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

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Seven children with strange symptoms attended the Children’s Mercy Kansas City Hospital in Missouri last month. Someone complained of a “stuck” eye. The other had a lump behind one ear. The third had difficulty swallowing and then began to drool.

Angela Myers, director of infectious diseases, recalled that there is no reason to think that these and four other cases, all of which occurred in children younger than 10 years old, could be related. But when the lab tests came back, they all pointed to the same culprit.

It was a potentially deadly form of Strep A.

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

Infection with Streptococcus pyogenes, or group A strep for short, typically produces mild symptoms that lead to strep throat, such as a rash, fever, or swelling of the tonsils. But in recent months, cases of a rare invasive form of the common bacterium have been popping up, often in Europe as well as the United States. sometimes confusing symptoms such as skin rashes, fever, a fast heart, and unexplained swelling.

The first confirmed child deaths in this country were reported last week in two young children in the Denver area. At least 16 children in the UK, seven in the Netherlands and two in France have died from the disease.

The rise of invasive strep A is one of the unconventional ways pathogens interact with us and each other this year amid the end of coronavirus-era social distancing and masking. Both the World Health Organization and the U.S. Centers for Disease Control and Prevention said they are investigating the cases, including whether the viral storm that keeps many people sick is at least partially to blame.

Why does a ‘triple disease’ make some people sick for weeks or even months?

Viral infections tend to disrupt a person’s immune system, making it easier for a secondary bacterial infection to take hold and intensify their effects in some cases.

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

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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. Many of the affected children have current or recent viral infections, said James Versalovic, the medical center’s chief pathologist. But he said it’s still too early to rule out other factors that may contribute to the severity of their illness.

“We may have changed our immune models, which may have increased our vulnerability due to the pandemic. But there can 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 people have been fighting for centuries.

Throughout history, it has been variously misidentified in relation to events such as comets and eclipses, or the introduction of inanimate matter into humans. By 1874, Austrian surgeon Theodor Billroth described an organism he saw under a microscope that appeared to be grouped into four or more chains 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 are infected with strep A each year in the United States, and in our modern world with abundant antibiotic supplies, it’s mostly a nuisance. It often turns into a sore throat and causes a missed school or work day for 24 hours after taking antibiotics such as penicillin and amoxicillin to stop being contagious.

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 it,” said Kristin Moffitt, an infectious disease specialist who works on bacterial infections at Boston Children’s Hospital. “It’s not a serious concern that I would normally be overly concerned about.”

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

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The first reports of unusual activity as a result of invasive strep A, mostly involving children aged 5 and under, came from the Netherlands between March and July. The doctors said in a preprint research article published Dec. 13 that it’s not just the number and severity of cases that matters, but the fact that many of the patients are co-infected with viruses such as the flu or chickenpox. (Unlike the US, the varicella vaccines that cause chickenpox are not part of the Dutch children’s immunization schedule.)

In 2018 and 2019, most children seen with invasive strep A in Dutch hospitals developed sepsis, a systemic infection or pneumonia. This year, however, many have been diagnosed with necrotizing fasciitis, a flesh-eating disease involving bacteria that destroys 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 detection and prompt treatment can save lives.

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

Serious illness in children has also been reported in the UK, Netherlands, France, Ireland and Sweden, but the patterns are not always the same. In the UK, doctors also reported an increase in scarlet fever caused by the strep A bacteria, at about the same time as invasive cases. However, this was not seen in the Netherlands.

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

Understanding what is going on in the United States is more difficult than in some other countries due to the lack of a national healthcare system that facilitates the tracking of cases. CDC spokeswoman Kate Grusich said in an email it was too early to say whether case numbers “return to pre-pandemic levels or have risen above what we normally expect”.

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

Email lists for pediatricians and infectious disease specialists in this country began exploding in October when a Midwest doctor asked a question: Has anyone else seen a spike in invasive strep A?

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

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At Texas Children’s, Versalovic said some children come with low blood pressure and septic shock, some with bacterial pneumonia, and some with skin infections. Many were so sick that they needed intensive care. He’s worried that some cases are being overlooked. To diagnose invasive strep A, doctors must take samples of the patient’s blood, skin, or fluid from their lungs or other areas. But if a child needs emergency care, there may not be time to consider the cause of the illness.

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

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

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

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

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

One of the hardest things about the disease is that it can look so different in different children, he said. The child, who had difficulty moving the eyeball, had an infection of the soft tissues of the orbital socket; infection of the bone in that area, which is a lump behind the ear; and the third patient, collection of pus at the back of the throat.

Myers urged parents to be cautious.

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

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