Poststreptococcal Illness: Recognition and Management

 

Am Fam Physician. 2018 Apr 15;97(8):517-522.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/rheumatic-fever.

Author disclosure: No relevant financial affiliations.

Group A beta-hemolytic streptococcus can cause several postinfectious, nonsuppurative immune-mediated diseases including acute rheumatic fever, poststreptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders, and poststreptococcal glomerulonephritis. Except for sporadic outbreaks, poststreptococcal autoimmune syndromes occur most commonly in sub-Saharan Africa, India, Australia, and New Zealand. Children younger than three years are rarely affected by group A streptococcus pharyngitis or rheumatic fever, and usually do not require testing. Rheumatic fever is a rare condition that presents as a febrile illness characterized by arthritis, carditis or valvulitis, and neurologic and cutaneous disease, followed many years later by acquired valvular disease. Recurrence rates are high. In addition to evidence of recent streptococcal infection, two major or one major and two minor Jones criteria are required for diagnosis. Electrocardiography, chest radiography, erythrocyte sedimentation rate, and an antistreptolysin O titer are the most useful initial tests. Echocardiography is recommended to identify patients with subclinical carditis. The arthritis usually responds within three days to nonsteroidal anti-inflammatory drugs. Poststreptococcal reactive arthritis is nonmigratory, can affect any joint, and typically does not respond to aspirin. Pediatric autoimmune neuropsychiatric disorders affect the basal ganglia and are manifested by obsessive-compulsive and tic disorders. The presentation of poststreptococcal glomerulonephritis ranges from asymptomatic microscopic hematuria to gross hematuria, edema, hypertension, proteinuria, and elevated serum creatinine levels.

Streptococcus pyogenes (group A beta-hemolytic streptococcus [GABHS]) is an anaerobic gram-positive coccus whose only reservoir is humans. It causes more than 700 million illnesses and more than 500,000 deaths worldwide each year.1 GABHS causes several postinfectious, nonsuppurative immune-mediated diseases, including acute rheumatic fever, poststreptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), and poststreptococcal glomerulonephritis. This article focuses on the recognition and management of these immune-mediated sequelae.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of group A streptococcal pharyngitis with antibiotics is indicated in patients with a positive rapid antigen detection test or throat culture result.

B

7, 13, 14, 17

Echocardiography should be performed to assess for subclinical carditis in patients with diagnosed or suspected acute rheumatic fever and no auscultatory findings.

C

33

Nonsteroidal anti-inflammatory drugs (aspirin or naproxen) are recommended for treating arthritis in acute rheumatic fever as soon as the diagnosis is confirmed.

B

6, 14, 19

Secondary antibiotic prophylaxis is indicated for patients with acute rheumatic fever or poststreptococcal reactive arthritis.

C

6, 14, 21, 24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of group A streptococcal pharyngitis with antibiotics is indicated in patients with a positive rapid antigen detection test or throat culture result.

B

7, 13, 14, 17

Echocardiography should be performed to assess for subclinical carditis in patients with diagnosed or suspected acute rheumatic fever and no auscultatory findings.

C

33

Nonsteroidal anti-inflammatory drugs (aspirin or naproxen) are recommended for treating arthritis in acute rheumatic fever as soon as the diagnosis is confirmed.

B

6, 14, 19

Secondary antibiotic prophylaxis is indicated for patients with acute rheumatic fever or poststreptococcal reactive arthritis.

C

6, 14, 21, 24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Over the past century in the United States, the incidence of GABHS disease has decreased sharply, and the clinical presentation has evolved.25 Scarlet fever is milder than in historic accounts, acute rheumatic fever is rare (one in 1,000,000 persons), and poststreptococcal glomerulonephritis is now more common in patients older than 60 years who tend to have debilitating conditions.511 Except for sporadic outbreaks, poststreptococcal autoimmune syndromes occur most commonly in sub-Saharan Africa,

The Authors

show all author info

DAVID L. MANESS, DO, MSS, FAAFP, is a professor at the University of Tennessee Family Medicine Residency Program, Jackson....

MICHAEL MARTIN, DO, is an assistant professor at the University of Tennessee Family Medicine Residency Program.

GREGG MITCHELL, MD, is the program director and associate professor at the University of Tennessee Family Medicine Residency Program.

Address correspondence to David L. Maness, DO, MSS, University of Tennessee Health Science Center, 294 Summar Dr., Jackson, TN 38301 (e-mail: dmaness@uthsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5(11):685–694....

2. Gordis L. The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease. T. Duckett Jones memorial lecture. Circulation. 1985;72(6):1155–1162.

3. McCarty M. The streptococcus and human disease. Am J Med. 1978;65(5):717–718.

4. Quinn RW. Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever. Rev Infect Dis. 1989;11(6):928–953.

5. Lee GM, Wessels MR. Changing epidemiology of acute rheumatic fever in the United States. Clin Infect Dis. 2006;42(4):448–450.

6. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005;366(9480):155–168.

7. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat?. JAMA. 2000;284(22):2912–2918.

8. Montseny JJ, Meyrier A, Kleinknecht D, Callard P. The current spectrum of infectious glomerulonephritis. Experience with 76 patients and review of the literature. Medicine (Baltimore). 1995;74(2):63–73.

9. Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol. 2008;19(10):1855–1864.

10. Kim KH. Clinical manifestation patterns and trends in poststreptococcal glomerulonephritis. Child Kidney Dis. 2016;20(1):6–10.

11. O'Brien KL, Beall B, Barrett NL, et al. Epidemiology of invasive group A streptococcus disease in the United States, 1995–1999. Clin Infect Dis. 2002;35(3):268–276.

12. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2014;58(10):1496]. Clin Infect Dis. 2012;55(10):1279–1282.

13. Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648–655.

14. Langlois DM, Andreae M. Group A streptococcal infections. Pediatr Rev. 2011;32(10):423–429.

15. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023.

16. Wannamaker LW, Rammelkamp CH Jr, Denny FW, et al. Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amounts of depot penicillin. Am J Med. 1951;10(6):673–695.

17. Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis. Am Fam Physician. 2016;94(1):24–31.

18. van Driel ML, De Sutter AI, Habraken H, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2016;(9):CD004406.

19. Hahn RG, Knox LM, Forman TA. Evaluation of poststreptococcal illness. Am Fam Physician. 2005;71(10):1949–1954.

20. Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J. 1987;6(7):635–643.

21. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009;119(11):1541–1551.

22. Murphy TK, Snider LA, Mutch PJ, et al. Relationship of movements and behaviors to group A streptococcus infections in elementary school children. Biol Psychiatry. 2007;61(3):279–284.

23. Martins TB, Veasy LG, Hill HR. Antibody responses to group A streptococcal infections in acute rheumatic fever. Pediatr Infect Dis J. 2006;25(9):832–837.

24. Martin WJ, Steer AC, Smeesters PR, et al. Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmun Rev. 2015;14(8):710–725.

25. Bisno AL, Rubin FA, Cleary PP, Dale JB. Prospects for a group A streptococcal vaccine: rationale, feasibility, and obstacles—report of a National Institute of Allergy and Infectious Diseases workshop. Clin Infect Dis. 2005;41(8):1150–1156.

26. Cunningham MW. Streptococcus and rheumatic fever. Curr Opin Rheumatol. 2012;24(4):408–416.

27. Martins TB, Hoffman JL, Augustine NH, et al. Comprehensive analysis of antibody responses to streptococcal and tissue antigens in patients with acute rheumatic fever. Int Immunol. 2008;20(3):445–452.

28. Guilherme L, Kalil J. Rheumatic fever and rheumatic heart disease: cellular mechanisms leading autoimmune reactivity and disease. J Clin Immunol. 2010;30(1):17–23.

29. Bisno AL, Brito MO, Collins CM. Molecular basis of group A streptococcal virulence. Lancet Infect Dis. 2003;3(4):191–200.

30. Quinn A, Kosanke S, Fischetti VA, Factor SM, Cunningham MW. Induction of autoimmune valvular heart disease by recombinant streptococcal m protein. Infect Immun. 2001;69(6):4072–4078.

31. Andrews M, Condren M. Once-daily amoxicillin for pharyngitis. J Pediatr Pharmacol Ther. 2010;15(4):244–248.

32. Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol. 2011;3:67–84.

33. Gewitz MH, Baltimore RS, Tani LY, et al. Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation. 2015;131(20):1806–1818.

34. Melnychuk I, Busby W. Rash and fever in a college student. Am Fam Physician. 2011;84(6):697–698.

35. Uziel Y, Perl L, Barash J, Hashkes PJ. Post-streptococcal reactive arthritis in children: a distinct entity from acute rheumatic fever. Pediatr Rheumatol Online J. 2011;9(1):32.

36. Barash J, Mashiach E, Navon-Elkan P, et al.; Pediatric Rheumatology study group of Israel. Differentiation of post-streptococcal reactive arthritis from acute rheumatic fever. J Pediatr. 2008;153(5):696–699.

37. Kurlan R, Kaplan EL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004;113(4):883–886.

38. Swedo SE, Leonard HL, Rapoport JL. The pediatric autoimmune neuro-psychiatric disorders associated with streptococcal infection (PANDAS) subgroup: separating fact from fiction. Pediatrics. 2004;113(4):907–911.

39. Singer HS, Gilbert DL, Wolf DS, Mink JW, Kurlan R. Moving from PANDAS to CANS [published correction appears in J Pediatr. 2012;160(5): 888]. J Pediatr. 2012;160(5):725–731.

40. Farhood Z, Ong AA, Discolo CM. PANDAS: a systematic review of treatment options. Int J Pediatr Otorhinolaryngol. 2016;89:149–153.

41. Gabbay V, Coffey BJ, Babb JS, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcus: comparison of diagnosis and treatment in the community and at a specialty clinic. Pediatrics. 2008;122(2):273–278.

42. Moreland NJ, Waddington CS, Williamson DA, et al. Working towards a group A streptococcal vaccine: report of a collaborative Trans-Tasman workshop. Vaccine. 2014;32(30):3713–3720.

43. Anthony BF, Kaplan EL, Wannamaker LW, Briese FW, Chapman SS. Attack rates of acute nephritis after type 49 streptococcal infection of the skin and of the respiratory tract. J Clin Invest. 1969;48(9):1697–1704.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


Aug 1, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article