THE SERUMANTISTREPTOLYSIN TITER IN CHRONICGLOMERULONEPHRITIS

BY DAVID P. EARLE, JR., EMILY N. LOEB, DAVID SEEGAL, JOHN D. LYTTLE,AND ELIZABETH L. JOST

(From the Research Serzice, First Division, Welfare Hospital, Department of Hospitals;Presbyterian Hospital; Babies Hospital; and the Departments of Medicine and Pediatrics,

College of Physicians and Surgeons, Columbia University, New York City)

(Received for publication March 6, 1942)

Previous reports (1, 2, 3) have dealt with theserum antistreptolysin titer response in acute glo-merulonephritis. Seegal, Lyttle and their asso-ciates (2) found that 94 per cent of 116 consecu-tive cases of acute glomerulonephritis were asso-ciated with significant rises in antistreptolysintiter. Longcope (3) found an increased anti-streptolysin titer in the acute stage of 72 per centof 36 cases of acute hemorrhagic nephritis (typeA). These studies show that the acute infections,which so typically precede the onset of acute glo-merulonephritis, are generally due to the group Ahemolytic streptococcus. Winkenwerder, McLeodand Baker (4), however, described another typeof glomerulonephritis (type B), characterized byan insidious onset of edema and a progressivedownhill course, and usually associated withchronic upper respiratory infection. Althoughgroup A hemolytic streptococci were often recov-ered from the upper respiratory passages of thesepatients (type B), Longcope (3) showed thatrises in antistreptolysin titer were a rarity. In-deed, the titers were frequently found to beabnormally low.

The present study is based on the examinationof the serum antistreptolysin titer response in pa-tients with chronic glomerulonephritis. The casematerial consists of 81 patients who have beenstudied at the Nephritis-Hypertension Clinic ofDr. Dana W. Atchley and Dr. Robert F. Loeb atthe Presbyterian Hospital, a similar clinic of Dr.John D. Lyttle at the Babies Hospital, and atthe Research Service of the First Division ofthe Welfare Hospital.

This study was undertaken with full knowledgeof the difficulty of establishing the diagnosis ofchronic glomerulonephritis. In this series of 81patients presenting the picture of chronic glomeru-lonephritis, 24 are known to have died. Autopsiesperformed on 13 of these revealed chronic glo-

merulonephritis. A biopsy of the kidney estab-lished the diagnosis in one additional case. In23 other cases, attacks typical either of acuteglomerulonephritis, i.e., the onset of the disease,or of an exacerbation of chronic glomerulonephri-tis, have been observed. Thus, the diagnosis ofglomerulonephritis seems to have been establishedbeyond doubt in 37 of the 81 cases. The remain-ing 44 patients were thoroughly studied and, inthe opinion of several experienced observers,there was no evidence of renal disease other thanchronic glomerulonephritis.

The patients comprising this study have beenobserved over periods of from 4 months to 8years. Twelve patients were followed for lessthan one year, the short follow-up being due toearly death in 10 instances. Fifty-two, or 64 percent, were followed for 2 or more years. Serafor the determination of the antistreptolysin titerwere obtained at varying intervals in each patient.In hospitalized cases, determinations were madeonce or twice a week. It was not possible toobtain tests with this frequency in the ambulatorypatients seen at the clinic. However, in the ma-jority of these instances, determinations weremade at intervals of from 1 to 4 months. Inaddition, the patients were instructed to report tothe clinic whenever an infection developed andwere then studied weekly.

Todd (5) developed the technique for the de-termination of serum antistreptolysin and withminor modifications (2) this technique has beenemployed throughout the present studies. Theantistreptolysin value is determined by the mini-mumamount of serum necessary to neutralize astandard amount of streptolysin. The value maybe recorded either as the amount of serum infractions of cubic centimeters necessary for theneutralization of the streptolysin, or as unitswhich are calculated as the reciprocal of the frac-

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D. P. EARLE, JR., E. N. LOEB, D. SEEGAL, J. D. LYTTLE, AND E. L. JOST

tion of cubic centimeters. The latter method wasused throughout this study. An increase in serumantistreptolysin value may be represented as themaximum value attained in the rise or as the risein titer over base-line determinations in individualpatients.

A significant increase in serum antistreptolysinhas been shown to indicate group A hemolyticstreptococcal infection, since a variefy of infec-tions and other diseases are not followed byincreases in the titer of this antibody (3, 5, 6).Mote and Jones (6), in a study of the antistrep-tolysin titer response of 811 "healthy" subjectsand 525 "sick" individuals, state that, ". . . in noinstance was the titer observed to increase in anindividual in whom infection by the hemolyticstreptococcus could be definitely excluded."

CRITERIA FOR RISE IN ANTISTREPTOLYSIN TITER

In order that a rise in serum antistreptolysintiter be considered significant, it was required that:

1. The increase in the titer reading be repre-sented by at least 2 decrements of 0.1 ml. ofstandard diluted serum over well-established base-line determinations for the individual patient.With the exception of 1 instance, each rise in thepresent study accepted as significant was basedon 3 or more such decrements.

2. The individual titer values of the rise oc-

Group A Hemo.streptpharynqetis

cur in a progressively increasing or decreasing(or both) curve. Thus, erratic fluctuations intiter (as shown in Figure 1) were not accepted assignificant.

In order to determine the true maximum valueof a rise in antistreptolysin titer, it was furtherrequired that at least one test be available within3 weeks of the onset of an infection; or, in a fewinstances, that the antistreptolysin titer curve bestill rising toward a maximum, if the first titer ofthe rise was determined on serum withdrawn morethan 3 weeks after the onset of an infection.

SUMMARYOF MATERIAL

There were 101 significant antistreptolysin titerrises occurring in 61 cases. Eighty-five of theserises form the basis of this study.'

1 In addition to the 16 rises in titer whose maxima werenot apparent, 36 other instances of variations in anti-streptolysin titer were discarded for the following rea-sons: (a) In two instances, clear cut end points in theantistreptolysin titrations could not be obtained. In bothcases, the sera were very lipemic. In one, the rise wasassociated with a group A hemolytic streptococcus tonsil-litis, while no infection was present in the other. (b)In 17 instances, the variations in antistreptolysin titerfluctuated without a definite trend being apparent. Sev-eral such fluctuations may be seen in Figure 1. Eight ofthese occurred in patients with edema. In 11 instances,there was no evidence of infection, while the remaining 6gave histories of frequent head colds. In no instances

7 Head colds26 throat culturesNeg9. for Hemo. strept.

Headcold A t NPN 88

'low.

20:l I | J Serum albumin- 1.9 I Renalfunciion falInq5 10 15 20 25 30 35 40 45 50 55 60 65

Time in MonthsFIG. 1. ANTISTREPTOLYSIN TITER CURVEOF PATIENT WITH CHRONIC GLOMERUILONEPHRITIS

SHOWINGLow TITERS ASSOCIATED WITH ONSET OF NEPHROTIC STAGE, ALTHOUGHGROUPAHEMOLYTIC STREPTOCOCCIWEREPRESENTIN THROATCULTURESDURING FIRST 6 MONTHSOFNEPHROTICSTAGE

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ANTISTREPTOLYSIN TITER IN CHRONIC NEPHRITIS

It should be noted that there were no variationsof antistreptolysin titer in 8 of the 81 patientswith chronic glomerulonephritis. These 8 patientswere followed over periods of from 8 to 102months, with an average of 35 months per patient.An average of 21 antistreptolysin determinationsper patient was made, with a range of 7 to 84.An analysis of these cases indicated no strikingdifferences in their clinical course as comparedwith that of the cases showing rises in titer.

The data presented in the foregoing sectionsare summarized in Table I.

TABLE I

Summary of antistreptlysin tiler data in 81 cases of chronicglmerulonephritis

101 definite rises in 61 cases.85 rises in 56 cases, with sufficient data to indicate the

maximum titer of the rise.16 rises with insufficient data to indicate the maximum

titer of the rise.36 questionable rises in 28 cases (includes some of the

cases above).8 cases with no variation of antistreptolysin titer in

period of study (8 to 102 months).

RELATION OF SEX AND AGE TO ANTISTREPTOLYSINTITER RESPONSE

Sex did not appear to modify the antistreptoly-sin titer response.- Of the 81 cases analyzed, 49were males and 32 females. Forty-eight of theadequately studied rises in antistreptolysin titeroccurred in male patients, 37 in female patients.Table II summarizes the sex incidence in relationto the maximum values of the antistreptolysintiter rises.

With respect to age, the rises in antistreptolysintiter were, in general, greater among the childrenthan among the adults. These data are sum-

TABLE II

Sex distribution of small, medium and large rises in anti-streptolysin titer in chronic glomeruonephritis

Maximum titer Number in Number inof rise 35 male patients 21 female patients

125 units or less (small) ........ 24 16144 units to 250 (medium)..... 14 15333 units or more (large) ....... 10 6

were the throat cultures positive for hemolytic strepto-cocci. (c) In 17 instances, the rise in titer was indicatedby a single determination. In 12 of these, there were gapsof 2 or more months between the titer showing the riseand the nearest base-line determinations.

TABLE III

Age distriuton of small, medium and large rises in anti-streptolysin titer in chronic glomerulonephritis

Number of Number of Number ofMaximum titer riw in rises in rises in

of ris S rpa8tisents8 risens, 48 patients,nse 1~~to 9 years 10 to 19 years 20 or moreof age of age years of age

125 units or less ...... 17 23144 units to 250 ...... 7 7 15333 units or more.. 4 9 3

Total rises ... 11 33 41

marized in Table III. It is possible that theseverity of the hemolytic streptococcal infectionsmay have played a role in this difference, but thenumber of children in this series was not largeenough to determine this point.

RELATION OF INFECTION TO ANTISTREPTOLYSIN

TITER RESPONSE

A culture was taken of each patient's throat atevery visit to the clinic. Routine throat cultureswere taken of hospitalized patients twice a week.Cultures were taken daily or every other day inhospitalized patients if there was any suspicion ofinfection. In addition, the patient was questionedin regard to the symptoms indicative of infection,and examinations of the nose, pharynx and cervi-cal lymph nodes were made at each clinic visit, andat appropriate intervals in hospitalized cases. Thethroat cultures were classified as positive or nega-tive for group A hemolytic streptococci. Infec-tions, if present, were classified as chronic oracute. The acute infections were further sub-divided into "deep" or "superficial" groups, fol-lowing the scheme previously reported (1). Deepinfections included mastoditis, peritonsillar or cer-vical abscess, moderate or severe cervical lympha-denitis, otitis media and sinusitis. Superficial in-fections included pharyngitis (usually with mildcervical adenitis) and the "common cold."

Fifteen of the 85 adequately studied rises inantistreptolysin titer were associated with deep,67 with superficial, and 3 with no observed infec-tions.- Twenty per cent of the rises in titer fol-lowing deep infections attained a maximum of333 units or more (large rises), 33 per centreached from 144 to 250 units (medium rises),and 47 per cent reached a maximum of 125 unitsor less (small rises). The superficial infections

485

D. P. EARLE, JR., E. N. LOEB, D. SEEGAL, J. D. LYTTLE, AND E. L. JOST

showed an almost identical distribution, namely19, 33 and 48 per cent, followed respectively bylarge, medium and small rises in antistreptolysintiter. In summary, the magnitude of the anti-streptolysin titer response among these patientswith chronic glomerulonephritis was unrelated tothe deep or superficial character of hemolyticstreptococcal infection.

The percentage of rises in antistreptolysin titerassociated with the presence of group A hemolyticstreptococci and the presence or absence of infec-tion are summarized in Table IV. Since a rise

TABLE IV

Percentage of small, medium and large antistreptolysin titerrises associated with cultures showing Group A hemolytic

streptococci and with infections in patients withchronic glomerulonephritis

Rises with Rises with infectionMaximum titer Num- Group A* -___- __

Of rise ber of hemolytic Nnrises streptococci Acute Chronic oebin cultures chronc eohper cent percent percent percent

125 units or less ... 40 42 78 20 2144 units to 250 ... 29 52 79 14 7333 units or more.. 16 75 100 0 0

All rises. 85 52

in antistreptolysin titer is confined to infectionscaused by hemolytic streptococci, usually GroupA, it is apparent that this test was of definitevalue in determining the etiology of many infec-tions occurring in patients with chronic glomerulo-nephritis.

These data indicate that rises. in antistreptolysintiter that attain a maximum of 333 units or more

are associated with a higher incidence of culturesshowing group A hemolytic streptococci than are

the smaller rises. Likewise, the greater rises are

all associated with acute infection, while 22 percent of the small rises and 21 per cent of themedium rises are associated either with chronicinfection or with no observed infection.

GROUPA HEMOLYTIC STREPTOCOCCALINFECTION

WITOUT RISE IN ANTISTREPTOLYSIN TITER

In this series of 81 patients with chronic glo-merulonephritis, there were 5 acute infections (1,otitis media;. 1, bronchitis; and 3, pharyngitis)apparently due to group A hemolytic streptococci,

wherein adequate antistreptolysin titer studies re-vealed no subsequent rise in titer. Three ofthese occurred in patients with edema, 2 in pa-tients without edema. All but one of these infec-tions occurred in patients who exhibited rises intiter at other times. Two of these infections oc-curred at a time when the titer was decliningfrom a previous rise.

Several other acute group A hemolytic strep-tococcal infections were observed in which ade-quate antistreptolysin titer data were not obtained.On this account, these infections could not beincluded in the analysis of the antibody response.

GROUPA HEMOLYTIC STREPTOCOCCUS"CARRIER

STATE"

There were 26 instances of the "carrier state"occurring in 20 patients. The "carrier state" inthis study refers, arbitrarily, to instances in whichgroup A hemolytic streptococci were recoveredfrom the throats of individuals without evidenceof acute upper respiratory infection and withoutsignificant rise in antistreptolysin titer. Occa-sionally only 1 or 2 isolated throat cultures werepositive for hemolytic streptococci, but usuallyrepeated cultures over periods of several weeks toas long as 6 months were positive. These "car-rier states" were frequently but not invariablyassociated with chronic sinusitis and post-nasaldischarge. It is recognized that these "carrierstates" may represent actual hemolytic streptococ-cal infection. However, this seems unlikely inthe majority of instances inasmuch as 18 of these20 patients had responded to hemolytic strepto-coccal infections at other times with definite risesin antistreptolysin titer.

EFFECT OF NEPHROTICPHASEON ANTISTREP-

TOLYSIN TITER RESPONSE

Edema associated with low serum albumin andhigh serum cholesterol concentrations was consid-ered to indicate the nephrotic phase of chronicglomerulonephritis. There were marked varia-tions in the degree of edema and in the levels ofserum albumin and cholesterol among the differentcases, as well as in particular individuals. Theproblem was further confused by the occurrence,in some cases, of edema due to circulatory failure.In a few instances there was a possibility that

486

ANTISTREPTOLYSIN TITER

the edema and hypoproteinemia were due to mal-nutrition. However, the status of each patient atthe time of a significant rise in antistreptolysintiter was evaluated and classified, to the best ofour ability, as being either non-nephrotic or ne-phrotic. Whenthis was done, it became apparentthat the antistreptolysin titer responses to hemoly-tic streptococcal infections were significantlygreater among the patients without edema thanamong those with edema. This is illustrated byFigure 2.

In addition, it should be noted that 18 of 26group A hemolytic streptococcal carrier states oc-

IN CHRONIC NEPHRITIS 487

curred in patients with the nephrotic element.Three of the 5 proven group A hemolytic strep-tococcal infections, not followed by a rise in titer,were also in the nephrotic group.

Although, as was previously indicated, therewas a higher incidence of the greater rises inantistreptolysin titer among the younger patientsthan among the older groups, the height of therise depended on the presence or absence of edema,as well as on the age distribution. This is illus-trated in Table V.

Many patients with chronic glomerulonephritishave been observed during periods of transition

35 Rises in Patients vwith the Nephrotic Stage

Maximuntiter of Irise in U

0

*

000 - -00 0 0000

0 00 0 00 000

0

0 0 0

ASL 5S0-4Z-11-8OO--12s-I6-2OO 33O O 7H1250-166inrts

50 Rises in Patients without the Nephrotic Stage0 0

0

00 0

0 0 0

0 00 0 0

0 00 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0

0

Maximumliter of ASISSSL 62_1IFi2S 333 ZC333100Q1 1112O -rise in units

FIG. 2. DISTRIBUTION OF MAXIMA OF ANTISTREPTOLYSIN TITER RISES INPATIENTS WITH CHRONIC GLOMEULONEPHRITIS, WITH AND WITHOUTEDEMA

TABLE VAge distribution of small, medium and large rises in antistreptolysin titer occurring among patients

wsth chronic glomerulonephritis and edema

Patients 9 years of age Patients 10 to 19 Patients 20 and moreand under years of age years of age

Maximum titer of risewNumber of rimes Number of rise Number oS rises Number of rises Number of rises Number of rises

in cases in case icases incases incases in caseswith edema without edema with edema without edema with edema without edema

125 units or less.0 0 12 5 13 10144 units to 250.2 5 1 6 5 10333 units or more.1 3 1 8 0 3

n

D. P. EARLE, JR., E. N. LOEB, D. SEEGAL, J. D. LYTTLE, AND E. L. JOST

from the dry to the edematous phase of the dis-ease, or vice versa. In 9 of these instancesstudied, significant changes in the base line levelof the antistreptolysin titer were noted, the titerbeing higher in the non-edematous than in theedematous phase. Figure 1 is an illustration ofthis point. However, in other instances, similarchanges in base line titers were not associatedwith changes from the nephrotic to non-nephroticphase of chronic glomerulonephritis, or vice versa.

DISCUSSION

A rise in serum antistreptolysin titer was foundto be of definite value in detecting group A hemo-lytic streptococcal infections, in the presence ofnegative throat cultures, among patients withchronic glomerulonephritis, as well as being ofconfirmatory value when the cultures were posi-tive. This test was not infallible, since therewere 5 acute infections associated with positivecultures for group A hemolytic streptococci whichwere not associated with rises in titer.

Males outnumbered females in this series. Sexdid not significantly modify the antistreptolysintiter response. No previous study on antistrep-tolysin titer in various diseases has noted anypositive effect of sex on the test.

With respect to age, the younger patients had,in general, greater rises in antistreptolysin titerfollowing infection than did the older patients.Lyttle and his colleagues (2) reported a similarcorrelation in their study of the serum antistrep-tolysin titer in acute glomerulonephritis. Lippardand Johnson (7), however, found that rises inantistreptolysin titer following hemolytic strepto-coccal infections among children more than 17months of age were comparable to those observedin adults. Infants under 17 months of age, incontrast, showed little tendency to exhibit risesin antistreptolysin titer. In cases of chorea,Bunim and McEwen (8) found "no strict cor-relation between the age of the patient, the severityof the chorea, and the height of the antistrep-tolysin titer." Mote and Jones (6) found thatthe incidence of rises in antistreptolysin titer wasgreater in younger "healthy" control subjects thanin the older age groups, presumably because of "ahigher incidence of very mild or subclinical respira-tory infections in children." In their rheumatic

patients, age had no effect on the incidence ofantistreptolysin titer response. They also statedthat age had no effect on the magnitude of theresponse in these patients.

In the present series of 81 patients with chronicglomerulonephritis, it was found that the greaterthe magnitude of the rise in antistreptolysin titer,the greater was the frequency of positive culturesfor group A hemolytic streptococci. It was alsonoted that the incidence of preceding acute infec-tion was higher in the group showing larger risesin titer, than among those exhibiting the mediumand small rises. However, whether the type ofinfection was "deep" or "superficial" apparentlymade no difference in the titer response.

Data have been presented (Figure 2) that indi-cate a smaller though definite response in anti-streptolysin titer among patients with the nephro-tic stage of chronic glomerulonephritis than amongpatients without edema. Previously Longcope(3) had noted that among his 19 cases of "typeB" glomerulonephritis, characterized by nephroticedema, the antistreptolysin titer was rarely abovenormal and was sometimes persistently very low.A severe hemolytic streptococcal tonsillitis in oneof Longcope's nephrotic patients was followed bya rise in anitistreptolysin titer that reached a maxi-mumof only 100 units. As Longcope pointedout, the explanation for the low titers and smallantistreptolysin response to hemolytic streptococ-cal infection in these patients is not clear.

In this connection, a recent study (9) hasshown that the antistreptolysin titer of childrenwith nephrosis is extremely low, usually less than10 units, and that when the patient recovers thetiter rises to the generally accepted normal range.Furthermore, when these individuals contractgroup A hemolytic streptococcal infections duringthe active phase of the nephrosis, in spite of verylow base line titers, large rises in antistreptolysintiter ensue in many instances.

SUMMARYANDCONCLUSIONS

1. The serum antistreptolysin titer responsewas analysed in 81 cases of chronic glomerulo-nephritis, studied over periods of from 4 monthsto 8 years.

2. Rises in serum antistreptolysin titer occur-ring in patients with chronic glomerulonephritis

488

ANTISTREPTOLYSIN TITER IN CHRONIC NEPHRITIS

were of value in detecting the hemolytic strepto-coccal etiology of many infections in which group

A hemolytic streptococci could not be isolatedfrom the pharynx.

3. A number of instances of chronic upper

respiratory infection were observed in which re-

peated cultures showed the presence of group Ahemolytic streptococci. These instances unasso-

ciated with rises in antistreptolysin titer were

designated as the "carrier state."4. Certain factors affecting the antistreptolysin

titer response in chronic glomerulonephritis were

examined with the following results:

a. Sex had no effect.b. In general, children exhibited greater titer

response to infection than did adults.c. The character of the preceding hemolytic

streptococcal infection ("deep" or "super-ficial") did not appear to affect the magni-tude of the antistreptolysin titer response.

d. In general, patients with "nephrotic" edemaexhibited smaller rises in titer than did thosewithout edema.

5. The relation of the serum antistreptolysintiter response to the exacerbation in chronic glo-merulonephritis is discussed in the accompanyingpaper (10).

The authors are indebted to Miss Grace Davis and Mr.Walter Meyer for their technical assistance.

BIBLIOGRAPHY

1. Seegal, D., and Lyttle, J. D., Antistreptolysin titerof the serum in acute glomerulonephritis. Proc.Soc. Exper. Biol. and Med., 1933, 31, 211.

2. Lyttle, J. D., Seegal, D., Loeb, E. N., and Jost, E. L.,

The serum antistreptolysin titer in acute glomerulo-nephritis. J. Gin. Invest., 1938, 17, 631.

3. Longcope, W. T., Studies of the variations in theantistreptolysin titer of blood serum from patientswith hemorrhagic nephritis. II. Observations on

patients suffering from streptococcal infections,rheumatic fever, and acute and chronic hemorrhagicnephritis. J. Gin. Invest., 1936, 15, 277.

4. Winkenwerder, W. L., McLeod, N., and Baker, M.,Infection and hemorrhagic nephritis. Arch. Int.Med., 1935, 56, 297.

5. Todd, E. W., Antihaemolysin titres in haemolyticstreptococcal infections and their significance inrheumatic fever. Brit. J. Exper. Path., 1932, 13,248.

6. Mote, J. R., and Jones, T. D., Studies of hemolyticstreptococcal antibodies in control groups, rheu-matic fever, and rheumatoid arthritis. I. The in-cidence of antistreptolysin "O," antifibrinolysin, andhemolytic streptococcal precipitating antibodies inthe sera of urban control groups. II. The fre-quency of antistreptolysin "O," antifibrinolysin, andprecipitating-antibody responses in scarlet fever,hemolytic streptococcal infections, and rheumaticfever. III. The magnitude of antistreptolysin "O,"antifibrinolysin, and precipitating-antibody re-sponses; the persistence of the antibodies, andvariations in antistreptolysin "O" curves in scarletfever, hemolytic streptococcal infections, and rheu-matic fever. J. Immunol., 1941, 41, 35.

7. Lippard, V. W., and Johnson, P., Beta hemolyticstreptococcic infection in infancy and in childhood.I. Antifibrinolysin and antistreptolysin response.Am. J. Dis. Child., 1935, 49, 1411.

8. Bunim, J. J., and McEwen, C., The antistreptolysintiter in rheumatic fever, arthritis and other dis-eases. J. Clin. Invest., 1940, 19, 75.

9. Lyttle, J. D., Seegal, D., Loeb, E. N., and Jost, E. L.,The antistreptolysin titer in nephrosis. Unpub-lished observations.

10. Earle, D. P., Jr., Seegal, D., Lyttle, J. D., Loeb, E. N.,and Jost, E. L., The relation of the serum anti-streptolysin titer to the exacerbation in chronicglomerulonephritis. J. Clin. Invest., 1942, 21, 491.

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