THE BACTERIOLOGIC FINDINGS, STREPTOCOCCAL IMMUNE RESPONSE, AND RENAL COMPLICATIONS IN CHILDREN WITH IMPETIGO

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Abstract
Cultures of the skin, nares, and pharynx were examined in 303 children with impetigo. One hundred and seventy-two skin cultures were positive: 50 for beta hemolytic streptococci, 104 for coagulase-positive staphylococci, and 18 for both organisms. Beta hemolytic streptococci were present in nasopharyngeal cultures of 26 children, 18 of whom also had these organisms in the skin. Staphylococci were found in 114 cultures of the nares and in 58 children these bacteria were also present in the skin culture. Of the 68 strains of beta hemolytic streptococci cultured from the skin, 53 were group A, one was group C, and 14 could not be grouped. Only 4 of the group A strains were typable by the precipitin reaction. None of the strains were known nephrotoxic types. Twenty-one strains were typed by slide agglutination: 20 showed agglutination patterns considered to be characteristic of impetigo strains. Twenty-five of 68 children with streptococci in the skin lesion had an elevated ASO titer, In 76 children with negative skin cultures, there was serologic evidence of streptococcal infection. On the basis of combined bacterlologic and serologic findings, 144 children (48%) with impetigo had evidence of streptococcal infection. Ninety-nine of the 122 strains of staphylococci isolated from the skin and 86 of 114 strains cultured from the nose were phage-typed. Phage-type 71 was the most common typable strain from both sources. At the first visit, 6 children had acute glomerulonephritis and 8 had microscopic hematuria. An additional 14 patients showed transient hematuria on follow-up examination. Five of the 6 patients with glomerulonephritis and 15 of 22 with transient microhematuria had evidence of a streptococcal infection. Kidney biopsies were performed in 2 patient with microscopic hematuria: one was normal and the other showed minimal changes of questionable significance. The group of children with pure cultures of streptococci who received penicillin appeared to improve more rapidly than those who received only local treatment. On the other hand, in patients with mixed cultures of streptococci and staphylococci as well as those with pure cultures of staphylococci, there was no difference in response in those given penicillin as compared with those treated with ammoniated mercury. In 5 children, microhematuria was not prevented by the administration of penicillin 7 to 10 days before the appearance of the abnormal urinary findings. The strains of group A streptococci isolated from skin lesions showed several distinctive patterns by the slide agglutination technique similar to those observed by other workers. Also in accord with English investigators, one phage-type of staphylococcal predominated in the strains isolated from the skin lesions. Abnormal urinary findings are common in children with impetigo, but are usually not associated with infection with the known nephrotoxic types of group A streptococci.