The nasty secondary diseases of streptococci

Parents can tell you a thing or two about it: Almost every child is affected by a streptococcal infection in the course of their life. Sometimes there are no clear symptoms and so the infection is carried over. Then it can happen that the weapons the body uses to defend itself against the infection change in such a way that they attack the body's own structures and trigger serious secondary diseases. We present them here:

Streptococcal secondary diseases: PANDAS

From one day to the next, Leyla Meyer suffered from a pathological compulsion to wash. Soaping her hands. Wash them off. Soap again. Wash again. Again and again. She couldn't stop, saw dirt everywhere, asked her parents to clean, make the bed, scrub the floor. They feared an obsessive-compulsive disorder. The thought that their eight-year-old daughter could have psychological problems at such a young age brought the couple close to despair.
Then the paediatrician treating the girl took a blood sample and found a high streptococcus titer. Extremely high. She prescribed an antibiotic and the astonished parents were able to watch as the girl got a little better every day; the obsessive behaviour disappeared more and more.

The diagnosis was PANDAS. This abbreviation stands for Pediatric Autoimmune Neuropsychatric Disorders Associated with Streptococcal Infections. Translated, this means that a streptococcal infection can trigger neuropsychiatric symptoms in children. «This connection is widely recognised,» confirms Christa Relly, senior physician in the Department of Infectious Diseases and Hospital Hygiene at Zurich Children's Hospital. Nevertheless, there are question marks regarding the exact mechanism. And: there are only a few cases. «Many paediatricians have never had to deal with this in their entire career,» admits Relly. Using an American study as a basis, she comes to the conclusion «that there should be roughly five to ten cases in Switzerland».

The tics and obsessive-compulsive disorders suddenly get better. It's like flicking a switch.

«Admittedly, you don't necessarily love this diagnosis,» says Peter Weber, Head of the Department of Neuro- and Developmental Paediatrics at the Children's Hospital Basel. «Because there are no clear findings from the laboratory, imaging or an EEG.» Such findings are often not available in neurology and this makes it difficult to differentiate between the two.

The symptoms of PANDAS are tics or obsessive-compulsive disorders, «which either already existed and intensify massively in the context of an infection - or appear for the first time,» explains Relly. Classically, there is a very sudden worsening of symptoms. The doctor confirms what the Meyers observed in their daughter: The neurological abnormalities improve abruptly or even disappear when antibiotics come into play. «It's like flipping a switch.» This also suggests that there is a connection with an infection. Tic and obsessive-compulsive disorders without an infection tend to follow a wave-like course.

However, the senior physician warns against scaremongering and pleads for a careful diagnosis. «Not every abnormal behaviour during a streptococcal infection is PANDAS.» Children of school age are typically affected, but there can also be cases in infants.
Experts who have dedicated themselves to PANDAS research suspect that the disease can take a chronic course if left untreated. Some tics and compulsions in adults could therefore be due to untreated PANDAS in childhood and adolescence.

Christa Relly recommends that parents of affected children discuss the condition with their paediatrician and consult a psychiatrist at the same time. She strongly advises against «experimental and expensive therapeutic approaches».

At the Children's Hospital in Basel, doctors treat PANDAS with immunoglobulins in combination with antibiotics. The doctors in Basel have also used cortisone to block the immune system or at least slow down its hyperfunction, which leads to the same psychiatric symptoms. Weber also argues in favour of psychiatric support - possibly also for the parents.

Rheumatic fever

Rheumatic fever can break out up to five weeks after a - possibly undetected - infection with the so-called A streptococci. In Western Europe, it only occurs rarely: «In six to ten-year-olds in less than two per cent of cases with untreated infections,» says Andreas Wörner, Head of Paediatric Rheumatology at the Children's Hospital in Basel.

In children suffering from rheumatic fever, the immune system attacks the body's own cells. This leads to inflammation of the joints and heart. The latter can lead to heart failure.

If children are suddenly unable to control their movements properly and their handwriting deteriorates, this may be an indication of this disease. If the joints are affected, children can often hardly move in the morning after waking up. «If rheumatic fever is recognised in time, the prognosis is very good,» says Wörner.

Once again, antibiotics are used to eradicate the streptococcus strain. The secondary diseases themselves «cannot be influenced with antibiotics, as it is an immune reaction and no longer the infection», explains Christa Relly. Affected children are usually given anti-inflammatory medication to treat the fever and pain in the joints. «If the heart is affected, medication to improve heart function may also be added,» says Relly.

Streptococci are not underestimated, say the experts. And they don't always make you ill.

Kidney inflammation

Dark or foamy urine, swollen eyelids and water retention in the hands and feet can indicate kidney inflammation caused by streptococci. «Affected children often have headaches because their blood pressure rises due to insufficient water excretion and they feel really ill,» says Wörner.

The expert is reassuring: «In more than 90 per cent of cases, such kidney inflammation heals without any consequences after treatment is started; there are very few chronic cases.» Christa Relly explains that kidney inflammation often does not require treatment, «as the child usually recovers spontaneously». It may need medication to lower blood pressure.

Streptococci: an underestimated danger?

Obsessive-compulsive disorder and heart failure as a result of supposedly harmless childhood illnesses: Are streptococci underestimated? «No», says Zurich doctor Christa Relly. According to her, infections caused by streptococci are among the «most common bacterial infections diagnosed and treated by paediatricians».
It is assumed that a streptococcal infection is responsible for around one in three schoolchildren who present to the paediatrician with a sore throat. In the vast majority of cases, these infections are harmless - «and even heal without antibiotic therapy».
They are not always noticed. According to Relly, children between the ages of 5 and 15 are typically affected. Toddlers are less frequently affected «and adults can also become infected, but not as often,» says Relly.

The doctor reassures: «Overly cautious observation of a child after a streptococcal infection - whether treated or not - is not advisable.» In the event of unclear symptoms such as prolonged fever, joint pain or swelling, parents should consult a doctor with their child anyway, regardless of any previous illness.

Other streptococcus species

In addition to group A streptococci, which can cause the above-mentioned diseases, there are other subgroups.
The streptococcus family also includes pneumococci, for example. They can cause severe meningitis and pneumonia, but can also be kept in check - because there is a vaccination against pneumococci, which is recommended by the Federal Commission for Vaccination and the Federal Office of Public Health.
Certain types of streptococci can be dangerous for newborn babies if their mother carries these bacteria in her vaginal flora. Pregnant women are advised to be tested shortly before giving birth. In 10 to 25 per cent of women, the test is positive and the mother is given an antibiotic in the hours before the birth. «This significantly reduces the risk of severe blood poisoning,» explains Andreas Wörner.
Streptococci are also often part of the mucosal flora in the mouth - and are involved in the development of tooth decay.
Incidentally, streptococci do not necessarily cause diseases. «We live with them, they are found in water, in soil, in dairy products and we carry them in our throat and intestines without becoming ill,» says Wörner.