Acute Rheumatic Fever among Army Trainees -- Fort Leonard Wood, Missouri, 1987-1988

In February 1988, the Office of the Army Surgeon General was notified of two cases of acute rheumatic fever (ARF) and four cases of suppurative axillary lymphadenitis associated with group A B-hemolytic streptococcus (GABHS) infections among soldiers who recently completed training at Fort Leonard Wood, Missouri. An investigation was conducted in March 1988 to determine the extent of ARF and GABHS among soldiers and their dependents at Fort Leonard Wood.

A retrospective records review revealed that from February 1987 through February 1988, 10 soldiers assigned to Fort Leonard Wood were hospitalized with ARF*; four additional patients developed signs and symptoms of ARF within 5 weeks of transfer to other army posts. Thirteen of the cases occurred from October 1987 through February 1988. Eight patients had carditis, 12 had polyarthritis, one had erythema marginatum, and one had subcutaneous nodules. Eleven had had a positive throat culture for GABHS, and 11 had an elevated antistreptolysin O titer. Neighboring hospitals and health departments reported no ARF cases among civilians during the same period.

An investigation based on data from routine hospital surveillance showed that hospitalization rates for acute respiratory disease (ARD) had also increased during the fall of 1987 among personnel in basic training (Figure 1). A review of records of throat cultures obtained from these patients indicated that recovery of GABHS increased from approximately 25% in late summer to more than 70% in early fall (Figure 1). From October 1987 to February 1988, 22 patients were also identified with a peritonsillar abscess (more than a threefold increase compared with the corresponding period of the previous year). Most patients with peritonsillar abscess had throat cultures positive for GABHS.

During the first week of March 1988, a questionnaire was administered to 735 basic trainees in six companies who were given physical examinations and who had throat cultures done; GABHS was recovered from 85 (12%). The prevalence of GABHS was 1% in new arrivals but over 45% in trainees in their sixth week of training. GABHS was isolated from 49 (14%) of 362 trainees with signs of pharyngitis (a beefy red pharynx and enlarged cervical lymph nodes), compared with 36 (10%) of the 373 trainees without signs of pharyngitis.

GABHS isolates from the ARF patients were not available for M-typing; however, of the 85 GABHS strains isolated during the survey, most had mucoid colony morphology, 74% were type M18, and 20% were type M3. Among the trainees with these GABHS-positive cultures, presence of type M18 was the only independent predictor of signs of pharyngitis. Convalescent serum samples were obtained from six of the patients with ARF; bactericidal antibodies to type M18 or type M3 strains were detected in only one.

In response to the outbreak, benzathine penicillin was given once during the second week of March to all nonallergic soldiers in training at Fort Leonard Wood, and all new trainees are now treated on arrival. No further cases of ARF have been reported. Admissions to the hospital for ARD and the percentage of throat cultures yielding GABHS have decreased after institution of the prophylactic regimen. Reported by: GL Sampson, COL, MC, USA, RG Williams, COL, MC, USA, MD House, NE Wetzel, MD, Fort Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri. JF Brundage, MAJ, MC, USA, JG McNeil, MAJ, MC, USA, CD Magruder, CAPT, MC, USA, GC Gray, LCDR, MC, USN, Div of Preventive Medicine, Walter Reed Army Institute of Research, Washington, DC. Respiratory Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The number of ARF cases seen by physicians in several areas of the United States where ARF data have been examined has increased recently (1-4). For example, in Utah, a high rate of the disease (11.8 cases/100,000 children 3-18 years old) was observed in 1985 (5). This rate was six times greater than annual rates for 1977 through 1981 in Memphis, Tennessee (6), and 19 times greater than those for 1971 through 1980 in suburban Los Angeles County (7). However, the Utah rate was similar to those reported in Baltimore from 1968 to 1970 (8) and in Olmstead County, Minnesota, from 1965 to 1978 (9). The report of an increase in cases of ARF at Fort Leonard Wood is similar to reports from civilian populations and a recent report from the Navy Training Center, San Diego, California (10). A marked increase in streptococcal pharyngitis and other suppurative streptococcal infections was observed in the military trainees coincident with each outbreak of ARF. Prophylactic use of penicillin in trainees to prevent ARF had been discontinued for several years at the Navy Training Center in San Diego before the outbreak there and at all U.S. Army facilities because of the absence of cases.

The predominance of type M18 among GABHS isolated at Fort Leonard Wood and the association of this M-type with clinical signs of pharyngitis suggest that type M18 may have caused the outbreak of ARF. Unfortunately, GABHS isolates were not available for typing from patients with ARF. The presence of mucoid strains and the association between mucoid colony morphology and type M18 GABHS have been described in Ohio, where an increase in ARF cases has also been observed (11). The lack of bactericidal antibody to type M18 or type M3 in all but one of the six patients with ARF is unexplained and suggests that either these M-types were not involved or that the bactericidal antibody response to these M-types cannot be used to determine their etiologic role.

Although the Army closely monitors respiratory infections among basic trainees, an ARF outbreak was difficult to detect because of 1) the variety of clinical syndromes, 2) the low clinical suspicion for diagnosing this disease, and 3) the latency from infection to the occurrence of ARF signs and symptoms, which caused at least four cases of ARF to appear at medical facilities removed from Fort Leonard Wood. Reduction of streptococcal pharyngitis and suppurative infections as well as ARF are the objectives of GABHS control programs for military trainees. Rapid detection of an increase in GABHS infections is required for control programs in the military not routinely using penicillin prophylaxis. Although mucoid colony morphology is an easily identifiable characteristic that has occurred coincident with reemergence of ARF in selected geographic areas, it is unknown whether this bacterial characteristic is important in the pathogenesis of ARF. Therefore, the presence of mucoid strains is not a valid criterion alone for reintroducing penicillin prophylaxis. The Army will continue to monitor cases of ARF and symptomatic trainees with GABHS-positive throat cultures to determine levels of activity. Surveillance data will also be used to determine a threshold level of GABHS disease for implementing prophylaxis. Rapid detection kits are useful for expediting identification of infected persons, but they should not be used as the only method to detect GABHS.

State health departments are requested to notify the Respiratory Diseases Branch (RDB), Division of Bacterial Diseases, Center for Infectious Diseases, CDC (404) 639-3021, of clusters of cases (two or more) of ARF. The Bacterial Reference Laboratory, RDB, serves as the national reference laboratory for serotyping streptococcal isolates from patients with known or suspected ARF.

References

1. Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 1987;316:421-7.

2. Hosier DM, Craenen JM, Teske DW, Wheller JJ. Resurgence of acute rheumatic fever. Am J Dis Child 1987;141:730-3.

3. Congeni B, Rizzo C, Congeni J, Sreenivasan VV. Outbreak of acute rheumatic fever in northeast Ohio. J Pediatr 1987;111:176-9.

4. Wald ER, Dashefsky B, Feidt C, Chiponis D, Byers C. Acute rheumatic fever in western Pennsylvania and the tristate area. Pediatrics 1987;80:371-4.

5. CDC. Acute rheumatic fever--Utah. MMWR 1987;36:108-10,115.

6. Land MA, Bisno AL. Acute rheumatic fever: a vanishing disease in suburbia. JAMA 1983;249:895-8.

7. Odio A. The incidence of acute rheumatic fever in a suburban area of Los Angeles: a ten-year study. West J Med 1986;144:179-84.

8. Gordis L. Effectiveness of comprehensive-care programs in preventing rheumatic fever. N Engl J Med 1973;289:331-5.

9. Annegers JF, Pillman NL, Weidman WH, Kurland LT. Rheumatic fever in Rochester, Minnesota, 1935-1978. Mayo Clin Proc 1982;57:753-7.

10. CDC. Acute rheumatic fever at a Navy Training Center--San Diego, California. MMWR 1988;37:101-4.

11. Marcon MJ, Hribar MM, Hosier DM, et al. Occurrence of mucoid M-18 Streptococcus pyogenes in a central Ohio pediatric population. J Clin Microbiol 1988;26:1539-42. *A case of ARF was diagnosed if the patient had clinical syndromes meeting the modified Jones criteria.

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