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"Actual Infectology" 1 (6) 2015

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Clinical - immunological characteristics of acute tonsillopharyngitis in children

Authors: Koloskova E.K, Ivanova L.A., Belashova O.V., Marusyk U.I. - Bukovinian State Medical University, Chernivtsi, Ukraine

Categories: Infectious diseases

Sections: Specialist manual

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Introduction. "Gold standard" diagnostic β-hemolytic streptococcus remains bacteriological smear - print from the mucous membrane of the tonsils and the posterior pharyngeal wall, but the deadline for the study is from 5 to 7 days. Today part of medical practice rapid tests to determine the pyogenic streptococcal antigens. According to current literature reports the sensitivity of these test systems is 96.8%, specificity - 94.7%. In Ukraine, these test systems have not already registered, and therefore remains an open question of finding additional clinical - paraclinical criteria for early differential diagnosis of streptococcal and non- streptococcal etiology, the solution of which should help to optimize the start of treatment of this disease in children. The purpose of the work. Assess the diagnostic value of clinical and immunological parameters in acute streptococcal verification streptococcal in children to optimize the starting etiotropic treatment. Materials and methods. To achieve this goal formed two clinical groups. The first (I, basic) group consisted of 10 children with a diagnosis of "acute streptococcal tonsillоpharyngitis." The second (II) clinical group included 16 patients with acute tonsillоpharyngitis (ATP) non- streptococcal etiology, as evidenced by the negative results streptatest and bacterial smears with mucous tonsils and posterior pharyngeal wall. The average age of patients of the main group was 5,6 ± 1,2 years, a comparison group - 6,3 ± 0,9 years (p> 0.05). All children underwent immunological study of blood II - III levels. The content of T lymphocytes (CD3), a T-helper (CD4), T-NK / blood suppressor (CD8) and B cells (CD22) was measured by immunofluorescence using monoclonal antibodies sets. The obtained results of the study were analyzed by the methods of Clinical epidemiology and biostatistics. To establish the diagnostic value of the test determines the sensitivity (Se), specificity (Sp), positive predictive (PV+) and negative value (PV-). From the standpoint of clinical epidemiology evaluated attributive and relative risks and odds ratio with the calculation of confidence intervals (95% CI). The results of the study. The total amount of points on the scale McIsaac exceeding 4 points recorded a third of patients (33,0 ± 4,2%) I group and only 4,0 ± 3,8% of the comparison group of patients (Pφ <0.05). Indicators of the diagnostic value of the use of the total score of McIsaac more than 4 points, for verification of streptococcal etiology ATP were as follows: Se - 33%, Sp - 96%, positive and negative perceived value – 89,2% and 59%, respectively, relative risk – 11,8 [95% CI: 3,9-34,9] attributable risk – 0,48, odds ratio – 2,1 [95% CI: 0,7-5,8]. It is shown that an increased content of CD3-lymphocytes in the peripheral blood (over 30,0%) was determined in 88,8% of children with acute streptococcal tonzillofaringit and only 60,0% of representatives of group II (Pφ> 0.05). Indicators of the diagnostic value of high content of T-lymphocytes in the peripheral blood of confirmation of streptococcal nature ATP were as follows: Se – 88,8%, Sp – 40,0%, PV+ - 59,4% and PV- - 77%. Promoted to the above-mentioned contents of the CD 3 lymphocytes in the peripheral blood were associated with the risk of having an acute streptococcal etiology of tonsillоpharyngitis follows: AR – 0,9 RR – 2,7 [95% CI 2,3-3,2] - odds ratio – 5,3 [95% CI 2,5-11,1]. Indicators of the relative content of CD8 - lymphocytes in the peripheral blood is higher than 10%, was recorded in 88,8% of children first clinical group and only 65,0% of patients with non- streptococcal ATP (Pφ> 0,05). Increased to above the level of the content of CD-8 cells were associated with the risk of having streptococcal ATP follows: attributable risk – 0,3, the relative risk – 2,4 [95% CI 2,0-2,8], at a ratio of 4 chances, 3 [95% CI 2,0-8,9]. Contents of CD 4 less than 20,0% was determined in 55,5 ± 16,5% of patients with streptococcal ATP and only 20,0 ± 8,9% of cases in the II clinical group (Pφ>0.05). In children with acute streptococcal tonsillоpharyngitis observed significantly lower contents of the CD 22 lymphocytes in contrast to the patients of the comparison group. Reduced to the above levels of CD-22 was associated with the risk of having streptococcal etiology of this disease: attributable risk – 0,4, the relative risk – 2,1 [95% CI 1,1-4,0], with odds ratios of 7,2 [95% CI 3,4-15,4]. The decrease in the relative content of B-lymphocytes in peripheral blood <18% as a test to confirm a streptococcal etiology ATP, characterized by the following indicators of diagnostic value: sensitivity - 44.4%, specificity - 90.0%, PV+ - 81.4%, PV- - 61.6%. Conclusions. 1. The total score of clinical evaluation by a modified scale McIsaac more than 4 may be used in combination with the differential-diagnostic search in favor of ATP streptococcal etiology (specificity - 96%, positive predictive value – 89,2%). 2. Given the lack of sensitivity of clinical performance and low specificity indices cell immunity in children, their own use inadvisable to confirm the etiology of acute streptococcal ATP. 3. Enough sensitivity indices (80%) and specificity (81,3%) allow the use of integrated clinical and immunological parameters consisting of the contents of CD8 - lymphocytes more than 10% in the blood with a total estimate of the clinical condition on a scale McIsaac ≥ 4 points for confirmation of streptococcal nature ATP in children. 4. In assessing the clinical status of children with acute ATP scale McIsaac ≥ 4 points and simultaneous determination of CD-3 peripheral blood lymphocytes > 30% risk of having streptococcal etiology ATP increases 10-fold (odds ratio – 10,5 [95 % CI: 5,1-21,4]). With the simultaneous definition in children with ATP such as integrated clinical and immunological test as assessment of the modified scale Mc Isaac ≥ 4 points and the content of CD22 - lymphocytes <18% in the peripheral blood of the risk of having streptococcal nature of the disease is increased by more than 10 times (the ratio chance – 10,4 [95% CI: 4,2-25,3]).

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