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Invasive strep A is on the rise and affecting children in unusual ways

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The seven children with bizarre symptoms arrived at Children’s Mercy Kansas City Hospital in Missouri in quick succession last month. One complained of a “stuck” eye. Another had a bump behind one ear. A third had trouble swallowing, then started drooling.

There was no reason to think that these cases and four others, all in children under the age of 10, could be linked, said Angela Myers, director of infectious diseases. But when the lab tests came back, they all pointed to the same culprit.

It was a life-threatening form of strep A.

“We were very surprised,” Myers said. “We just don’t see so many people together in such a short time.”

Infection with Streptococcus pyogenes — or group A strep, for short — usually produces mild symptoms, such as a rash, fever, or swollen tonsils leading to the eponymous strep throat. But in recent months, cases linked to a rare invasive form of the common bacteria have emerged in the United States, as well as in Europe, often in contact with Sometimes confusing symptoms including skin rashes, fever, rapid heartbeat and unexplained swelling.

The first confirmed pediatric deaths in this country, in two young children in the Denver area, were reported last week. At least 16 children died from it in the UKseven in the Netherlands and two in France.

The rise of invasive Strep A is one of many unusual ways pathogens are interacting with us — and each other — amid the end of social distancing and masking the coronavirus era this year. The two World Health Organization and the US Centers for Disease Control and Prevention said they were investigating the cases, including to determine whether the viral storm that has sickened many people could be at least partially responsible.

Why a ‘triple epidemic’ is making some people sick for weeks or even months

Viral infections tend to create disturbances in a person’s immune system, which makes it easier for a secondary bacterial infection to set in and intensifies 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 that it was investigating not only an increase in cases of invasive strep A, but also a possible increase in other serious 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 four-fold 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’s still too early to rule out other factors that might be contributing to the severity of their illnesses.

“We may have changed 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. Nobody knows.”

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

It has been variously, erroneously, described throughout history as being associated with phenomena such as comets and eclipses, or the introduction of non-living matter into humans. It was not until 1874 that Austrian surgeon Theodor Billroth described an organism he saw under a microscope that appeared to be grouped together in chains of four or more that would later be classified as bacteria. Bacteria can live inside or outside a patient’s body, unlike viruses, which are a set 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 are infected with Strep A each year, and in our modern world, with its abundant supply of antibiotics, it is mostly a nuisance. This usually results in a sore throat and possibly a missed day of school or work within the 24 hours needed to stop being contagious after taking antibiotics such as penicillin and amoxicillin.

“The good news is that we know how to treat it and how to test for it,” said Kristin Moffitt, an infectious disease expert at Boston Children’s Hospital who studies bacterial infections. “Normally that’s not a serious cause for concern that I would be hyper-anxious about.”

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

The first reports of unusual activity following invasive strep A, mostly involving children aged 5 and under, came from the Netherlands between March and July. It wasn’t just the number of cases and their severity, doctors said pre-printed research paper posted in Dec. 13, but also the fact that many patients had been co-infected with viruses such as influenza or chickenpox. (Unlike the United States, vaccination against varicella, which causes chickenpox, is not part of the childhood vaccination program in the Netherlands.)

In 2018 and 2019, most children seen in Dutch hospitals with invasive strep A developed sepsis, systemic infection or pneumonia. But this year, many have been diagnosed with necrotizing fasciitis, a flesh-eating disease involving bacteria that destroy tissue under 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 alert and aware of unusual pediatric presentations,” they wrote.

Severe 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 have reported an increase in scarlet fever – which is also caused by the bacteria strep A – around the same time as invasive cases. But this has not been seen in the Netherlands.

Several hospitals in the United States said they were unaware of any unusual scarlet fever activity in their area.

Understanding what is happening in the United States is trickier than in some other countries due to the lack of a national health care system that makes it easy to track cases. CDC spokeswoman Kate Grusich said in an email that it was too early to tell if the number of cases was “just returning to pre-pandemic levels, or increasing beyond that. what we would normally expect”.

The “CDC is monitoring this data closely and talking with monitoring sites and hospitals in several states to learn more about trends,” she said.

Email mailing lists for pediatricians and infectious disease specialists in this country began to explode in October with a question from a Midwestern doctor: Has anyone else seen a increase in invasive streptococcus A?

Responses were mixed, as expected, given that these cases tend to cluster. Boston Children’s hadn’t seen anything to worry about. But doctors in Kansas City, Houston and Denver did.

At Texas Children’s, Versalovic said some children arrived with low blood pressure and septic shock, some with bacterial pneumonia and still others with skin infections. Several were so ill that they required intensive care. He fears that some cases will be missed. To diagnose invasive strep A, doctors must take samples of blood, skin, or fluid from a patient’s lungs or other areas. But if a child needs emergency care, there may not be time to investigate the cause of the illness.

Invasive strep A “does not follow a simple linear progression,” he said.

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

Dominguez sought to balance assurances that it is a relatively rare infection with calls to be on the lookout for warning signs.

Versalovic accepted. “We don’t want to raise too many alarms, 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 gates. to a more serious bacterial infection. “I think there’s a lot at play that we don’t fully know yet,” she said.

One of the tricky things about the condition is that it can look so different in different children, she said. The child with difficulty moving his eyeball had a soft tissue infection in the eye socket; the one with the bump behind the ear, an infection of the bone in that area; And the third patient, a collection of pus at the back of the throat.

Myers urged parents to err on the side of caution.

“If a child looks sicker than they should after developing a fever, it’s always a good idea to get them to a doctor if they’re having trouble breathing or if you notice anything else, even a swollen eye,” she said.

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