Jpn. J. Infect. Dis., 54, 1371139, 2001

Original Article
lsolation of Group A β‑Hemolytic Streptococci in the Tbnsillopharynx

of School Children in Madras City and Correlation
with Their Clinical Features
Shanthi Rajkumar* and Rajkumar Krishnamurthy

Department of Microbiology, Dr A.L.M. Post Graduate InstituteofBasic Medical Sciences, UniversiO) ofMadras,Chennai 600113, India(Received July 6, 2001. Accepted September 1 1, 2001)

SUMMARY: Today, rheumatic fever is the most common cause of heart disease in children and young adults,
and it accounts for about half of all cardiovascular diseases causlng death in the first four decades of life, inlndia･ ln the present study, conducted during 1991‑1992 at Chennai, India, a total of 666 school girls aged 5‑1 5years were examined clinically for one or more of the followlng SlgnS and symptoms: repeated sore throat, jolnt

pain/swelling, epIStaXis, chest pain, breathlessness, palpitation, abdominal paln, etC. Out of the 666 children screened,

124 were recmited for the present study, based on their meetlng One Or more Of the abc‑ve mentioned clinicalcriteria･ They were screened for the presence of group A a‑hemolytic streptococci, and for antistreptolysin 0 andC‑reactive protein. Thus, the aim of the present study was to reduce the load of streptococcal infection and theconsequent risk ofdeveloplng rheumatic fever and rheumatic heart disease. ln the present study group, 89.5% of
the children indicated a history of repeated sore throat. However, only 4.0% of the children in the study groupwere positive fわr group A β‑hemolytic streptococci. The antistreptolysin 0 and C‑reactive protein levels werehigher in lトto 15‑year‑old patients than in 5‑ to 10‑yeaト01d patients in the study group.

chil血en aged 5‑1 5 years at a govement girls'middle school,lNTROD UCT10N

Madras, were analyzed, and children having at least one of the

Streptococcal pharyngltlS, Caused by SblePtOCOCCuS PyOgeneS,

fo1loTiヮg signs and symptoms (repeated sore throat, abdominal

represents one of the most common bacterial infections, andpalm, JOlnt pain/swelling, eplStaXis, chest pain, breathlessness,school children･ A high prevalence and incidence of strepto‑

palpitation, etc.) were recmited. A detailed history was taken
uslng a preteSted open‑ended questiomaire that inquired about
the followlng: fever, previousdocumented history of RF,

coccal pharyngltlS, a term used for sore throat, tonsillitis,

number of episodes and frequency, socioeconomic status,pharyngitis, and nasopharyngitis, in thisvulnerable group (i.e.,

number of members in the family,type of housing and nヮmberchildren of schooトgoing age) have been recognized in mostof rooms, family history of RF瓜HD, penicillin prophylaxIS, andis most o洗en noted in children and young adults. Streptococcal

infection has been referred to as an "occupational disease" ofcountries (1). Today, rheumatic fTever (RF) is the most common

allergy to penicillin. A general of clinical examinations werecause of heart disease in children and young adults, and it

conducted, and height and weight were noted. For the control

accounts fわr about half of all cardiovascular diseases causlng

group, 54 children who were apparently nomal were used.

death in the first four decades of life in India. The pathogenic

Microbiological investigations: A single throat swab for

relationship of group A β‑hemolytic streptococci (GABHS)

culture and a blood sample to test for antistreptolysin 0 (ASO)

to sequelae produced (e.g., acute rheumatic fever lARF]
and rheumatic heart disease [RHD]), as well as acute post
streptococcal glomerulonephritis (PSGN), makes the organ.ism
unique (2). Hence, the concem orclinicians, microbiologlStS,

and C‑reactive protein (CRP) were collected.
Culture: Throat swab was inoculated into sheep blood agar
for isolation of B‑hemolytic streptococci･ Colonie.s wereidentified based on colony morphology and sensitivlty tO aand epidemiologlStS is to recognlZe Streptococcal pharyngltlSbacitracin differentiation disc.

early and to administer treatment to prevent the sequelae. A
communlty control program for RF and RHD should beinitiated in to maintain control of the RHD through existlng

Behring latex agglutination kit (Hoechst India Ltd., Mumbai,

Serology: As° and C氏p levels were detemined uslng aIndia).

health seⅣice resources. Thus, the aim of the present study isto reduce the load of streptococcal infection and, consequently,

RES U IiTS

the risk ofdeveloplng RF and RHD in the communlty.

Out of the 666 children screened, 1 24 were recruited fわr

the present study, based on their meetlng One Or more Ofthe

MATERIALS AND METHODS

clinical criteria: repeated sore throat, abdominal palm, JOlnt

Climical investigatiorLS: ln a preliminary survey, 666 schoolpalm, eplStaXis, chest palm, breathlessness, etc. Among the*Co汀eSpOnding author: Present address: Department or Micro‑biology and Parasitology, School of Medical Sciences, Unive.rsity

study group, 89.5% had repeated sore throat; 57.2% hadabdominal pain; 42.0% hadjolnt palm; 8.1% had eplStaXis;
21.0% had chest pain; 25.0% had breathlessness; etc. Addi‑

Saiれs Malaysla, 1 61 50, Kubang Kerian, Kelantan, Malaysla.

tionally, 54 normal children were used as a control group.

Tel: +6017653370 ext. 2595, E‑mail: shanthi@kb.usm.mySeventy10ne Children (57.2%) had a history of passing worms

137

Table 1. History analysts
Study group

Serial no.

(〟‑I 24)

1 2 つJ 4 5 ′LU 7 0 ノ 0 ‑ 2

Repeated sore throat+Abdominal pan+Chest palm
+Brcathlcssncss+Joint palm
0 5 0ノ 7 ‑ 2 5 てJ RU tJ 0Repcatcd sore throat+Abdominal pain+Chest pain+Joint palm

08520007｣79

1 つ1｣ 1 7 2 5 3 1 I1 0 2 1･ 1 /LU 2 1 7 0 7 1

Rcpcatcd sore throat+Abdominal pain+Joint palれ

20 52421 ‑Rcpcatcd sore throat

Abdomillal palm
Chest palm
Joint palm

Brcathlcssncss
Palpitation

Epistaxis

Ccrvical lymphadcnitis
Family history ofRHD

Table 2. Distribution ofpathogcnic and normal commensal in the throat swab of study and control groups
Studygroup
Serial no.

Controlgroup∫)value

Throat swab culturc

Normal nora (Neisseria spp.,

n‑1 24n‑5411050

5 つJ 2 42200

0.60

α‑hemolytic streptococci, diphtheroids)
2 つJ 4 5′0 4Group A β‑hcmolytic streptococci

0 03700

Klebsiella spp.
Proteus spp･
Staphylococcus aureus

Table 3. Pattern of distribution ofantistreptolysin 0 (ASO) andin stools. Eleven children (9.0%) had a family history ofRHD,

C‑reactive protein (CRP) titers in study group

though none had definite evidence ofRFI The other commonly
elicited complaints are shown in Table 1.

Study group 〟‑124

Though 89.5% of the children recmited gave a history ofASO

repeated sore throat, examination of tonsils gave varylng(IU/ml)results. Among the study group 56.0% had unduly enlarged
tonsils, 21.0% had infected tonsils, and 22.0% had normal<2005‑10years

128

tonsils. One child did not have any tonsils; they had been

400

23

removed.

800

4of the study and control groups are presented in Table 2.

ll15years(57)
0 0ノ 0 0 2 0

2200

Distribution ofpathogens and commensal in the throat swab1(67)

2 4 4 1 0 7 つJ 2 2 01 21 600

03200

0

Distribution of pathogenic and normal commensal in thethroat showed that 88.7% and 92.6% yielded only normal

CRP

nora in the study and control groups, respectively. Throat(mg/1)(67)

cultures were positive f♭r GABHS in 4.0% and 3･7% of the<641

study and control groups, respectively. Other organisms grown620

35‑10years

were Klebsiella spp･ (2･4% in the study group., and 3･7% in12the control group). 1n the study group, two stralnS OfPy10teuS

242spp. Were isolated in two children and one strain of Staphylo‑

48

1coccus aureus in four children. Ofthe children in the study960I

I‑15years

(57)

33

7 つJ 4 3 0ノ ′b 2 0つJ ′LU 4group, 28 Were available for repeat throat cultures, all of which

The signirlCant As° and CRP titcrs obtained wcrc 46.0% andyielded normal nora. The first throat culture of the same 28403%, respectively in the study group.

children had also yielded normal commensals. All five children
who had a throat culture positive for GABHS in the study groupwere above 6 years of age.

titer.

The ASO antibodies are transmitted to the fetus throughThe pattem of distribution of the ASO titer in different age

the placenta and fall to minimal levels during the first year ofgroups revealed that the group of 1 1‑ to 15‑yeaト01ds showed

hfe. Thereafter, they build up rapidly, reaching peak levels inhigher titer values than the group or 5‑ to 10‑year‑olds.

the young school‑aged population. Therefわre, titers of 400

However, the titer of the control groups fわr all ages did not

1U/m1‑300 1U/ml are common in healthy children aged 6‑14

exceed 400 IU/ml (Table 4).

years (3). C氏p titers of 6 mg/1 and above were taken as

The CRP levels in this s山dy showed that the group of 1 1‑ topositive. The slgnificant ASO titers were obtained in 46.0%of the study group and 1 1.0% of the control group (Tables 3and 4). As also shown in Tables 3 and 4, 40.3% of the study

15‑year‑Olds had a higher titer ofCRP than the group of5‑ to10‑year‑olds. However, only two children (5‑ 1 0 years old) inthe control group showed a CRP titer as high as 1 2 mg/I (Tablegroup and 26.0% orthe control group had a positive C氏p4).

138

those ofMyers and Koshi. ln the present study, 77.0% orsubjects had enlarged tonsils, 2 I.0% of which were infected.

Table 4. Pattern of distribution ofantistreptolysin 0 (ASO) andC‑reactive protein (CRP) titers in control group

In our study, 46.0% of the study group and 1 1.0% of the normalcontrol group showed significant ASO titer (>400 IU/ml).

Control group n‑54ASO(IU/ml)5‑10years

I(22)1‑15years

The CRP levels noted were 40.3% and 26.0% of the study(32)

and control groups, respectively. Among the chil血en GABHS‑0ノ 0ノ ′LU 0 0 018200821

400

33

significant ASO titer (>400 1U/ml) and two had CRP of more

800

00than 6 mg/1, which丘ndings were strong evidence of recent

1600

00

streptococcal infection (9‑ 1 I ).

320000<20011 2

positive by throat swab culture in this study, three had

Unless a communlty‑based survey lS undertaken in bothrural and urban areas, many patients with RHD go undetected;

CRP

5‑10years

11‑15

figures derived by other methods (e.g., hospital surveys) mayyears

be grossly misleading. Useful information can often be(mg/1)

(22)

(32)

<614

2

66

local or reglOnal basis. The screenlng Of school‑aged chil血en

122for RHD and the creation ofa registry for the cases detected
are essential features of such a program.

240480960′0 ′h〉 0 0 0 0obtained when RF prevention programs are implemented on a4 1 0 2 lZ 0 0 0

REFERENCES

The significant As° and CRP titcrs obtained were 1 1.0% and1. World Health Organization (1987): Study group on26.0%, respectively inthe control group.

rheumatic fever and rheumatic heart disease. p. 1 2.

2･ World Health Organization (1980): CommuTityControl ofrheumatic heart disease in developlng COunhes. StrategleS

DISCUSSION

for prevention and control. WHO Chronicle, 34, 389‑
395.

In developlng countries, most Cases OfRF and R力D present

3. Ratz, L A., Raudall, E. and Rautz, H. H. (1948): Anti‑
streptolysln "0": A study of the antibody in health andwith severe heart disease by the time secondary prophylaxis
can be initiated. Early case detection is therefわre crucial to thesuccess of any communityControl program based on secondary

in haemolytic Streptococcus in respiratory disease in man.

prophylaxis. Since RF has been temed an "occupational

Am. ∫. Med., 5, 3.

disease of school children" (4), it is appropriate that pupils

4. Taranta, A. and Markowitz, M. (1989): Role ofhealthplay an important role in its control. The control ofRF andRHD is a prlOrlty in India, where it affects 5.4 to 6.0 per
thousand children in whom the presence of GABHS is a cause

workers other than physicians in the control of rheumaticfever. p. 89‑92. Rheumatic Fever, 2nd ed. Kluwer
Academic, Boston.
5. Koshi, G. and Benjamin, V. (1977): Surveillance ofof acute pharyngitis. It is important to study the burden of thisillness so that appropnate antibiotics can be glVen in a timely

streptococcal infections in children in a south Indian

fashion, and RF can be prevented (primary prophylaxis). Inthe pr.esent study, oral penicillin V (250 mg) 3 times daily

communlty. 1. A pilot survey. Indian ∫. Med. Res., 66,379.

6. Koshi, G. and Mammen, K. C. (1969): Haemolytic strepto‑

was glVen fわr 10 days as prlmary prophylaxis.

In the present study, data included the medical history of

Cocci and immune response in children with rheumaticfever. Indian J. Med. Res., 57, 1347‑1360.

124 school children, and the symptoms and signs recorded
included repeated sore throat, breathlessness, abdominal pain,

7. Padmavathi, S. (1978). Rheumatic fever and rheumatic

anterior cervical lymphadenitis, joint palm, Chest palm,

heart disease in developlng COuntries. Bull. WHO, 16,epistaxis, enlarged tonsils, etc. In 1 977, Koshiand Benjamin (5)543‑550.

8. Myers, R. M. and Koshi, G. (1961): Beta‑hemolytic

conducted a similar study at Vellore among rural children.
They reported that in 287 children who had clinical pharyngltlS,streptococci in suⅣey throat cultures in an Indian popula‑

81% had enlarged tonsils, 73% had dysphagia, 58% hadtion. Am. ∫. Public Health, 51, 1872‑1892.

cervical lymphadenitis, 66% had cough,and 78% had congested

9･ Wann.amaker, L･ W･ and Ayoub, E･ M･ (1960): Antibodythroat. In our study, throat cultures were positive for GABHS

titers ln acute rheumatic fever. Circulation, 2 1 , 59816 14.

only in 4.0%, and 88.7% had normalflora, and the remainlng
cultures grew various organisms, such as Klebsiella spp., S.

10. Ganguly, N. K., Mohan, C. andMahajan, R. C. (1975):
Comparison of streptozyme test with antistreptolysin‑0aureus, and Proteus spp. The low percentage of positive throat

in rheumatic fever. Indian J. Med. Res., 63, 1001‑1005.

culture in this study may be due to antibiotics received prlOr

I 1. McLaren, M. ∫., Hawkins, D. M., Koo血of; H. ∫., Bloom,to screening. Notably, our findings are comparable with thoseK. 良., Bramwell‑Jones, D. M., Cohen, E., Gale, G. E.,

in studies made by Koshi and Mammen (6) and Padmavathi

Kanarek, K., Lachman, A. S., Lakier, ∫. B., Pocock, W A.

(7). In 1961, Myers and Koshi (8) could isolate GABHS only

and Barlow, J. B. ( 1 975): Epidemiology of rheumatic heart

in 5% of subjects who gave a history of upper resplratOry tract
infection. Hence, our results were also in accordance withdisease in black schoolchildren of Soweto, Johannesburg.
Br. Med. ∫., 3, 474‑478.

139