CASE STUDY 1

GROUP 1
CASE NARRATIVE

A 7 year old boy was admitted to the hospital

due to high fever and swollen tonsils and noted with
pus. The mother reported to the doctor on
consultation that his tonsillitis was recurrent.
The doctor requested for the following lab tests:
Throat Swab Culture and Sensitivity Testing; CBC,
Urinalysis, and Streptozyme Test.
LABORATORY FINDINGS

 Throat swab was cultured and revealed S.

pyogenes, and sensitivity to erythromycin.
 CBC showed elevated count at 18,000/cu mm with
70% neutrophils.
 Urinalysis showed negative for sugar, positive for
proteins, microscopic sediments not significant.
 Streptozyme test: Reactive
CASE QUESTIONS

1. Illustrate and describe S. pyogenes in terms of its

bacteriologic properties, disease(s) caused especially in
young children.

S. pyogenes is a gram positive spherical, ovoid,

or lancet shaped organism that is catalase negative
and often seen in pairs of chains. Some of its
distinguishing characteristics from other β hemolytic
group of Streptococci is its susceptibility in 0.04U
Bacitracin and the production of Pyrrolidonyl
arylamidase.
CASE QUESTIONS

1. Illustrate and describe S. pyogenes in terms of its

bacteriologic properties, disease(s) caused especially in
young children.

β- hemolysis on BAP Gram (+) cocci in chains or pairs

CASE QUESTIONS

Group A streptococci (GAS) are a major cause of bacterial

pharyngitis (a throat infection) and childhood impetigo (a skin
infection). Additional cell wall components, the M and T proteins,
allow for further classification and identification.
The M protein is the major virulence factor of S. pyogenes.
This inhibits phagocytosis and antibody synthesized against the M
protein provides a type-specific immunity to group A streptococci.

Other extracellular products that are important in the

pathogenesis of disease:
 Streptolysin O
 Streptolysin S
 Hyaluronidase
 Dnases (A, B, C, D)
 Streptokinase
 Erythgenic Toxin
CASE QUESTIONS

Upper respiratory tract infections

caused by S. pyogenes occur most
frequently in school-aged children and
are uncommon in children younger
than 3 years.
Pharyngitis (Strep Throat) – begins
with sudden onset of sore throat and
fever, which rapidly progresses in
severity. Pharyngeal erythema with
purulent tonsillar exudate and
petechiae may be observed in the
palate, posterior pharynx, and tonsils.
Impetigo – begins as a papule. The
lesion may itch and will eventually
crust over and heal. Impetigo is
more likely to infect children ages
2–5, especially those that attend
school or day care
Scarlet Fever – is the result
of pharyngeal infection with
a strain of Group A
Streptococcus that produces
erythrogenic toxin that is
responsible for the rashes.
The rash develops at the 2nd
day of illness and results in
hyperkeratosis with
subsequent peeling.
CASE QUESTIONS

2. Describe the autoimmune sequelae (autoimmune

disease) that arise from S. pyogenes infection.

Acute rheumatic fever develops as a sequela to

pharyngitis or tonsillitis in 2% to 3% of infected
individuals. It does not occur as a result of skin infection.
The latency period is typically 1 to 3 weeks after onset of
the sore throat. Characteristic features of acute rheumatic
fever include fever, pain caused by inflammation in the
joints, and inflammation of the heart. The disease is most
likely caused by antibodies originally produced against
streptococcal antigen that cross-react with antigens
present in human heart tissue.
 The second main complication following a
streptococcal infection is acute glomerulonephritis, a
condition characterized by damage to the glomeruli in
the kidneys. This condition may follow infection of
either the skin or the pharynx, whereas rheumatic
fever follows only upper respiratory tract infections.
Glomerulonephritis caused by a streptococcal infection
is most common in children between the ages of 2 and
12 and is especially prevalent in the winter.
CASE QUESTIONS

3. What is the clinical significance of an increased WBC

count, with a concomitant increase in neutrophils?
(Describe the role played by neutrophils in natural
secondary line of defense).

The most common cause of marked neutrophilia

is a bacterial infection.
CASE QUESTIONS

4. What is the nitroblue tetrazolium test (NBT)? Describe its

principle and usefulness of the test.

The nitroblue tetrazolium test checks if certain immune

system cells can change a colorless chemical called nitroblue
tetrazolium (NBT) into a deep blue color.
NBT is used in a diagnostic test, particularly for chronic
granulomatous disease and other diseases of phagocyte
function. When there is an NADPH oxidase defect, the
phagocyte is unable to make reactive oxygen species or radicals
required for bacterial killing. As a result, bacteria may thrive
within the phagocyte. The higher the blue score, the better the
cell is at producing reactive oxygen species.
 The chemical NBT is added to the white blood
cells in the laboratory. The cells are then examined
under a microscope to see if the chemical has made
cells turn blue.
CASE QUESTIONS

5. A new version of the test is also available currently,

which is based on flow cytometry using dihydrorhodamine
label. Describe this test and its principle.

In this test, neutrophils are labeled with

dihydrorhodamine (DHR). DHR will fluoresce when it is
reduced. The neutrophils are then activated using phorbol
myristate acetate (PMA), which is mitogenic for
neutrophils. The resultant oxidative burst will reduce DHR,
resulting in fluorescence that may be quantitated on a flow
cytometer. The neutrophils from CGD patients will be
unable to undergo the oxidative burst and show less
fluorescence than normal neutrophils.
CASE QUESTIONS

6. What is the significance of a positive streptozyme test?

Also describe its principle.

It is a slide agglutination screening test for detection

of antibodies to several streptococcal antigens. Sheep red
blood cells are coated with Streptolysin, Streptokinase,
Hyaluronidase, DNase and NADase so that antibodies to
any of these antigens can be detected. A positive
streptozyme test indicates that one or more antibodies to
the antigens impregnated in the test kit is present in the
patient’s serum.
CASE QUESTIONS

7. Other than the streptozyme test, cite other serologic tests

to detect antibodies to diagnose rheumatic fever and
poststrep glomerulonephritis. Describe the principles.

ASO tests detect antibodies to the Streptolysin O

enzyme produced by group A streptococcus, which is able
to lyse red blood cells. Presence of antibodies to
streptolysin O indicates recent streptococcal infection in
patients suspected of having acute rheumatic fever or
poststreptococcal glomerulonephritis following a throat
infection.
CASE QUESTIONS

7. Other than the streptozyme test, cite other serologic

tests to detect antibodies to diagnose rheumatic fever
and poststrep glomerulonephritis. Describe the
principles.

The principle of the test is based on Latex

Agglutination wherein latex particles are coated with
Streptolysin O. When latex particles is mixed with a
serum containing ASO, agglutination occurs.
CASE QUESTIONS

7. Other than the streptozyme test, cite other serologic tests

to detect antibodies to diagnose rheumatic fever and
poststrep glomerulonephritis. Describe the principles.

Testing for the presence of anti-DNase B is clinically

useful in patients suspected of having glomerulonephritis
preceded by streptococcal skin infections, as ASO
antibodies often are not stimulated by this type of disease.4
In addition, anti- bodies to DNase B may be detected in
patients with acute rheumatic fever who have a negative
ASO test result.
CASE QUESTIONS

7. Other than the streptozyme test, cite other serologic tests

to detect antibodies to diagnose rheumatic fever and
poststrep glomerulonephritis. Describe the principles.

The principle of the test is based in neutralization

methodology. If anti-DNase B are present, they will
neutralize reagent DNase B, preventing it from
depolymerizing DNA. The presence of DNAse is measured
by its effect on a DNA-methyl-green conjugate which when
hydrolyzed by DNase, the methyl green is reduced and
become colorless.
CASE QUESTIONS

8. If CRP and C3 tests would be performed, what is the

correlation of these tests to acute rheumatic fever and post
strep glomerulonephritis? Describe the principles of the
tests.

In post-streptococcal glomerulonephritis, there is a

deposition of circulating immune complexes in the
glomeruli, activating the complement system as a
consequence. Usually the alternative pathway is activated
in PSGN and is manifested by a depression of C3 levels.
CASE QUESTIONS

8. If CRP and C3 tests would be performed, what is

the correlation of these tests to acute rheumatic
fever and post strep glomerulonephritis? Describe
the principles of the tests.

CRP is usually used as a non-specific indicator of

acute inflammation. Monitoring levels may be useful
for monitoring the disease process and observe the
response of treatment. In ARF, CRP levels are elevated
at the onset of disease.
8. If CRP and C3 tests would be performed, what is the
correlation of these tests to acute rheumatic fever and
post strep glomerulonephritis? Describe the principles of
the tests.

CRP test use the principle of Latex Agglutination,

wherein the latex particles are coated with antibody to
CRP and are reacted to the patient’s serum. In this case,
the CRP acts as antigen. Presence of agglutination
indicates a positive reaction.
8. If CRP and C3 tests would be performed, what is the
correlation of these tests to acute rheumatic fever and
post strep glomerulonephritis? Describe the principles of
the tests.

C3 test is usually done to measure the amount or

the function of complement proteins in the blood and if
this contributes to increased infections or increase
autoimmune activity. It can also help monitor the
activity and treatment of autoimmune disease and
immune complex-related diseases.
CASE QUESTIONS

9. Recurrent bacterial infections in young children may be

due to chronic granulomatous disease. Describe fully this
condition.

Chronic granulomatous disease is characterized by a

susceptibility to repeated bacterial and fungal infections. It
is a group of inherited either an X-linked or autosomal
recessive gene that affects neutrophil microbicidal
function. Usually one of the five genes (CYBA, CYBB,
NCF1, NCF2, or NCF4) that encodes a different part of the
enzyme Nicotinamide adenine dinucleotide phosphate
oxidase has a mutation. Mutations in these genes lead to
reduced levels of NAPDH oxidase and in severe case, no
enzyme is produced.
 NAPH oxidase is an essential enzyme that help
make toxic substances to kill bacteria and fungi that
invade the body before they can cause infection.
Neutrophils are particularly affected in this condition.
Normally, neutrophil stimulation leads to production
of reactive oxygen molecules, such as Hydrogen
Peroxide, by NADPH oxidase on its plasma membrane.
Neutrophil granules fuse with, and release their
contents into, the phagosome. Hydrogen peroxide is
then used by the granule enzyme myeloperoxidase to
generate the potent microbicidal agent hypochlorous
acid.
THANK YOU