STUDIES ONTHE IMMUNERESPONSEOF THE RHEUMATICSUB-JECT ANDITS RELATIONSHIP TO ACTIVITY OF THE RHEU-

MATIC PROCESS. VI. THE SIGNIFICANCE OF THE RISEOFANTISTREPTOLYSINLEVEL IN THEDEVELOPMENT

OF RHEUMATICACTIVITY 1

By ALVIN F. COBURNAND RUTHH. PAULI

(From the Department of Medicine, College of Physicians and Surgeons, Columbia University,and the Presbyterian Hospital, New York City)

(Received for publication June 3, 1935)

The authors have observed that respiratoryinfection with a strain of hemolytic streptococcusproducing strong toxin is not invariably followedby rheumatic recrudescence 2 in a susceptible sub-ject. This observation has been made under sev-eral different circumstances. (a) Two rheumaticchildren escaped rheumatic activity in spite ofinfection with a strain of hemolytic streptococcusthat produced severe recrudescences in fourteenothers living in the same home (1). (b) In-fections with a scarlatinal strain of hemolyticstreptococcus, occurring simultaneously in tworheumatic siblings were followed by rheumaticattacks, one of which was severe and prolonged,the other extremely mild (2). (c) Scarlet feverin one rheumatic subject under close observationwas followed by only mild carditis. (d) Severalof the strains described in the fourth paper ofthis series (2) produced strong toxin and strepto-lysin but were not effective in initiating recrudes-cences. The one characteristic common to all ofthese individuals who escaped attacks was the fail-ure to develop a significant rise in antistreptolysintiter. The present paper deals with the significanceof changes in antistreptolysin level in the rheu-matic subject.

The natural antistreptolysin level and the averagerange in good hea-lth

It has already been shown (3) that the naturalantistreptolysin level in subjects who have beenfree of hemolytic streptococcus infection is ap-

1 The work reported in this communication was carriedout under The W. K. Kellogg Foundation.

2 The term " recrudescence " is applied to the develop-ment of an acute attack in a known rheumatic subject,following a period of quiescence. It is not to be confusedwith an exacerbation of symptoms, such as may occur latein a polycyclic rheumatic attack.

proximately 50 units. The range of titers tobe expected in apparently healthy persons livingin New York City was determined in a study of146 individuals of various ages. They are re-ported in five groups as specified in Table I.

TABLE I

The frequency of high and low antistreptolysin titersamong several groups of subjects living in

New York City

Number of cases with titer of

GroupBewn1oo units Beteend 200 unitsor less 200 units or more

Mothers ................. 29 7 1Babies .................. 25 10 2

Medical students ......... 8 1 1

Nurses-probationers(1931) ................ 14 5 3

Nurses-probationers(1932)................. 34 6 0

Total ................... 110 29 7

Per cent ................. 75 20 5

These data are summarized in Table III where itis seen that the median titer for 176 individuals ingood health was 83 units. This is significantlyhigher than the natural level of 50 units.

These findings serve as an index of what maybe expected in New York City in the populationas a whole. The results show that 75 per centhad antistreptolysin titers of 100 units or less, 5per cent had titers of 200 units or more, 20 percent were intermediate. The median 3 of the 146

8To facilitate comparisons between groups, medianshave been used throughout rather than averages, as it isnot mathematically permissible to average quantities ofsuch different magnitudes as the titers in question.

769

ALVIN F. COBURNAND RUTH H. PAULI

determinations was 71 units, slightly higher thanthe natural level of 50 units. This indicates thedifference between the range of titers to be ex-pected during " good health " or following otherinfections and the natural antistreptolysin levelof individuals who have been free of hemolyticstreptococcus disease for a long period of time.

The range of antistreptolysin titers followinghemolytic streptococcus infection

The authors are in entire agreement with Todd(4) that the presence of an antistreptolysin titerof 200 units or more is strong evidence of recentinfection with hemolytic streptococcus. However,in interpreting the significance of titers below 200units it is important to know the frequency ofsuch levels in persons convalescing from these in-fections. For this purpose, determinations weremade on sera obtained from a number of suitablepatients. The readings were of two kinds, singledeterminations made four weeks after recoveryfrom infection, and determinations made seriallyfor six months following infection.

Single observations in a group of 26 casesshowed that 10 per cent (following scarlet fever),16 per cent (following mastoiditis) and 50 percent (following pharyngitis) had titers below 200units. In 24 patients with hemolytic strepto-coccus pharyngitis whose titers were determinedrepeatedly, 55 per cent developed maximum levelsof less than 200 units. Most of these low titersfollowed infections contracted during the fall andwinter months.4 There was wide variation inthe type of titer curve developed. Some indi-viduals (Type A) showed a progressive increasein antistreptolysin level, which reached a peak infive to twenty weeks. Other individuals (TypeB) had a sharp initial rise, which was maintainedfor only a few weeks. Nearly all of the patientsdeveloped a secondary rise of titer some monthsafter the primary maximum. Illustrative curvesof both types are presented in Figure 1. The

4 This seasonal variation is mentioned because the au-thors have also noted a similar fluctuation in productionof toxin and in the frequency with which these infectionsare followed by a rheumatic attack. In New York Citythe activity of hemolytic streptococcus appears to be ata minimum in the early autumn, and to increase pro-gressively throughout the winter and spring months.

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FIG. 1. THE DEVELOPMENT OF ANTISTREPTOLYSINTITERS IN YOUNGADULT, NON-RHEUMATIC SUBJECTSFOLLOWING THROAT INFECTIONS WITH HEMOLYTICSTREcTOOCCUS.

data for all the single and serial determinations are

presented later, along with the observations on

rheumatic patients in Table VII.

Antistreptolysin titers during the attack of acuterheumatism

Working in conjunction with Dr. E. W. Todd,the authors reported finding high antistreptolysintiters in the sera of patients with acute rheuma-tism (5). Similar studies published by Myersand Keefer (6) of Boston have substantiatedthese findings in part, but have raised certainquestions which it seems advisable to discuss atthis point, before presenting any more data.Myers and Keefer agree that the antistreptolysintiter in acute rheumatism is elevated to a levelequal to that following proven streptococcal in-fections; but they question any significance beingattached to readings of 200 or 250 units, since 200was the " average " level of their normal controlgroup. The choice of a few hospital assistantsfor their "normal control group," may well ac-

count for these high readings. The failure ofWilson et al. (7) to detect the significance of theantistreptolysin titer in children with rheumaticfever may result from their use of averages, ap-

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770

ANTISTREPTOLYSIN LEVEL

plied at a critical point in their argument to onlyten cases. Since titer readings increase geomet-rically, arithmetic averages are meaningless.

Antistreptolysin determinations have beenmade in this laboratory on all of the authors'patients with frank attacks of rheumatic fever,those with chorea being excluded. Altogether,the sera of 175 patients were examined in 1933,1934 and 1935. Single readings were made onthe first group of patients; weekly titrations weremade in 1934 and 1935. The results were as fol-lows: In 1933, the median was 250 units, the (ge-ometric) mean 224; in 1934, the median was 500units, the mean 430 units; in 1935, the medianwas 500 units, the mean 562. These data arepresented in Table VII.

The occurrence of these high titers in acuterheumatism did not appear to depend on the ageof the individual. The authors' patients rangedfrom 18 months to 50 years of age.5 The per-centage distribution of titer levels in relation toage is shown in Table II.

TABLE II

Percentage distribution of antistreptolysin titers in rela-tion to age, itn 271 patients wtith acute rheumatism

1930-1935

Range of antistreptolysin titers

Age Number Mediangroups of cases 50 100 200 500 1000 titers

to to to to to 250083 167 333 833 1667

years0 to 2 5 20 60 20 5003 to 7 22 35 30 30 5 5008 to 13 115 1 4 48 24 19 4 333

14 to 21 72 1 10 48 30 10 1 33322 to 30 29 21 59 10 10 25031 to 50 28 30 50 17 3 250

It is seen in Table II that the titer distributionswere approximately the same at all ages. Therewas a slight tendency towards higher levels in theyounger age groups and a similar tendency to-wards lower levels in adults with acute rheuma-tism.

6 In 80 per cent of 37 cases studied, blood from the cordof the newborn contained more antistreptolysin than thecorresponding maternal blood.

The fall in antistreptolysin titer during subsidenceof rheumatic activity

It was possible to observe 41 of these patientsfor two years following an attack of acute rheu-matism and to obtain sera for titer determinationsat appropriate intervals. So far as could be de-termined, none of these patients was reinfectedduring this period. The changes in titer levelsduring convalescence are presented in Table III.

The changes in titer seen in Table III are sim-ilar to the observations made at The PelhamHome (1). The rate of fall in titer during con-valescence varied markedly. In no instance wasthe titer higher during recovery than during theacute attack. Sera of all individuals tested at theend of six months showed a fall in titer, with theexception of one child who maintained a titer of333 units for two years. More than half of thepatients had reached natural levels at the end oftwo years; the remainder had only a slight eleva-tion of titer. The median value for the group atthis time was 71 units. In contrast, the medianvalue for the same patients during the acute at-tack was 250 units. From these observations itis seen that the antistreptolysin titer diminishesas the rheumatic process becomes quiescent. Thisis believed to indicate subsiding activity of thetissues producing antibody to hemolytic strepto-coccus.

In summary it is apparent that the range ofantistreptolysin titer during the attack of acuterheumatism is (1) similar to that observed duringconvalescence from scarlet fever, (2) higher thanthat following hemolytic streptococcus pharyngi-tis, (3) considerably higher than that of rheu-matic subjects apparently quiescent, (4) strik-ingly higher than that of individuals in goodhealth or with diseases not of hemolytic strepto-coccus origin.

Serial antistreptolysin determinations make itpossible to investigate the time relationship be-tween the development of rheumatic activity andthe production of antibodies to hemolytic strepto-coccus. The authors are of the opinion that al-though the antistreptolysin titer represents onlya fraction of this antibody response, it is the bestavailable index of the total immune response toinfection with this agent. The following observa-tions are presented in detail to show a relation-

771

772 ALVIN F. COBURNAND RUTH H. PAULI

TABLE III

Antistreptolysin titers of patients recovering from acute rheumatism (units per cc.)

Acute rheumatism Symptom free Apparently quiescentName

(Month) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Faiman ................ 250 143Neal .................. 250 250 111Pagano ................ 333 100Paul .................. 333 143 100Riccardi. 333 333 333 100 100Romorofsky ... 200 71Scibelli . 250 200 143 125 111Sullivan, M.1000 167Sullivan, H....... ...... 333 250Anderson S00 143 100Acconero, P............ 83 125 83Braun. 333 200 143 143Clifford ............... 167 50 50 50Clowry ................ 500 125 125deMario ............... 250 250 125DeBiai . .250 111Feeley ................. 333 167 200 100 100Franklin. .. 250 167 125Giralt ................. 500 500 50 50 33 33Hall .................. 250 100 50 50 71Herman 200 143 125Hickey 167 167 83Howe................. 500 250 71Korson 111 50 25Kouba ................ 500 125 125 111 71Lally .................. 250 50Lun .................. 333 100McDonald ............. 333 500 250Mackay 111 50Maurer ................ 1250 1250 143Mazorra ............... 143 71Mazzia ................ 250 333 333 333 333Mullins ............... 500 500 111Oxford ................ 167 111Prek .................. 333 83 83Rexach ................ 125 71 33Shanahan............. 500 167 200Stone ................. 250 250 250 200 167Temestocle ............ 333 333 200Tsea .................. 250 111Galiano ............... 250 100

ship between rheumatic fever and activity of theantibody-producing mechanism.

The relationship between the height of the anti-streptolysin titer attained and the severity

of the rheumatic attackThe authors have studied a group of rheumatic

subjects over a period of years to determine theeffect of respiratory infections on their disease.The members of this group who developed acuterheumatism showed a coincident rise in antistrep-tolysin titer with each recrudescence. Further-more, those rheumatic subjects who appeared toescape activity of the rheumatic process followingrespiratory infection usually showed little or nochange in titer level. Five year observations ontwo illustrative patients are presented along withtheir antistreptolysin titer curves. Each of thesepatients, one child and one young adult, had sev-eral respiratory infections with d-ifferent types ofhemolytic streptococcus in the course of the ob-servation period.

CASE HISTORIES

H. D., Number 69558. The patient, an American boyof Italian parentage, has been under the authors' caresince 1928 when he was first seen at the age of seven withrheumatic heart disease. Between 1930 and 1935, he waskept under close clinical observation. Throat cultureswere examined each month and blood samples obtained atintervals for antistreptolysin determinations. Two throatinfections occurred during the five year period.

The first of these hemolytic streptococcus infectionswas contracted on February 17, 1934. The patient wasadmitted to Babies Hospital where he ran the course ofacute pharyngitis with a three day fever. On March 1,the sedimentation rate of the blood, which had been fall-ing, showed a moderate rise. He was discharged on thetenth of the month, symptom-free, with, however, anelevated sedimentation rate. Three weeks later he de-veloped a frank attack of polyarthritis, accompanied bymarked increase in the sedimentation rate. This attackrequired hospitalization and prolonged convalescent care.

The patient was again in excellent condition when hecontracted the next throat infection, March 9, 1935. Hewas cared for in the wards of the Presbyterian Hospital.Recovery from acute pharyngitis was rapid and con-valescence uneventful until April 2 when the pulse rate,sedimentation rate of the blood and white blood count

ANTISTREPTOLYSIN LEVEL

rose slightly and electrocardiographic changes appeared-" T waves have become definitely abnormal suggest-ing heart muscle damage, possibly active." All of theselaboratory changes disappeared within a few days, andthe patient was in good condition until April 23 when hedeveloped epistaxis, then polyarthritis, followed on May 1by a severe rheumatic attack with pericarditis.

Hemolytic streptococcus was recovered from the pa-tient's throat once in 1931 and 1932, but did not appear tocause local infections or initiate rheumatic activity. OnFebruary 16, 1934, hemolytic streptococcus appeared inpredominance during the period of pharyngitis and per-sisted until January 1935. On March 9, 1935, the organ-

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In summary, it seemed that each of these strep-tococcus infections was followed by a moderaterise in antistreptolysin titer which then remainedconstant for two weeks before making a secondrise to a higher level. During each period of thelower plateaus, there was laboratory evidence sug-gesting mild rheumatic activity. With the devel-opment of both of the secondary titer rises therewas an explosive outburst of rheumatic mani-festations. These changes are shown graphicallyin Figure 2.

Jw

Patient H.D

Good a4gue Rheumdtic Good Acute Good SevereHealth Sqmptoms Health Rheumaticrever Health ,Pancarditis

353 Mil11;d with AcuteCaLrditis Rheumatic

Fever

2HemStrep. Herp.Strej

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XTEJ 1 1r1PA'M'J'J'A!'0'Nl J'r tiAwj j SN 'D|J ' r rlN' J JIA sOqD r'rYA'M'JIJIAISIOINID' JIF IH1'I' J J'AISOINtD

19311952 1933 1934 ~~~~~1935FIG. 2. CHANGESIN ANTISTREPTOLYSIN LEVEL IN PATIENT H. D., FOLLOWINGHEMOLYTIC STREPTOCOCCUS

INFECTIONS FROM 1931 TO 1935

isms reappeared in predominance coincident with the onsetof throat symptoms. Sugar fermentation reactions ofthese two strains of hemolytic streptococcus showed themboth to be Streptococcus pyogenes, according to Holman'sclassification. Studies of the antistreptolysin level werebegun in 1930 when the patient was in good health with atiter of 83 units. The titer rose during a period of vaguesymptoms in the spring of 1932 to 111 units, was 50 unitson January 2,1933, when the patient appeared in excellenthealth. Two weeks after pharyngitis it rose to 144units, and remained constant for two weeks. Then oc-curred a rise to 333 units coincident with the onset ofacute rhematism. The level had fallen to 111 units whenthe 1935 throat infection occurred. Following this in-fection there was a rise to 167 units and then a fall to 143units at the time that the patient appeared to have escapedrecrudescence. However, ten days later the titer roseprecipitously to 333 units coincident with the onset ofsevere pericarditis.

M. O., Number 82235. The second patient, an Irishmaid of eighteen, came under the authors' observation inMay 1929 when she was admitted to the PresbyterianHospital with acute rheumatic fever and mitral stenosis.At that time her throat flora contained hemolytic strepto-coccus. Between 1929 and 1935 she reported monthly forexamination and throat cultures. Samples of blood forantistreptolysin determination were obtained at appropri-ate intervals. During five years of observation she con-tracted four distinct throat infections.

On February 21, 1931, she contracted acute pharyngitiswith fever for three days. Muscle pains, mild pyrexiaand tachycardia appeared on March 7, 1931. The elec-trocardiographic tracing showed extensive migration ofthe pacemaker. All symptoms and cardiac changes dis-appeared in one week. On January 13, 1932, she againcontracted acute pharyngitis with a three day fever.During the latter part of February vague manifestationswere noted. Suddenly, on March 7, 1932, she became

773

ALVIN F. COBURNAND RUTH H. PAULI

acutely ill with severe polyarthritis, pyrexia, dyspnea andtachycardia. The electrocardiographic tracing againshowed nodal rhythm with shifting pacemaker, and therewas a return to normal in one week. Symptomatic re-covery from this attack occurred in three weeks. OnJanuary 30, 1933, she again contracted acute pharyngitis.This infection was severe and was followed by extensivecervical adenitis. While at rest in bed in the Presby-terian Hospital on February 17, 1933, she developedmuscle pains, epistaxis, mild pyrexia, leukocytosis andincreased sedimentation rate of the blood without elec-trocardiographic changes. All evidences of rheumaticactivity disappeared in five days. On December 29, 1934,she again contracted acute pharyngitis with a three dayfever. This infection was followed by three months ofexcellent health without symptoms, signs or any labora-tory evidence suggesting rheumatic activity. Another in-fection in April, 1935, was followed by a mild rheumaticattack.

The throat cultures from this patient showed the ar-rival of hemolytic streptococcus on February 21, 1931;on January 13, 1932; on January 30, 1933, and on De-cember 29, 1934. This organism was predominant orpresent in large quantities in both tonsillar fossae during

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was moderately elevated to 125 units. After the patienthad been in good health for eight months the titer fell tothe natural level of 50 units. There was no change intiter during the 1932 pharyngitis; however, with the on-set of acute rheumatism on March 10, 1932, the level roseto 333 units. This was followed by a gradual decline inantistreptolysin level. During the severe throat infectionin 1933 the titer reached a value subnormal for this pa-tient, then one week later returned to natural level, andwith the onset of mild rheumatic symptoms rose to 111units and then to 166 units. The patient maintained aconstant level of 71 units through 1934. Followingpharyngitis in December, 1934, the titer remained practi-cally stationary, and the patient symptom-free. How-ever, another throat infection in April, 1935, was followedby a rise in titer to 143 units, coincident with the develop-ment of rheumatic symptoms.

In summary, there was a close correlation between thedegree of rheumatic activity and the height to which theantistreptolysin titer rose. In the absence of appreciablechange in titer, this rheumatic subject infected withhemolytic streptococcus escaped all clinical and labora-tory signs of recrudescence. The changes in antistrepto-lysin level are presented in Figure 3.

SocPatient [1.0.

Mild Good Acute Mild Rheumatic Good Good Escaped allRheumatism He Rheumatic Fever 54Imptoms Health Health Rheumatic Mild

335t l Sqmptoms Phwumatic

250-HemStrep. Hem.'Strep. Hem. Stre Hem.Slmp.

Phrunditis Pharqnc~tifs Phar nifi3 P____runc_____i_____

167-143 -

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ATE 1 1931 1932 1933 1934 1935

FIG. 3. CHANGESIN ANTISTREPTOLYSIN LEVEL IN PATIENT M. O., FOLLOWINGHEMOLYTIC STREPTOCOCCUSINFEC-TIONS FROM 1931 TO 1935

each of these infections and disappeared entirely from thepharyngeal mucosa in one to six weeks with all but thelast infection. Studies of the cultural and biologicalcharacteristics of these oiganisms indicated that these in-fections were caused by different types of beta hemolyticstreptococcus.

The antistreptolysin studies were begun during themild rheumatic attack in 1931. At this time the level

The observations on the two patients just dis-cussed suggest a relationship between the heightof antistreptolysin level attained and the intensityof the rheumatic attack. In order to investigatethis possibility in a large number of subjects withacute rheumatism, the authors have made serialdeterminations on 72 consecutive admissions to

774

ANTISTREPTOLYSIN LEVEL 775

the hospital. All of these individuals had frank character of the rheumatic attack. The individualrheumatic fever, those with chorea being excluded. antistreptolysin readings for the entire group areThe subjects have been classified according to the presented in Table IV.

TABLE IV

Serial antistreptolysin determinations (units per cc.) on 72 consecutive admissions with rheumatic fever

Week of rheumatic attackClass Patient

1 2 3 4 51 6 7 8 9 10 1 1 12 13 14 15 16 17 18 24

Acosta 1667

Deas 251667 Died in fulminating rheumatic attackMcGinley 333

I Bent 500 1667 2500 1250 1667 1667 1667 1667 1667 1667 1667 1667 2500 1250 1250Hickey 500 1000 1000 833 833 625 833 250 250Kondrup 714 1250 1667 1000 1250 1667 1667 1250 1250 1250 1000Masiello 500 1000 1250 1250 2500 833 833 714 625 555 500Waldhelm 500 1250 1667 1667 1250 714Wise 333 500 333 625 714 333 333 333 333 333 333 250

Aquinto 333 333 1250 833 333Cahill 333 333 333 333 333 250 250 333 333 333 250 250Callahan 2500 2500 2500 1667 1250 1250 333 333Carmody 1667 2500 1667 1667 1667 1667 625Gatto 200 625 500 625 333 333 250 250 250 200Hallett 500 833 714 833 833 833 1000 833 1000 714 714Hanzar 333 333 500 714 714 500 333 333Howard 714 625 500

II Jones 2500 1667 833 833 1000 714 111Kokinakis 500 500 250 333 333 333 625 250 333Kuchinsky 500 500 250 333 333 333 625 250 333 250 333 250 250 250 250Lord 333 500 500 500 500 333 333 333 333 333 333Mulchione 333 333 333 333 250 333 333 250 250 200Neal 1000 833 714 714 714 714 714 625 714 556 500 333Noonan 333 1667 1250 1667 1667 1250 1000 250 200Santiago 714 1250 833 833 625 714 714 625 556 333Zwirlein 1000 1000 1000 1000 833 625 625 625 556 500

Allaine 333 333 333 250 125 111Brown 200 333 333 250 250Delaney 250 250 200 250 333 333 333 333 200 250Digerlando 200 250 250 200 62 62Ellingson 250 250 250Faiman 250 200 250 250 250 167 167

III Harris 333 200Howe, K. 200 200 200 125Israels 500 500 250 333 250 333 250Kovner 500 333 333 333 250 200 143 100Murphy 200 333 333 333 333 250 200 200Nurse 333 333 250Spanos 250 333 250 167

Crimaldi 250 250 500 333 500 125Fenty 200 333 250 333 250 250 250 250 200Heinelt, M. 500 833 833 1000 1000 333

IV Howe, W. 500 500 1000 1250 1250 833 714 714 200Hubner 500 500 500 500Lowe 333 1000 500 1000 1000 1667 500Mintz 250 333 500 833 500 333 333 333 200Wilchynsky 167 200 250 200 167 250 250 200 200 167 100

Alnerado 200Campbell 143 200 200 167Clark 333 500

V Currlin 250 250Krom 250 250Morris 333 250 250 200 167 143Tanis 500 833 625

Comito 250 250 250 250 200 333 333 250D'Amico 200 250 333 250 200 200 167 167 125 125 100 83Daugherty 500 833 625 250 250Demasi 200 200Earls 333 500 333 333 333 333 333 333 333 250 250Einhorn 500 556 333 200 333 200 125Doorley 143 125 125 167Goadby 250 333 333

VI Heinelt, A. 1000 1000 1000 1000 1000 833 714 625 555McGirr 333 500Ojia 333 333Ohrbach 250 333 250 333 333 333 250 200 200Roos 333 333 333 250 250Starrett 500 500 333Temestocle 333 333 500 500 500 714 556Walsh, C. 333 250 333 333 200 200Walsh, G. 333 333

ALVIN F. COBURNAND RUTH H. PAULI

The classes in Table IV have been defined asfollows:

Class I-Fulminating polycyclic attack with in-tense pancarditis.

Class II-Continuous, severe carditis, insidiousin onset.

Class III-Severe monocyclic polyarthritis withmild carditis.

Class IV-Severe polycyclic polyarthritis withmild carditis.

Class V-Mild, vague rheumatic attacks ofshort duration.

Class VI-Mixed types.

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Class 1. Most of the patients who survived forthree weeks or more developed extremely highantistreptolysin titers. Two died during the firstweek of the attack probably before the titer levelshad reached maximum values. A similar observa-tion was made during The Pelham Home epi-demic (1). Illustrative titer curves are presentedin Figure 4.

Class II. Most of these individuals came un-der observation late in the rheumatic attack and,although symptom-free, developed rapidly pro-gressive carditis while at rest in bed. All of thesechildren developed extremely high antistreptolysinlevels, as shown in sample curves, Figure 4.

WEEKSAFTER ONSET or RHEUMATICATTACK0 3 6 q 12 15 0 3 6 q 12 Is 18

2500166712501000633625500

333250'nn

I0 3 6 9 12 15 0 3 6 9 12 15

WEEKSAFTER ONSETOf 1HEUMATICATTACK18

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FIG. 4. ANTISTREPTOLYSIN TITER CURVESOF FOURCLINICAL TYPES OF

PATIENTS WITH RHEUMATICFEVER

167. I.167125 123100. '0063. 6363 6350_5033 CLASS I CLASS EI 3325 2520 20

2500 25001667 .6671250 12501000 - 1000833. 833625 625500 500

250 250200 200__125 ~~~~~~~~~~~~~~~~125

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ANTISTREPTOLYSIN LEVEL

Class III. These patients had severe but brief

rheumatic attacks without serious carditis. The

disease process seemed to subside rapidly and

spontaneously. The attacks were limited to a

single cycle of approximately two weeks duration.

None of the titers exceeded 500 units at any time

and all tended to fall shortly after the disappear-

ance of symptoms. Illustrative curves are shown

in Figure 4.

Class IV. In contrast., these patients who at

first were clinically similar to those in Class III,

developed repeated cycles of polyarthritis. These

exacerbations were accompanied by marked in-

creases in titer levels, bringing them into the titer

range of Classes I and IL. See Figure 4.

Class V. These patients had vague manifes-

tations with, laboratory findings indicating mild

rheumatic activity. Recovery was prompt and in

most instances the titer levels were only slightly

elevated.

Class VI. These individuals presented a mixed

clinical picture. It has been considered advisable

to exclude them from the well defined groups.

In summary, it appears that extremely high

antistreptolysin levels (over 500 units) are asso-

ciated with intense or prolonged rheumatic ac-

tivity. The lower levels seem to be associated

with acute rheumatism that is either short in dura-

tion or mild in character. These observations are

believed to indicate that the intensity of the rheu-

matic attack is associated with the degree of ac-

tivity of the subject's antibody production to

hemolytic streptococcus.

The relationship between the rise i-n antistreptoly-

sin titer and the o-nset of rheumatic activinty

Another relationship suggested in the titer

curves in Figures 2 and 3 is the coincidence of

a sharp rise in titer with the onset of the rheu-

matic attack. This observation was found to be

true in The Pelham Home epidemic (1). In

order to study this time relationship in a sig

nificant number of cases, the authors made deter-

minations on 30 patients during hemolytic strep-

tococcus pharyngitis, the quiescent interval and

the attack of acute rheumatism. The determina-

tions for the entire group are presented in Table

V.

TABLE V

The dievelopment of antistreptolysin titer (Units per cc.) between hemolytic streptococcus infection and the rheumatic attack

During ~Quiescent interval Acute rheumatismBefore Duig(weeks) (months) Character

Patient in- in- __offection fection I-- attack

1 2 3 4 5 6 7 1 2 3 4 S 6 7 8 9 10 11 12

Aceto........200 500So 1000 500 500 SevereAita ........ 20 25 25 111R 125 125 125 71 50 SevereAlfisi, 25 50 R 200 167 167 33 MildAlfisi, S.......125 200 R 250 333 125 MildBent........167 250 500 RI 1667 2500 1667 SevereCermey.50..... s 25 71 PI 1250 143 SevereD'Amico ...... 71 50 100 143 143 .1431 333 500 333 125 ModerateD'Amico (2d atk). 125 111 167 167 167 143 143 R 333 250 ModerateDigerlando ....83 167 I R 250 250 MildEarls....... 250 250 333 333 R 500 ModerateEinhorn.. 63 50 125 125 500 556 333 ModerateFrizzell ...... 250 167 167 167 167 R 250 250 250 MildGilligan....... 33 33 33 1111 I200 500 125 71 71 ModerateHanke 50...... s 50 RI 200 ModerateHickey....... 83 125 200 I R 500 1000 1000 833 625 SevereLemone.......143 125 166 R I250 500 500 500 200 ModemateMaurer.......143 250 R I500 2500 333 333 SevereMurphy ...... 200 R I333 MildNeal .100..... R So50 1000 250 ModerateNeal (2d atk) .... 250 R 1000 833 ModerateO'Hare.50..... s 50 I 333 250 25 ModerateO'Hare....... 83 100 125 R143 MildPagano.......100 143It200 2500 1667 1250 1250 200 SeverePrek.50...... s 143 333 250 250 167 143 ModerateRiccardi ......100 100 143 250 250 250 250 250 250 ModerateRifkin .......83 2I 250 333 250 167 143 111 ModerateSchiosser...... 71R 200 50 ModerateAcbelli....... 7 1 1167 Ik250 250 250 17 Moderate

Servetman ..... 33 125 R 250 56 SevereTerentino .....167 250 R 500 500 250 200 143 SevereWeb-er ......167 167 R 200 250 250 143 SevereWynne.50.... s 25 25 33 33 125 R 250 250 t1110 Mild

*R indicates time of onset of rheumatic symptoms.

777

ALVIN F. COBURNAND RUTH H. PAULI

It is seen in Table V that the onset of eachrheumatic attack occurred at the time that theantistreptolysin titer was rising. The developmentof the rheumatic attack coincident with the im-mune response to hemolytic streptococcus hasbeen a consistent finding during these studies.

The maintenance of low antistreptolysin level inrheumatic subjects who escaped recrudescence

follouwng hemolytic streptococcuspharyngitis

The authors have pointed out (5) that whenrheumatic subjects are infected with hemolyticstreptococcus, some develop frank recrudescences;others get mild rheumatic symptoms and the restappear to escape rheumatic activity entirely. Thepresent section concerns itself with the last ofthese groups of patients. Their titer changes arepresented in Table VI.

lar observations are to be found in Figure 2, inan earlier paper of this series (2), and were alsomade in the epidemic at The Pelham Home (1).Representative titer curves of patients who devel-oped attacks and of those who did not are shownin Figure 5.

All of the titers discussed in this study havebeen classified in Table VII with reference totheir frequency distribution. The logarithms ofthe units have been used as a basis for classifica-tion, (a) to correct for the skewness of the dis-tribution of titer units on an arithmetic scale, and(b) thus permit the calculation 6 of means andprobable errors, and the determination by statisti-cal methods of the significance of differences be-tween groups. As already mentioned, the titersof the first five groups are taken from single de-terminations and those in the last seven groupsrepresent the maximum of a series of determina-tions.

TABLE VI

Antistreptolysin titers (units per cc.) in individuals with streptococcus pharyngitis not followed by rheumatic attacks

After pharyngitisPharyngitis

Name Weeks Months

Before During 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 6 12

Auris ............... .o50 50 50Bourie ................... 143 125 167 167 167 200 167 167 143 143Brogan .................. 71 143 167 167 2S0Byrnes .................. 71 50 50 50 50 50Delaney 71 71 100Elphick .................. 333 200 200 333 333Fromer .................. 250 250 250 250 250 333Grassi ..................... 167 250 250 250 250 250 250 250 250Grasso ..................... 333 333 333 333Jackson .................... 83 71 71 71 71 71Levy 63 63 71 71McFarland ................. 143 143 143 143 143 143 143 125 143Miller, H................... 125 143 143 111Miller. ................... 125 100 111 111 111 111 125Morris ..................... 12* 71 167 125 125Murphy ................... 83 83 100 143O'Brien .................. 111 125 111 111 100O'Hare .................. 71 71 71 71 83Phillips .................... 50 71 50 71 50 71 71 35Pisello 125 125 143 143 143Rappa .................... 71 71 71 83 111Rodriquez ..................o50 S0 50Skea. 250 200 143 143 125 125Solomon ....................... 33 33 33 33 33 71Vitale .. 167 167 167 143 125

* This infection was severe and probably accounts for the depressed titer level.

It is seen from Table VI that in individualscontracting pharyngitis with hemolytic strepto-coccus not followed by rheumatic recrudescence,the antistreptolysin titer either fell, remained sta-tionary or rose slightly. These titer levels arein distinct contrast to those of patients who de-veloped frank attacks of acute rheumatism. Simi-

6 The statistical methods used in this paper were takenfrom Garrett, H. E., Statistics in Psychology and Educa-tion. New York, Longmans, Green and Company, 1926.The calculation of those probable errors which dependupon relatively few cases (13 or less) was made by theformulae of R. A. Fisher, as given by Dunn, H. L.,Physiol. Reviews, 1929, 9, 275.

778

ANTISTREPTOLYSIN LEVEL

0 5 10 15 20 0 5 10 15 20 25

WEEKSAFTER ONSET OF INFECTION5. ANTISTREPTOLYSIN TITER CURVESOF RHEUMATICSUBJECTS DURING AND AFTR HEMOLYTIC

STREPTOCOCCUSPIIARYNGITISA. Developed rheumatic attacks.B. Escaped rheumatic attacks.

As is seen in Table VII the geometric means

(calculated from the average log u) differ onlyslightly from the medians. This indicates thatthe logs of the titers have an approximately nor-

mal distribution. In view of the probable errors

of the average log u's, the following conclusionscan be drawn: (a) There is no significant differ-ence between Group 1 and 2; (b) Groups 3, 4,and 5 are significantly higher than both 1 and 2;(c) There is an apparent difference betweenGroups 4 and 5; however, because of the smallnumber of cases in Group 4, it is unwise to drawconclusions; (d) Groups 6 and 3 are almost iden-tical; (e) Group 7 is significantly lower than 6and 8; (f) The average mean log u of Groups 7and 8 does not differ significantly from the mean

log u of Group 6; (g) There is no significantdifference between Groups 8, 9 and 10; (h) Thedifferences between these three groups and Group5, which are significant, may be attributed to themethod of collecting material; (i) Groups 11 and12 are significantly lower than Groups 8, 9 and 10.

From the data obtained in 1934 and 1935, therange of titers to be expected with rheumaticfever in terms of log units is 2.69 + 0.31 (S.D.).This will include %of such cases, and the rangeof 2.69 + (3 X 0.31) will include practically allpatients with acute rheumatism. Expressed inunits this range corresponds to titers of 240 to

1260 units for % of the cases with the largestnumber falling at about 490 units.7

The patients who escaped recrudescence follow-ing pharyngitis with hemolytic streptococcus(Group 7) showed distinctly less antistreptolysinresponse to infection than either non-rheumaticsubjects following comparable infection or pa-

tients with acute rheumatism. This cannot beattributed in all cases to the nature of the infectingagent (2) but in some instances seems to be as-

sociated with a diminished immune response of thehost.

DISCUSSION

Sufficient data are not yet available to determinewhether the antibody response of the rheumaticsubject differs from that of the non-rheumaticsubject. This discussion will therefore be con-

fined to rheumatic subjects. The data presentedfor this group show wide variations in the anti-body response to hemolytic streptococcus infec-tion. These variations seem significant in deter-mining the development of rheumatic activity.In general, the greater the antibody response, themore severe the accompanying rheumatic attack;and conversely, in the absence of antibody re-

sponse the rheumatic attack fails to develop. The7 The authors are indebted to Dr. A. A. Weech for ad-

vice in applying statistical methods to these data.

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titer level attained by any individual patient seemsto be the result of at least three factors: the char-acter of the infecting strain, the intensity of thepatient's response to that particular infection, andthe capacity for antibody production character-istic of the individual. The close time relationshipbetween the antistreptolysin rise and the onsetof rheumatic activity, together with the close cor-respondence between the absence of such rise intiter and the quiescence of the rheumatic process,has led to the belief that the association is not ac-cidental. However, the mechanism responsiblefor the simultaneous occurrence of these immuno-logical and clinical changes remains to be deter-mined. One of a number of possible explanationsis dealt with in the following paper (8).

SUMMARY

The median of the antistreptolysin determina-tions on 176 individuals in good health was 71units. This is somewhat higher than the naturalhuman level of 50 units.

The median titer developed in acute rheumatismwas 500 units, and the geometric mean 490 units.In most instances the titer returned to approx-

imately natural level within a period of one year.

The onset of acute rheumatism coincided witha sharp rise in antistreptolysin titer.

Rheumatic patients infected with hemolyticstreptococcus who escaped recrudescence, showedlittle or no change in antistreptolysin titer.

The relation of the immune response of thehost to the development of rheumatic activity isdiscussed.

BIBLIOGRAPHY1. Coburn, A. F., and Pauli, R. H., Studies on the im-

mune response of the rheumatic subject and itsrelationship to activity of the rheumatic process.II. Observations on an epidemic of influenza fol-lowed by hemolytic streptococcus infections in a

rheumatic colony. J. Exper. Med., 1935, 62, 137.III. Observations on the reactions of a rheu-

matic group to an epidemic infection with hemo-lytic streptococcus of a single type. Idem, 1935,62, 159.

2. Coburn, A. F., and Pauli, R. H., This series. IV.Characteristics of strains of hemolytic streptococ-cus effective and non-effective in initiating rheu-matic activity. J. Clin. Invest., 1935, 14, 755.

3. Coburn, A. F., and Pauli, R. H., This series. I. Thedetermination of antistreptolysin titer. J. Exper.Med.,.1935, 62, 129.

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4. Todd, E. W., Further observations on the virulenceof hemolytic streptococci, with special reference tothe morphology of the colonies. Brit. J. Exper.Path., 1928, 9, 1.

5. Coburn, A. F., and Pauli, R. H., Studies on the rela-tionship of streptococcus hemolyticus to the rheu-matic process. III. Observations on the immuno-logical responses of rheumatic subjects to hemo-lytic streptococcus. J. Exper. Med., 1932, 56, 651.

6. Myers, W. K., and Keefer, C. S., Antistreptolysin con-

tent of the blood serum in rheumatic fever andrheumatoid arthritis. J. Clin. Invest., 1934, 13,155.

7. Wilson, M. G., Wheeler, G. W., and Leask, M. M.,Antistreptolysin content of blood serum of chil-dren. Its significance in rheumatic fever. Proc.Soc. Exper. Biol. and Med., 1934, 31, 1001.

8. Coburn, A. F., and Pauli, R. H., This series. VII.Splenectomy in relation to the development ofrheumatic activity. J. Clin. Invest., 1935, 14, 783.

781