Strep' Demands Immediate Care 
by Margie Patlak

    Few childhoods go by without the tell-tale fever and sore throat of a     
Streptococcus, or "strep," infection. Although these throat infections are    
common and easily treated, the recent rise of particularly deadly or          
troublesome strains of Group A Streptococcus has pushed the bacterium into    
the medical limelight--again. 
    In the past, Group A strep has played a starring role in a number of      
deadly medical epidemics, particularly the scourges of rheumatic fever that   
swept across the nation in the first half of this century, killing or         
debilitating thousands of children each year. 
    After World War II, the number of cases of rheumatic fever dramatically   
declined until, during the 20 years between 1965 and 1985 alone, the yearly   
number of cases of rheumatic fever among school-age children dropped by more  
than 90 percent. The medical community had assumed that less crowded living   
conditions and the use of antibiotics were keeping the disease at bay. Some   
physicians even went so far as to call rheumatic fever a "vanishing disease   
in suburbia."
    That complacency was shaken in the mid-1980s when outbreaks of rheumatic  
fever were reported among children and young adults in various cities         
scattered throughout the country. Those reports were followed by others of a  
new and deadly form of strep infection that was afflicting adults. This       
disease, which is called toxic streptococcal syndrome, made the headlines     
when public television's "Sesame Street" puppeteer Jim Henson was reported    
to have died from it last year. There's also evidence to suggest that blood   
infections caused by Group A strep are on the rise.
    "Group A Streptococcus seems to have taken a little twist again," says    
Rosemary Roberts, M.D., a medical officer with the Food and Drug              
Administration's division of anti-infective drug products. "We're seeing      
manifestations like rheumatic fever that we haven't seen for awhile, as well  
as more invasive strains of Group A strep that are making people sicker much  
more quickly."
    The jury isn't in yet on why Americans are experiencing such a boost in   
the severity of strep infections. Preliminary findings by researchers at the  
national Centers for Disease Control in Atlanta suggest that a population     
increase among previously rare strep types may be behind both the recent      
rheumatic fever outbreaks and cases of the new toxic streptococcal syndrome.  
Heightened production of disease-causing toxins by more common strep types    
may also be responsible for the latest strep casualties.
    There are more than 80 known types of Group A Streptococcus, which can    
cause more than a dozen different illnesses. Group A Streptococcus, in turn,  
is part of a broader category of strep organisms that cause an even larger    
number of diseases. (See box.)
    Some of the more well-known Group A strep afflictions include upper       
respiratory diseases such as strep throat and scarlet fever, skin disorders   
such as impetigo, and inflammatory diseases such as rheumatic fever or        
kidney disease. In addition, blood infections due to Group A strep are a      
serious and frequent complication of wounds or surgery.
    Group A strep infections are treatable with antibiotics, the drug of      
choice being penicillin. Other antibiotics, such as erythromycin and various  
cephalosporins, are effective alternatives for patients allergic to           
penicillin. FDA is responsible for ensuring the safety and effectiveness of   
these drugs.

Strep Throat
    Strep throat (streptococcal pharyngitis) is probably the most well-known  
Group A strep infection. Although strep throat can occur at any age and at    
any time of the year, it mainly afflicts school-age children during the       
winter and spring. The many symptoms of strep throat include an extremely     
red and painful sore throat, ear pain, fever, enlarged and tender lymph       
nodes in the neck, white spots on the tonsils, or dark red spots on the soft  
palette. However, about 1 out of 5 people who has strep throat experiences    
no symptoms.
    Because nearly all the symptoms of strep throat can also occur with       
viral infections, laboratory tests are used to confirm a doctor's suspicion   
that a patient's sore throat is caused by Group A strep. The traditional      
laboratory test to identify strep is a throat culture. To isolate and         
identify Group A strep from a throat swab takes from one to three days using  
the culture method. In recent years, a number of tests have become available  
that use antibodies to detect the presence of Group A strep directly on a     
throat swab, and these devices can provide test results in a matter of        
minutes. Many physicians feel that the rapid tests do not detect as many      
positive results as the culture method, so if the rapid test results are      
negative, a follow-up throat culture is recommended. 
    Strep throat is highly contagious among children because they are in      
close contact with one another. In addition, they have not yet developed      
resistance to any of the strains, as adults have. 
    The incubation period for strep throat is two to five days. During        
epidemics, siblings of a strep throat patient have a fifty-fifty chance of    
also succumbing to the disease, whereas only 20 percent of the parents of     
such patients will develop strep throat. Children with strep throat should    
not return to school until their fever returns to normal and they've had at   
least a day's worth of antibiotics. 
    Strep throat is easily treated with antibiotics. Treatment is usually     
not necessary for those individuals who harbor the strep throat microbe but   
show no signs of an active infection. These people are unlikely to spread     
infection to others, according to the American Academy of Pediatrics, or      
experience the complications of a strep infection, which include rheumatic    
fever and kidney disease. 

Scarlet Fever
    One of the more colorful variants of a strep infection is scarlet fever.  
The hallmarks of this disease include a bright red tongue, a brilliant        
scarlet rash (particularly on the trunk, arms and thighs), a flushed face,    
sore throat, and fever. 
    "Scarlet fever is simply strep throat with a rash," says Roberts. The     
red rash that typifies this disease is prompted by a toxin generated by the   
Streptococcus bacterium. The striking symptoms of scarlet fever make it easy  
to diagnose, but most physicians confirm their clinical diagnosis with        
laboratory tests.
    Like strep throat, scarlet fever primarily afflicts school-aged children  
during the winter and spring months. Scarlet fever is easily treated with     
antibiotics, and, if left untended, the disease can foster the same           
complications prompted by strep throat.

Rheumatic Fever
    Lurking behind several types of strep infections is the possibility of    
rheumatic fever. Although a relatively uncommon disease, the effects of       
rheumatic fever are serious enough to warrant concern. Signs of rheumatic     
fever include a red rash, pea-sized lumps under the skin, tender joints,      
fever, involuntary jerky movements, heart palpitations, chest pain, and, in   
severe cases, heart failure. Although most symptoms disappear within weeks    
to months, about half the time the disease leaves behind deformed heart       
valves that may limit patients' physical activities and foster premature      
death from heart failure.
    Diagnosis of rheumatic fever is based on its symptoms in conjunction      
with a history of a recent strep infection, which can be confirmed by tests   
for strep antibodies in the blood.
    Rheumatic fever is thought to be triggered by an overly active immune     
system, which inadvertently destroys body tissues in its zeal to rid the      
body of a strep infection. Most symptoms of rheumatic fever crop up one to    
four weeks after a strep infection, although involuntary jerky movements may  
not surface for as long as six months after infection. About half of the      
recent cases of rheumatic fever, however, developed with mild to no previous  
signs of a strep throat infection, such as a sore throat with fever.
    It's these signs of a strep infection that physicians rely on to prevent  
rheumatic fever. As many as 3 percent of untreated cases of strep throat can  
develop into rheumatic fever. But antibiotic treatment, even if it's not      
started until several days after the onset of symptoms, can squelch the       
possibility of rheumatic fever. 
    Once rheumatic fever occurs, doctors can do little to prevent its damage  
in the body. Anti-inflammatory drugs (such as aspirin or steroids) can ease   
many of the symptoms and possibly prevent some of rheumatic fever's more      
serious developments. Antibiotics are also used to treat any lingering strep  
infections. But even with such therapies, the disease often wreaks such       
damage on heart valves that they have to be surgically repaired or replaced   
with synthetic or animal implants. 
    Rheumatic fever usually recurs whenever its victims experience any new    
strep infections. To prevent such flare-ups, the American Heart Association   
recommends that anyone who has experienced rheumatic fever take prophylactic  
(preventive) doses of antibiotics. How long rheumatic fever patients require  
such a preventive drug regime depends on whether they experienced heart       
damage and whether they're likely to develop a future strep infection.        
Children who've had rheumatic fever, for example, generally take antibiotics  
on a daily basis until they reach adulthood, when the risk of a strep         
infection greatly diminishes. 

Skin Infection
    When Group A streptococci literally get under the skin, they can foster   
a common skin disease known as impetigo. This contagious disease frequently   
afflicts mainly children during the summer, when insect bites, cuts and       
scrapes are prevalent. These skin infringements serve as portals of entry     
for the streptococci.
    Impetigo starts out as a rash of pinhead-sized blisters or pimples that   
rapidly run together to form yellow, flaky crusts. The impetigo rash may      
itch or burn, but rarely causes pain. The disease is diagnosed with the aid   
of cultures of the fluid lodged beneath the crusts. If large numbers of       
strep bacteria crop up in these cultures, their guilt in causing the disease  
is firmly established. Impetigo can also be caused by other bacteria,         
including Staphylococcus, or by mixtures of staphylococcal and streptococcal  
bacteria. 
    Impetigo is combated with the use of topical or oral antibiotics,         
depending on its severity and frequency within a given population. Doctors    
advise impetigo patients to remove the skin crusts and wash their rash with   
soap on a regular basis. Occasionally, if not treated, streptococcal          
impetigo develops into a blood infection, and it can also foster kidney       
disease.

Kidney Disease
    All kinds of strep infections can foster an inflammation of the kidneys   
(acute glomerulonephritis), although the disease most often follows           
impetigo. Less than 1 percent of all strep infections foster kidney disease,  
but because certain strains of strep are particularly prone to causing this   
complication, small epidemics of acute glomerulonephritis can crop up in      
private homes or in schools. 
    Symptoms of the disorder include a puffy face due to water retention,     
blood in the urine, pain in the loins, malaise, nausea, headache, and high    
blood pressure. These symptoms usually surface one to three weeks following   
a strep infection and subside within the same amount of time. 
    Diagnosis of acute post-streptococcal glomerulonephritis is based on      
symptoms, a history of a recent strep infection, and elevated levels of       
antibodies to strep in the blood. This form of kidney disease, like           
rheumatic fever, is thought to stem from an overactive immune response to     
strep. 
    Little can be done to prevent this heightened immune response once it's   
begun, although various drugs (such as diuretics) and dietary measures (such  
as restricted salt or protein intake) can ease many of its symptoms. Most     
patients recover without any permanent problems, although occasionally        
kidney damage inflicted by the disease may require dialysis or a kidney       
transplant. 
    Patients rarely experience a recurrence of acute glomerulonephritis       
following additional strep infections because of the immunity they develop    
to the specific type of strep bacterium that caused their disorder. (Only a   
handful of strep types can cause glomerulonephritis, and most cases of the    
disorder can be traced to a specific Group A streptococcal strain known as    
Type 12.) 

Blood Infection
    Although the number of bloodstream infections (septicemia) of Group A     
strep appears to be on the rise, they are still extremely rare. Only about 4  
to 5 people out of 100,000 develop these infections each year, according to   
the national Centers for Disease Control in Atlanta. But nearly one-third of  
all patients with Streptoccocus blood infections will die from them.
    Septicemia usually gets its start when streptococcal bacteria on the      
skin delve into an opening as large as a surgical or battle wound or as       
small as a minor cut or scrape. Normally, the body's immune system checks     
these bloodstream invaders before they wreak havoc in the body. In those      
individuals whose resistance is lowered, however, Streptoccocus travels far   
and wide, causing such symptoms as fever, low blood pressure, chills,         
confusion, diarrhea, vomiting, or a red skin rash. Septicemia usually         
afflicts people over 60 who have an underlying disease such as diabetes or    
renal failure that compromises their immune defenses. 
    In addition to relying on clinical signs to diagnose septicemia,          
physicians use laboratory findings, including positive blood cultures,        
positive antibody tests, and extremely high numbers of white blood cells in   
the blood. 

Toxic Streptococcal Syndrome
    The new toxic streptococcal syndrome, first described in 1987 in this     
country, is similar to septicemia. Patients with this disorder have many of   
the same symptoms as those of septicemia, but because of the disease's rapid  
progression, by the time they seek treatment they are often gravely ill.      
Toxic streptococcal syndrome patients frequently go into shock and            
experience multi-organ failure, as well as complications such as the          
pneumonia that reportedly killed Jim Henson.
    Only 1 or 2 people out of 100,000 fall prey to toxic streptococcal        
syndrome each year. Unlike septicemics, most of these patients don't have     
any underlying diseases hampering their immune defenses. Of 21 cases studied  
extensively by researchers, most patients were in their 30s and the youngest  
was 25 years old. 
    "The individuals who are getting strep septicemia and toxic strep         
syndrome," points out CDC epidemiologist Walter Straus, "are not the same     
ones who are getting strep throat."
    Patients with toxic streptococcal syndrome are treated with antibiotics   
as well as with medical measures aimed at curbing the severe complications    
of the disease. The sooner patients are treated with antibiotics, the more    
likely they will recover from the syndrome, which kills about one-third of    
its victims.
    Whether Group A Streptococcus infects the skin, blood, internal organs,   
or the throat, it is usually checked by prompt and appropriate antibiotic     
therapy. This is why, though recent outbreaks of serious strep infections     
are cause for some concern, they are not likely to prompt the extensive       
death or debilitation once tied to them. n

Margie Patlak is a freelance writer in Elkins Park, Pa.

Signs of a Group A Strep Infection

- sore throat accompanied by fever
- chest pain
- shortness of breath
- shock
- red rash accompanied by fever
- tender joints
- involuntary jerky movements
- blood in urine
- yellow flaky crusts on the skin
- puffy face and 
       malaise
Persons developing any of these symptoms should seek immediate medical care. 

The Streptococci Family
    The streptococcal bacteria are extremely versatile and common. Able to    
invade almost any part of the body, streptococci cause a host of diseases.    
These microbes are divided into more than a dozen different groups, based on  
the proteins they harbor in their cell walls and their performance on         
various laboratory tests. Here's a list of some of the more troublesome       
categories or species of Streptococcus and the diseases for which they are    
well known:

Group A: strep throat, scarlet fever, rheumatic fever, impetigo, toxic        
streptococcal syndrome, streptococcal kidney disease, blood infections

Group B: blood infections in newborns, meningitis, childbed fever

Groups C,D,G,H,K: urinary tract infections, heart infections, meningitis,     
upper and lower respiratory tract infections

Streptococcus mutans: dental caries (cavities)

Streptococcus pneumoniae: pneumonia, ear infections, meningitis, sinus        
infections.