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Key Clinical Message: This pediatric case report underscores the importance of maintaining a high clinical suspicion for polyarteritis nodosa (PAN) in patients presenting with atypical features, such as migratory arthritis and subcutaneous nodules. Importantly, it highlights the focus on the potential relationship between streptococcal infection and cutaneous PAN. Early recognition and prompt, aggressive treatment is critical, as PAN can be a life‐threatening condition if left unmanaged. This case emphasizes the need for a multidisciplinary approach to effectively identify and manage this rare vasculitis disorder in the pediatric population. Polyarteritis nodosa (PAN) is a rare and life‐threatening vasculitis with diverse clinical presentations, posing a diagnostic challenge. Early recognition and prompt intervention are crucial to prevent organ damage. We present the case of an 8‐year‐old boy who exhibited atypical symptoms including migratory arthritis, myalgia, digital discoloration and ischemic changes, and subcutaneous nodules. Initial concerns for septic arthritis were ruled out. A comprehensive evaluation revealed elevated inflammatory markers and a confirmatory skin biopsy demonstrating active leukocytoclastic vasculitis, are highly suggestive of a diagnosis of PAN. Notably, elevated ASO titers suggested a possible concurrent streptococcal infection. The aggressive treatment approach with high‐dose aspirin, steroids, methotrexate, and tocilizumab is justified given the severity of the patient's symptoms and the nature of the disease process. This case underscores the importance of considering PAN in the differential diagnosis for children presenting with atypical features. Early diagnosis and prompt intervention, including addressing potential infectious triggers, are crucial for optimal outcomes in pediatric PAN. [ABSTRACT FROM AUTHOR]

Pulmonary‐renal syndrome (PRS) is defined as a combination of diffuse alveolar haemorrhage and glomerulonephritis. An 18‐year‐old woman visited our hospital with a 2‐day history of fever, dyspnoea, and leg edema. Laboratory investigations revealed an elevated inflammatory reaction, increased serum creatinine levels, and normocytic anaemia. Additionally, the anti‐streptolysin‐O titre was positive, and complement component‐3 levels were decreased. Urinalysis revealed proteinuria and hematuria. Bronchoalveolar lavage aliquots were progressively more hemorrhagic. These findings supported a diagnosis of PRS secondary to streptococcal infection. The patient was treated with high‐dose methylprednisolone and antibiotics. After 4 days of treatment, her respiratory symptoms and serum creatinine levels improved. Steroid tapering was performed over 15 days. The findings in this case indicate that streptococcal infection is a potential cause of PRS, and that short‐term steroid therapy is an effective treatment. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate the incidence of neonatal early-onset group B streptococcal (GBS) infection in Sweden after promulgation of guidelines (2008) for risk factor-based intrapartum antibiotic prophylaxis, and evaluate the presence of risk factors and obstetric management in mothers.Material and Methods: National registers were searched for infants with early-onset GBS infection during 2006-2011. Medical records of cases and case mothers were abstracted. Verified cases of sepsis/meningitis and cases with clinical sepsis/pneumonia were documented, as well as risk factors in case mothers and timeliness of intrapartum antibiotic prophylaxis administration.Results: There were 227 cases with verified infection, with an incidence of 0.34‰ of live births during the whole period. There was a significant decrease after promulgation of guidelines, from 0.40 to 0.30‰ [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.57-0.99]. A significant decrease in the number of cases with clinical GBS sepsis/pneumonia was also observed. In parturients with one or more risk factors, the incidence of any GBS infection was reduced by approximately 50% (OR 0.47, 95% CI 0.35-0.64), although there were many cases where the opportunity for timely administration of intrapartum antibiotic prophylaxis was missed. In infants of mothers without risk factor(s) there was no reduction in early-onset GBS morbidity. The mortality in verified cases was 4.8% (95% CI 2.1-7.6).Conclusions: The introduction of national guidelines for risk-based intrapartum antibiotic prophylaxis coincided with a significant 50% risk reduction of neonatal early-onset GBS infection in infants of parturients presenting with one or more risk factors. A stricter adherence to guidelines could probably have reduced the infant morbidity further. [ABSTRACT FROM AUTHOR]

Background The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile. Methods A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed. Results Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval ( CI) 13.9%-28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71-0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002- July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens. Conclusion This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality. [ABSTRACT FROM AUTHOR]

We herein present the case of a four-yr-old boy with PA who developed AMR after ABO-incompatible LDLT despite undergoing B cell desensitization using rituximab. Although the CD19+ lymphocyte count decreased to 0.1% nine days after the administration of rituximab, he developed a high fever which was accompanied by arthralgia due to a streptococcal infection 13 days after rituximab prophylaxis. After the clearance of the infection, he underwent ABO-incompatible LDLT 36 days after the administration of rituximab. The CD19+ lymphocyte count just prior to LDLT was 1.2%. He developed AMR five days after LDLT, and the antidonor-type IgM and IgG antibody titers increased to 1:1024 and 1:1024, respectively. He was treated by plasma exchange, IVIG, steroid pulse therapy, and rituximab re-administration; however, his liver dysfunction continued. Despite intensive treatment, he died due to complicated abdominal hernia, acute renal failure, and ARDS. This case suggests that a streptococcal infection may induce the activation of innate immune responses; thus, additional desensitization therapy should be considered prior to ABO-incompatible LDLT if B cell reactivation is suspected. [ABSTRACT FROM AUTHOR]

The increasing incidence of invasive group A streptococcus has been well documented in the temperate climates of North America, Europe and the United Kingdom. Studies also suggest that there are high rates of invasive group A streptococcus infection within the indigenous population of Northern Australia. This review article presents the case of infant Aboriginal twins with invasive group A streptococcal infection complicated by streptococcal toxic shock syndrome, highlighting both the severity and high transmissibility of invasive group A streptococcal disease. We review the epidemiology of group A streptococcal infection and suggest a potential role for chemoprophylaxis of household contacts to reduce the burden of disease within the indigenous population of Northern Australia. [ABSTRACT FROM AUTHOR]

A tubo-ovarian abscess (TOA) is a common complication of pelvic inflammatory disease in premenopausal women; however, in virginal females, TOAs are an exceedingly rare occurrence. Within this rare subset of patients, there is almost always an underlying condition, such as vaginal voiding, or a concomitant disease process. A virginal adolescent female with no prior medical history presented with a large pelvic mass which proved to be a TOA. An exploratory laparotomy was eventually required to establish the diagnosis. Open drainage and antibiotic therapy successfully treated the patient. With only the organism, Streptococcus viridians, isolated in her cultures, an etiology of direct ascension from the lower genitourinary tract is implicated. We believe this to be the youngest case of a TOA occurring in a virginal adolescent female without a predisposing condition. A TOA should be considered in the differential diagnosis of pelvic masses in previously healthy pediatric patients regardless of their sexual activity. [ABSTRACT FROM AUTHOR]

Background: Early recognition of necrotizing fasciitis (NF) can be difficult, but is important as infections progress rapidly and have significant mortality. The aim of this study of patients with NF was to determine the clinical characteristics at presentation, causative pathogens and subsequent clinical outcome. Methods: We retrospectively reviewed consecutive patients with NF presenting to Middlemore Hospital from January 2000 to June 2006. Results: Eighty-two patients were evaluated: 56% male, mean age 54.9 years (standard deviation 18.5), 40% Pacific Islanders. The site of infection was the lower limb in 46 (56%) patients, upper limb in 12 (15%) patients and perineum in 13 (16%) patients. Twenty-two (27%) patients were taking non-steroidal anti-inflammatory drugs, 29 (35%) had diabetes mellitus, 25 (30%) had gout and 17 (21%) had congestive heart failure. Forty-nine (60%) patients had a surgical procedure within 24 h of admission. Streptococcus pyogenes was isolated from tissue or blood cultures in 33 (40%) patients and 26 (32%) patients had polymicrobial infection. Twenty-five (30%) patients died, 17 (68%) within 72 h of admission. Independent predictors of mortality include congestive heart failure (P = 0.033) and a history of gout (P = 0.037). Conclusion: NF remains an important disease in our community with significant morbidity and mortality. Pacific Islanders were disproportionately represented. Early diagnosis of NF can be difficult and requires a high index of suspicion in all patients presenting with cellulitis or unexplained sepsis. Congestive heart failure and gout are independent predictors of mortality and patients with these conditions and sepsis need early assessment with more aggressive hospital triaging. [ABSTRACT FROM AUTHOR]

Objective Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS) should be considered in sudden onset, prepubertal Anorexia Nervosa (AN), arising shortly after an apparent streptococcal infection. However, the absence of a specific biological marker of PANDAS renders the diagnosis difficult. This paper critically reviews available tests for PANDAS and recommends a standardized approach to its investigation. Method Medline database review between 1990 and 2008. Results Existing tests may be categorized as: (i) Non-specific markers of inflammation or immune response (Erythrocyte sedimentation rate, ESR; C-reactive protein, CRP; Neopterin), (ii) specific markers of streptococcal infection (throat swab and anti-streptococcal antibodies, Anti-streptolysin, ASO; Antideoxyribonuclease B, antiDNaseB), (iii) non-specific markers of auto-immune reaction (Antineuronal antibodies, AnAb; D8/17). No one test reliably identifies PANDAS. The lack of specificity and methodological problems may lead to errors of diagnosis. Discussion When PANDAS–Anorexia Nervosa (PANDAS–AN) is suspected clinically we recommend conducting all the above investigations. The more positive results there are the more likely is the diagnosis, but particular weighting should be given to AnAb and D8/17. Copyright © 2010 John Wiley & Sons, Ltd and Eating Disorders Association. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine whether antibiotic prophylaxis during periods of neutropenia reduced streptococcal (S. viridans) sepsis and overall bacterial sepsis.Methods: The authors reviewed outcomes of 78 evaluable patients who were consecutively treated for acute myeloid leukemia (AML) from October 2002 through January 2007. Several successive prophylactic antibiotic regimens were used. All patients received antifungal prophylaxis with oral voriconazole.Results: Oral cephalosporins did not significantly reduce the odds of bacterial sepsis (P = .81) or streptococcal (S. viridans) sepsis (P = .90) relative to no prophylaxis. Intravenous (iv) cefepime completely prevented streptococcal (S. viridans) sepsis and reduced the odds of bacterial sepsis 91% (P < .0001) relative to no prophylaxis, but resistant gram-negative bacteria emerged in 2 patients. Vancomycin with oral ciprofloxacin or a cephalosporin reduced the odds of bacterial sepsis by 93% (P < .0001) and streptococcal (S. viridans) sepsis by 99% (P < .0001). The fungal infection rate did not differ significantly between patients who did and did not receive antibiotic prophylaxis (1.0 per 1000 patient-days for both groups). The observed reduction in average hospital days per chemotherapy course for patients given vancomycin regimens or cefepime was 5.7 (P < .0001) and 4.1 (P = .0039) days, respectively. No reduction was observed with oral cephalosporins (P = .10). Furthermore, vancomycin regimens or cefepime were associated with a 20% reduction in healthcare charges (P = .0015) relative to using no antibiotics. One patient, who was on oral cefuroxime alone, died of septicemia.Conclusions: Prophylaxis with intravenous cefepime or a vancomycin regimen, and voriconazole, reduced morbidity in children with AML, and resulted in dramatic decreases in the incidence of septicemia and hospitalization days. [ABSTRACT FROM AUTHOR]

Objective: Substantial evidence exists for the concept of pediatric autoimmune neuropsychiatric disorders associated with streptoccoccal infection (PANDAS) such as some cases of obsessive-compulsive disorder and tics/Tourette's syndrome. More recently PANDAS-AN has been described. The aim of this article is to provide a critical review of this concept. Method: The literature was searched using Medline, Psychinfo, and Google. Results: There is some evidence for the entity of PANDAS-AN but this is considerably limited by a wide range of methodological problems, including the seemingly low prevalence, the lack of clarity in diagnostic criteria, and the lack of specificity in the diagnostic tests. Innovative treatment approaches hold promise but require further evaluation. Conclusion: Further research into PANDAS-AN, using more clearly defined and consistent diagnostic criteria is needed, given the potential for enhancing the understanding of the pathogenesis of AN and for more effective treatments. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2008 [ABSTRACT FROM AUTHOR]

Aim: Post-streptococcal glomerulonephritis (PSGN) is a frequent cause of acute nephritis in children. Numerous studies have described PSGN in high-risk populations yet few data describing PSGN in a low-incidence population exist. This study aimed to describe the epidemiology, clinical manifestations, diagnosis, complications and outcomes of PSGN in an urban Australian population. Methods: A 16-year retrospective review of case notes and laboratory data was conducted at a tertiary Sydney paediatric hospital. Results: Thirty-seven children were treated for PSGN with a mean age of 8.1 years (range 2.6–14.1 years). Twenty-eight subjects (75.7%) had a history of a recent upper respiratory tract or skin infection. Hypertension and/or oedema was present in 29 subjects (78.4%). Streptococcal pharyngitis was identified as the likely source in 17 subjects (45.9%). Skin infections occurred less frequently. Antibodies against streptolysin O, streptokinase or deoxyribonuclease B were elevated when a single titre was measured in 35 subjects (94.6%). Thirty subjects (81.1%) developed renal impairment (median peak creatinine, 95 µmol/L, range 39–880 µmol/L). No correlation was demonstrated between peak creatinine, age, ethnicity, streptococcal titres and serum complement levels. The mean length of admission was 8.2 days. Seven subjects (18.9%) had a complicated course with three subjects requiring dialysis. Only one subject has ongoing renal dysfunction. Conclusion: Significant differences are seen in a low-incidence urban Australian population with PSGN when compared with endemic or epidemic disease in high-risk populations. The higher rates of complications that were seen compared with previously studied populations need further clarification. [ABSTRACT FROM AUTHOR]

Background: A laminin-binding protein (Lmb) similar to that of group B streptococcus is conserved in group A streptococcus (GAS) and has a role in adhesion of GAS to epithelial cells. The role of this protein is yet to be clarified in disease process and thus, it is important to know its role in binding of GAS to laminin and the immunogenic response against it in patients related with GAS infection.Methods: A recombinant protein (rGAS-Lmb) was purified using thelmbgene from M1 GAS and tested for its role in binding of GAS with laminin. The antibody response against rGAS-Lmb in patient sera related with GAS infection was measured by ELISA.Results: The rGAS-Lmb bound with laminin directly and inhibited the binding of GAS to laminin. The antibody response against rGAS-Lmb in patients with uncomplicated streptococcal infection (U. Strep) and those with rheumatic fever (RF) were significantly higher than those in the control group (P < 0.0001 andP < 0.001, respectively). No difference of anti-rGAS-Lmb antibody titer could be found between these two disease groups.Conclusion: The higher antibody response in patients with GAS infection implies that the protein is well expressed during the period of infection and may be related with the colonization and infection of GAS in pharyngeal mucosa. [ABSTRACT FROM AUTHOR]

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS) is a recently recognized syndrome in which pre-adolescent children have abrupt onsets of tics and/or obsessive-compulsive symptoms, a recurring and remitting course of illness temporally related to streptococcal infections, and associated neurologic findings including adventitious movements, hyperactivity and emotional lability.Inspired by observations of similar symptoms in children with Sydenham's chorea, a search was undertaken for clinical and laboratory evidence in support of the new syndrome.Consistent and predictable clinical findings have been described in a large case series. Magnetic resonance imaging has supported the postulated pathobiology of the syndrome with evidence of inflammatory changes in basal ganglia. Antibasal ganglia antibodies have been found in some acute cases, mimicking streptococcal antigen epitopes.While PANDAS remains a controversial diagnostic concept, it has stimulated new research endeavors into the possible links between bacterial pathogens, autoimmune reactions, and neuropsychiatric symptoms. [ABSTRACT FROM AUTHOR]

Background: Previous studies have documented that various behavioral disturbances accompany Sydenham's chorea, a neurologic variant of rheumatic fever. Further, an immunological marker associated with rheumatic fever (monoclonal antibody D8/17) has been reported to be elevated in several neuropsychiatric disorders, most frequently tics and obsessive-compulsive disorder. We examined this association in a community sample of children previously identified as being D8/17 positive or negative. It was hypothesized that D8/17 positivity would predict increased rates of tics and obsessive-compulsive disorder, even in the absence of Sydenham's chorea. Possible associations with other disorders accompanying Sydenham's chorea - hyperactivity, anxiety, and depression, also were explored. Method: From 1991 to 1995, 2631 children (mean age = 9.6 ± 1.6 years) from a low socioeconomic area of Mexico City were screened for the D8/17 marker. In a 2- to 5-year follow-up of 240 of these children (108 positive and 132 negative), structured psychiatric interviews and rating scales were administered to the child and main caretaker. Assessments were conducted and scored blind to the child's D8/17 status. Results: No association was seen between D8/17 positivity and tics or OCD. Conclusion: This study failed to provide support for the generalized use of D8/17 as a marker of susceptibility to tics and OCD in a community sample. [ABSTRACT FROM AUTHOR]

This report presents the relapse and treatment of streptococcal infection in the postpartum period in a patient with severe group A streptococcal sepsis. [ABSTRACT FROM AUTHOR]

We report the case of a young man who presented with a severe acute akinetic–rigid disorder 2 weeks after complete recovery from an episode of pharyngitis. Magnetic resonance imaging scan abnormalities strikingly localized to the basal ganglia were accompanied by serological evidence of recent streptococcal infection and the presence of anti‐basal ganglia antibodies in the serum. The case represents an unusually clear example in the spectrum of inflammatory neurological disorders associated with streptococcal infection, an etiology that should be considered in the differential diagnosis of all acute onset movement disorders. © 2005 Movement Disorder Society [ABSTRACT FROM AUTHOR]

Describes a boy with extensive skin changes, who had coincident streptococcal colonization. Medical record of the patient; Laboratory findings; Background on the medical condition.

Background: Retropharyngeal abscess (RPA) is an uncommon, potentially fatal condition found more frequently in children than adults. Prompt diagnosis and surgical management of this condition is imperative to prevent complications including airway obstruction and mediastinitis. Few studies have been dedicated to paediatric retropharyngeal abscess. Methods: A retrospective analysis of 21 cases of retropharyngeal abscess at the Sydney Children's Hospital over a 12-year period was performed. Results: There were 12 boys and nine girls involved in the analysis. Their ages ranged from 3 months to 12 years. Common ­presenting symptoms and signs included fever, dysphagia, neck swelling and torticollis. Respiratory compromise was present in 29% of the children at presentation. Foreign body ingestion accounted for 10% of cases. Seventeen cases were managed with surgical drainage. Surgical approaches adopted included transoral (70%), external cervical approach (20%) and a combined approach in 10%. There was no mortality. Mediastinitis occurred in two patients, one of whom also had recurrent laryngeal nerve palsy. No other serious complications occurred. Conclusion: Retropharyngeal abscess should be considered in all children presenting with neck pain and dysphagia. Prompt diagnosis and institution of appropriate medical and surgical therapy is imperative to prevent complications such as airway obstruction. The management of this condition should occur in a paediatric institution with appropriate medical, surgical and intensive care ­facilities. [ABSTRACT FROM AUTHOR]