Invasive Strep A is increasing and affecting children in unusual ways

Invasive Strep A is increasing and affecting children in unusual ways

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The seven children with strange symptoms arrived at Children’s Mercy Kansas City Hospital in Missouri in quick succession over the past month. One complained of an eye that was “stuck.” Another had a lump behind one ear. A third had trouble swallowing and then started drooling.

There was no reason to believe that these and four other cases, all in children under 10, might be related, recalled Angela Myers, director of infectious diseases. But when the lab tests came back, they all pointed to the same culprit.

It was a potentially deadly form of Streptococcus A.

“We were very surprised,” Myers said. “We just don’t see that much together in such a short amount of time.”

An infection with Streptococcus pyogenes — or group A strep, for short — usually causes mild symptoms, such as a rash, fever, or swollen tonsils, leading to strep throat. But in recent months, cases linked to a rare invasive form of the common bacterium have emerged in the United States as well as Europe, often in association with sometimes confusing symptoms, including skin rashes, fever, fast heart rate, and unexplained swelling.

The first confirmed pediatric deaths in this country in two young children in the Denver area, were announced last week. At least 16 children died from him in Great Britainseven in Holland and two in France.

The rise of invasive Strep A is one of a number of unusual ways pathogens are interacting with us — and each other — amid the end of social distancing and masking since the coronavirus era this year. Both World Health Organization and on US Centers for Disease Control and Prevention said they were investigating the cases, including whether the virus storm that kept many people sick might be at least partly to blame.

Why “triple demia” keeps some people sick for weeks, even months

Viral infections tend to create a disorder in a person’s immune system, making it easier for a secondary bacterial infection to take hold and amplify its effects in some cases.

Minnesota health officials said they saw 46 cases of invasive strep A across all ages in November, more than double the average of 20 cases in previous months. Colorado reported investigating not only an increase in cases of invasive strep A, but also a possible increase in other severe or invasive bacterial infections in children.

Texas Children’s Hospital said it saw more than 60 patients with invasive strep A in October and November — a fourfold increase from the same period the previous year. James Versalovic, the medical center’s chief pathologist, said many of the affected children had current or recent viral infections. But, he said, it is still too early to rule out other factors that may contribute to the severity of their illnesses.

“We may have altered immunity patterns due to the pandemic, which may have increased our vulnerability. But it could also be … different variants of strep, he said. “It could be a combination of factors. No one knows.”

Unlike SARS-CoV-2, Strep A is something humans have been fighting for centuries.

It has been described variously, incorrectly, throughout history as being associated with phenomena such as comets and eclipses, or the introduction of inanimate matter into humans. It wasn’t until 1874 that the Austrian surgeon Theodor Billroth described an organism he saw under a microscope that appeared to be grouped in chains of four or more that would later be classified as bacteria. Bacteria can live inside or outside the patient’s body, unlike viruses, which are a collection of molecules that can only replicate in a host. Both are transmitted in similar ways – through air, water, food and living things.

Several million people in the United States contract strep A each year, and in our modern world, with the abundance of antibiotics, it’s mostly an inconvenience. It usually results in a sore throat and perhaps a missed day of school or work during the 24 hours it takes to stop being contagious after taking antibiotics like penicillin and amoxicillin.

Strep A: What you need to know about the usually mild infection

“The good news is we know how to treat it and how to test for it,” said Christine Moffitt, an infectious disease expert at Boston Children’s Hospital who studies bacterial infections. “Normally it’s not a source of serious concern that I would worry too much about.”

But in a small number of cases, Strep A can become dangerous when it invades parts of the body where the bacteria don’t normally exist. When it gets into such areas, including the blood, cerebrospinal fluid, bone marrow, and organs such as the brain and heart, it can spread quickly and kill.

The first reports of unusual activity due to invasive Streptococcus A, mostly affecting children under 5 years of age, came from the Netherlands between March and July. Not only the number of cases and their severity, said doctors in a preprint research paper published on December 13, but also the fact that many of the patients were co-infected with viruses such as influenza or chicken pox. (Unlike in the United States, vaccinations against varicella, which causes chickenpox, are not part of the childhood immunization program in the Netherlands.)

In 2018 and 2019, most of the children seen in Dutch hospitals with invasive strep A developed sepsis, systemic infection or pneumonia. But this year, many were diagnosed as suffering from necrotizing fasciitis, a flesh-eating disease that involves bacteria that destroys tissue beneath the skin. Doctors Evelien B. van Kempen, Patricia CJ Bruijning-Verhagen and their co-authors urged the public to be aware that early recognition and prompt treatment can save lives.

“Clinicians and parents should be vigilant and aware of unusual pediatric presentations,” they wrote.

Serious illnesses in children have also been reported in the UK, the Netherlands, France, Ireland and Sweden, but the patterns are not always the same. In the UK, doctors reported a spike in scarlet fever – which is also caused by strep bacteria – around the same time as the invasive cases. But this was not seen in the Netherlands.

Several hospitals in the United States said they knew of no unusual activity of scarlet fever in their areas.

Figuring out what’s happening in the United States is more difficult than in some other countries because of the lack of a national health care system to facilitate case tracking. CDC spokeswoman Kate Grusich said in an email that it’s too early to say whether the number of cases is “simply returning to pre-pandemic levels or rising above what we would normally expect.”

“CDC is closely monitoring this data and talking to surveillance sites and hospitals in multiple states to learn more about any trends,” she said.

E-mail lists for pediatricians and infectious disease specialists in this country began blowing up in October with a question from a doctor in the Midwest: Has anyone else seen an increase in invasive Strep A?

The responses were mixed, as expected, given that similar cases tend to cluster. Boston Children’s had seen nothing alarming. But doctors in Kansas City, Houston and Denver had.

At Texas Children’s, Versalovic said some children came in with low blood pressure and septic shock, some with bacterial pneumonia and others with skin infections. A few were so sick that they needed intensive care. He worries that some of the cases are being missed. To diagnose invasive Strep A, doctors must take samples from the patient’s blood, skin, or fluid in the lungs or other areas. But if the child needs urgent help, there may not be time to consider the cause of the illness.

Invasive Strep A “doesn’t follow a simple linear progression,” he said.

In Denver, Samuel Dominguez, an infectious disease specialist at Children’s Hospital Colorado and a professor at the University of Colorado School of Medicine, said the cases he’s seen are “across the age spectrum” in children, noting that they may be more susceptible as bacteria tend to colonize more aggressively in their throats and skin than in adults.

Dominguez tried to balance assurances that it was a relatively rare infection with calls to watch for warning signs.

Versalovic agreed. “We don’t want to raise too much alarm, but these infections can progress very quickly,” he said.

Myers said all patients seen at Children’s Mercy in Missouri have recovered with treatment, but she urged parents to make sure their children’s vaccinations are up to date to prevent a viral infection that could open the door to more -severe bacterial. “I think there’s a lot we don’t fully know yet,” she said.

One of the complicated things about the disease is that it can look so different in different children, she said. The child who has problems with the movement of the eyeball has an infection of the soft tissues of the eye socket; the one with the lump behind the ear, a bone infection in that area; and the third patient, a collection of pus at the back of the throat.

Myers urged parents to be careful.

“If a child seems sicker than they should after developing a fever, it’s always a good idea to take them to the doctor if they have trouble breathing or notice anything else — even a swollen eye,” she said.

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