obvious portal of entry and no beta-hemolytic streptococci in specimens from conventional culture sites all had group G streptococci in cultures of specimens from the anal canal. It is suggested that anal colonization with group G streptococci, and possibly group A and other beta-hemolytic streptococci, may constitute a reservoir for streptococci in such cases.

Changes in erythrocyte sedimentation rate C-reactive protein and hematological parameters in patients with acute malaria

Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and routine hematological parameters were reviewed in 258 patients with acute malaria and compared to a control group of 120 patients with other febrile illnesses after visiting malaria endemic areas. Thrombocytopenia was found in 80% of the malaria patients compared to 13% in controls (p less than 0.01). The malaria patients also had lower white blood cell counts and marginally lower hemoglobin values than control patients. No major differences were found in ESR or CRP values. Furthermore, there were no major differences in the hematological parameters between patients infected with different malaria species, or between patients with different ethnic background. Thrombocytopenia (platelet count less than 150 x 10(9)/l) had a predictive value positive of 56% and a predictive value negative of 95% for malaria in a febrile patient coming from an endemic area. Thus, the risk of malaria in a febrile thrombocytopenic patient coming from an endemic area was 56%, while the risk that another patient with a normal platelet count still had malaria was 5%.

How safe is proguanil? A post-marketing investigation of side-effects

Side-effects of proguanil reported to the Swedish Adverse Drug Reaction (ADR) register from 1981 to 1988 are described and related to sales figures of the drug in Sweden during the same period. One serious reaction, thrombocytopenia, and 7 minor reactions, mainly urticaria and exanthema were believed to be causally related to proguanil intake in an estimated 60,000 users of the drug. Proguanil can be considered a very safe drug but rare hematological side-effects may possibly occur.

Dynamics of the Immune Response against Extracellular Products of Group A Streptococci during Infection

ABSTRACT The immune response against the infecting group A streptococcus (GAS) extracellular products (EP) was determined in acute- and convalescent-phase sera from 75 patients with different clinical manifestations of GAS infection. All EP elicited a high proliferative response in human peripheral blood mononuclear cells. In patients with bacteremia, low neutralization in acute-phase sera was associated with development of streptococcal toxic shock syndrome. Lack of neutralization in acute-phase sera was more common in patients infected with the T1emm1 serotype. The majority of patients did not develop the ability to neutralize the mitogenic activity of their infecting isolate despite a significant increase in enzyme-linked immunosorbent assay titer in early convalescent-phase sera. In patients with the ability to neutralize GAS EP, the immune response remained high over at least 3 years. In contrast, the neutralization capacity conferred by intravenous immunoglobulin and/or plasma treatment disappeared within 3 months.

Minimal criteria for identification of Moraxella (Branhamella) catarrhalis

A study was performed which aimed at testing the reliability of our routine diagnostic tests for identification of Moraxella (Branhamella) catarrhalis in clinical samples from the respiratory tract. A preliminary diagnosis of 122 isolates as Moraxella catarrhalis was obtained by using colony morphology and results of Gram stain and oxidase test as the sole diagnostic criteria. By using additional tests we could show that the preliminary diagnosis was incorrect for 21 isolates, which were classified as different Neisseria species. 20 of these were isolated from sputum samples. We propose that at least a test for DNA hydrolysis should be included in the routine procedure for identification of Moraxella catarrhalis in sputum.

Gonorrhoea Diagnostic and Treatment Uncertainties: Risk Factors for Culture Negative Confirmation after Positive Nucleic Acid Amplification Tests.

Gonorrhoea incidence has increased substantially in Stockholm during the past years. These increases have coincided with changes in testing practice from solely culture-based to nucleic acid amplification tests (NAAT). Gonorrhoea NAAT is integrated with Chlamydia trachomatis testing and due to opportunistic screening for chlamydia, testing prevalence for gonorrhoea has increased substantially in the Stockholm population. The aim of this study was to examine epidemiological risk-factors for discordant case which are NAAT positive but culture negative. These discordant cases are especially problematic as they give rise to diagnostic and treatment uncertainties with risk for subsequent sequelae. All gonorrhoea cases from Stockholm county during 2011–2012 with at least one positive N. gonorrhoea NAAT test and follow-up cultures were included (N = 874). Data were analysed using multivariate and stratified logistic regression models. Results showed that women were 4-times more likely (OR 4.9; 95% CI 2.4–6.7) than men to have discordant cultures. Individuals tested for gonorrhoea without symptoms were 2.3 times more likely (95% CI 1.5–3.5) than those with symptoms to be discordant. NAAT method and having one week or more between NAAT and culture testing were also indicative of an increased likelihood for discordance. Using NAAT should be based on proper clinical or epidemiological indications and, when positive, followed-up with a culture-based test within one week if possible. Routine gonorrhoea testing is not recommended in low prevalence populations.