Exotoxins of Bacteria

[sf_mom]

I've been obsessed with reading/researching the exotoxins of bacteria. I've been mystified by lack of positive cultures, ASO and anti-DNAse-B titers in many PANDAS children as well as Kawasaki's...

 

Again, confirmed RF in my son' friend, 10 days later it looked 'like' Kawasaki's in my older son but recovered on his own (first TIC six months post illness), 10 days later Kawasaki's in my younger son and currently has CaM Kinase of 148, no elevated ASO, no elevated Anti-DNAse-B. In Kawasaki's the exotoxin of the S. pyogene was found in 100% of all Kawasaki's patients tested in the post acute phase. Kawasaki's share 93 symptoms with RF.

 

Here is what I found..... the toxin itself can cause the disease.

 

Bacterial Toxins

 

• ‘Microbial toxins are components or products of microorganisms

 

which, when extracted and introduced into host animals, can

 

reproduce disease symptoms normally associated with infection

 

without infestation by those microorganisms’, Williams and Clarke,

 

1998

 

http://www.agls.uidaho.edu/foodtox/lecture...sis_outline.pdf

 

 

I asked Madeleine Cunningham if this was possible and her response: of course. the organisms have

lots of ways to make us ill!!

 

Is it possible that just the toxin is passed along, mirroring the illness but not the actual bacteria? If so, couldn't you just test for the exotoxin (the toxin the bacteria throws off)?

 

-Wendy

[Buster]

Is it possible that just the toxin is passed along, mirroring the illness but not the actual bacteria? If so, couldn't you just test for the exotoxin (the toxin the bacteria throws off)?

 

If you are interested in the exotoxins of GABHS, a good reference is http://books.google.com/books?id=k_gROZ_xu...SPE&f=false

 

The short summary is that the exotoxins are thought to cause more leakage across epithelial cells (i.e., the BBB). The common tests of Anti-Streptolycin-O and AntiDNAse-B are actually tests of the amount of antibodies to these two exotoxins. What I'm getting at is that the tests currently performed don't test for strep, they test for antibodies to exotoxins of strep.

 

Buster

[sf_mom]

Well that is confusing because they found the exotoxin of S. pyogenes in Kawasaki's patients and there are typically no positive cultures, no raised ASO and no Anti-DNAse-B the reason the medical community differentiates between RF and KAWASAKI's.

 

http://www.springerlink.com/content/l34qj830548q4q46/

 

 

streptococcal pyrogenic exotoxin one produced by Streptococcus pyogenes, existing in several antigenic types and causing fever, the rash of scarlet fever, organ damage, increased blood-brain barrier permeability, and alterations in immune response.

 

-Wendy

[sf_mom]

Buster, Do you know if the ASO and Anti-DNAse-B are measuring specific antibodies to the exotoxin? Is it possible the test just doesn't pick up the RIGHT antibody?

[Buster]

Buster, Do you know if the ASO and Anti-DNAse-B are measuring specific antibodies to the exotoxin? Is it possible the test just doesn't pick up the RIGHT antibody?

ASO is a test of the body producing an antibody to Streptolycin-O (an exotoxin of GABHS). Deoxyribonuclease B is also an exotoxin of GABHS. Anti-DNAseB is a measurement of antibodies to this exotoxin.

 

Other known exotoxins are known as A, B, C, ... Z, Stretokinase (SK), Hyaluronidase (HA) and Cysteine proteinase. There are undoubtedly many more that haven't been found yet. A..Z are usually written as Spe A, Spe B, ... standing for streptococcal pyogenes exotoxin A, .... Deoxyribonuclease B is also known as Spe F, although it was only recently these were found to be immunologically identical.

 

So with so many exotoxins why do doctors use Streptolycin-O?

 

The reason doctors like Streptolycin-O is that it is generated by all known emm-types of GABHS in vitro (i.e., outside the body). While this is true, it isn't as true in the human body. Kaplan discovered that cholesterol seems to neutralize streptolycin-O (so if you have strep on the skin, or in an area with high concentrations of cholesterol, you won't see an ASO response). This appears to be contributing to the >46% false negative rate even on perfect timing of taking ASO samples.

 

About 85% of the strains produce cysteine proteinase (aka SPE B ) but this seems to be neutralized in many and so is not in general tested.

 

Streptokinase is the next most popular test (it's found on 71% of strains). Some laboratories run this test if requested.

 

Spe A is found in 25% of the GABHS strains (primarily those expressing M1 or M3).

 

Hyaluronidase was found in only 10% of the strains.

 

You can find out about others at http://www.ncbi.nlm.nih.gov/pubmed/9361388

 

The bottom line is without knowing the emm-type of the strep, there's not good concensus on what exotoxin to measure.

 

Hope that helps,

 

Buster

[sf_mom]

Wow, That helps tremendously and I plan to bring a copy of your comments to my next appointment with Dr. Lewis!!!!!!!!!!!!!

 

My theory..... if it looks like a duck and quacks like a duck, ITS A DUCK. Sometimes without proof it makes it difficult to sway opinion... PANDAS, is SC, is Kawasaki's, is RF (I've revised a little to include Kawasaki's). I think Dr. K thinks I might be right, I think Madeleine Cunningham will give it much further consideration and hopefully I'll convince Lewis. Its M1, M3 or M18 strain.

 

-Wendy

 

 

Buster, Do you know if the ASO and Anti-DNAse-B are measuring specific antibodies to the exotoxin? Is it possible the test just doesn't pick up the RIGHT antibody?

ASO is a test of the body producing an antibody to Streptolycin-O (an exotoxin of GABHS). Deoxyribonuclease B is also an exotoxin of GABHS. Anti-DNAseB is a measurement of antibodies to this exotoxin.

 

Other known exotoxins are known as A, B, C, ... Z, Stretokinase (SK), Hyaluronidase (HA) and Cysteine proteinase. There are undoubtedly many more that haven't been found yet. A..Z are usually written as Spe A, Spe B, ... standing for streptococcal pyogenes exotoxin A, .... Deoxyribonuclease B is also known as Spe F, although it was only recently these were found to be immunologically identical.

 

So with so many exotoxins why do doctors use Streptolycin-O?

 

The reason doctors like Streptolycin-O is that it is generated by all known emm-types of GABHS in vitro (i.e., outside the body). While this is true, it isn't as true in the human body. Kaplan discovered that cholesterol seems to neutralize streptolycin-O (so if you have strep on the skin, or in an area with high concentrations of cholesterol, you won't see an ASO response). This appears to be contributing to the >46% false negative rate even on perfect timing of taking ASO samples.

 

About 85% of the strains produce cysteine proteinase (aka SPE B ) but this seems to be neutralized in many and so is not in general tested.

 

Streptokinase is the next most popular test (it's found on 71% of strains). Some laboratories run this test if requested.

 

Spe A is found in 25% of the GABHS strains (primarily those expressing M1 or M3).

 

Hyaluronidase was found in only 10% of the strains.

 

You can find out about others at http://www.ncbi.nlm.nih.gov/pubmed/9361388

 

The bottom line is without knowing the emm-type of the strep, there's not good concensus on what exotoxin to measure.

 

Hope that helps,

 

Buster

[Buster]

Hi Wendy,

 

I'm pretty sure Dr. Lewis won't value comments off the internet by parents even if backed with good scientific data. It just doesn't seem to be the nature of immunologists :-)

 

Usually a good paper on a topic, particularly one in a notable journal (like JNI or Nature), is more effective.

 

If it's not a paper he's already read, he'll scan it in the 15 min before the appointment. I think he, like many specialists, are looking for a reason to treat --but they want to have a reason and not just be experimenting. Unfortunately, the science (and funding) here is still 5-10 years away from the conclusive evidence that is really needed.

 

I think you've met with with him before, right? He is extremely well versed in Kawasaki's disease and has his own research around T cells. My strongest recommendation would be to consider what you want done, and why you think it will help, and then ask him what he'd need to see in tests or otherwise to support you? I presume he's already done his own lab work, discovered nothing particularly unusual, so he's not finding a way yet to support you.

 

My memory is that you have a ~3 year old diagnosed and treated for Kawasaki's. A ~6 year old diagnosed and treated with IVIG (Sept 21) for PANDAS and a playmate who had peeling hands and lymph issues of KD but likely has PANDAS. So, just wondering if you are trying to dangle a good research direction in front of Lewis (i.e., a good topic for one of his grad students to work on) or trying to get him to do something?

 

Best wishes and hopes,

 

Buster

 

 

Wow, That helps tremendously and I plan to bring a copy of your comments to my next appointment with Dr. Lewis!!!!!!!!!!!!!

 

My theory..... if it looks like a duck and quacks like a duck, ITS A DUCK. Sometimes without proof it makes it difficult to sway opinion... PANDAS, is SC, is Kawasaki's, is RF (I've revised a little to include Kawasaki's). I think Dr. K thinks I might be right, I think Madeleine Cunningham will give it much further consideration and hopefully I'll convince Lewis. Its M1, M3 or M18 strain.

 

-Wendy

 

 

Buster, Do you know if the ASO and Anti-DNAse-B are measuring specific antibodies to the exotoxin? Is it possible the test just doesn't pick up the RIGHT antibody?

ASO is a test of the body producing an antibody to Streptolycin-O (an exotoxin of GABHS). Deoxyribonuclease B is also an exotoxin of GABHS. Anti-DNAseB is a measurement of antibodies to this exotoxin.

 

Other known exotoxins are known as A, B, C, ... Z, Stretokinase (SK), Hyaluronidase (HA) and Cysteine proteinase. There are undoubtedly many more that haven't been found yet. A..Z are usually written as Spe A, Spe B, ... standing for streptococcal pyogenes exotoxin A, .... Deoxyribonuclease B is also known as Spe F, although it was only recently these were found to be immunologically identical.

 

So with so many exotoxins why do doctors use Streptolycin-O?

 

The reason doctors like Streptolycin-O is that it is generated by all known emm-types of GABHS in vitro (i.e., outside the body). While this is true, it isn't as true in the human body. Kaplan discovered that cholesterol seems to neutralize streptolycin-O (so if you have strep on the skin, or in an area with high concentrations of cholesterol, you won't see an ASO response). This appears to be contributing to the >46% false negative rate even on perfect timing of taking ASO samples.

 

About 85% of the strains produce cysteine proteinase (aka SPE B ) but this seems to be neutralized in many and so is not in general tested.

 

Streptokinase is the next most popular test (it's found on 71% of strains). Some laboratories run this test if requested.

 

Spe A is found in 25% of the GABHS strains (primarily those expressing M1 or M3).

 

Hyaluronidase was found in only 10% of the strains.

 

You can find out about others at http://www.ncbi.nlm.nih.gov/pubmed/9361388

 

The bottom line is without knowing the emm-type of the strep, there's not good concensus on what exotoxin to measure.

 

Hope that helps,

 

Buster

[sf_mom]

Buster,

 

With our older son, we wanted a long term strategic health plan locally and I got that from Dr. Lewis. He said he would treat Corsa if he had a relapse. He wasn't willing to give PID/monthly IVIG based on strep titers without revaccinating and we were/are unwilling. We did have a second IVIG scheduled with Dr. K for that very purpose. We did notice creeping symptoms (mood liability, mild OCD, reappearance of dark circles under eyes and chapped lips) with Corsa 7 to 8 weeks post first IVIG and Dr. K felt either the first treatment wasn't enough or he had been exposed to strep again. Thankfully, the 2nd IVIG has been 'very' successful, one week post 2nd treatment... no emotional symptoms, minor dark circles under eyes and chapped lips still resolving.

 

Dr. Lewis had reviewed my son's friend's labs (at first visit) and he was the one that mentioned to me that Adrian might have RF. Since our visit we were able to confirm RF diagnosis in Adrian. Now, that our younger son, Romy's labs are not looking so great, CaM Kinase 148, Low White Blood Count, Low Red Blood Count, Deficiencies in 13 of 14 Strep Antibody Titers, ASO Negative, Anti-DNase-B Negative and we are very concerned about some of the behavior (hard to tell at 2 1/2). We plan to test IgG subclasses this week and if they are low or low side of normal, we'll test them again in 3 months and Dr. K said he would treat for PID if they were still low. I'm interested to see if Dr. Lewis would recommend similar, see if they could actually test for strain of strep (M1, M3 or M18) especially since he has had experience with Kawasaki's..... my hope would be for monthly IVIG for 3 months if IgG subclasses are low so we don't have to go all the way to Chicago for treatment. That is why I've been frantically searching for information on exotoxins to give Dr. Lewis. Prove Kawasaki's is essentially RF.

 

So YES... I'm trying to do both..... dangle a good research direction in front of Lewis (i.e., a good topic for one of his grad students to work on) and trying to get him to do something perhaps for my younger son. BUT, I'm not overly invested in which direction he'll go because Dr. K will treat. Ultimately, if not my children, maybe Lewis will treat another child that has similar labs.

 

 

Interesting information:

 

Adrian sick November 4th, 2007 (play date) lab results below, Corsa sick November 14th, 2007, Romy sick November, 24th, 2007.... exactly 10 days apart consistent with incubation period for S. pyogenes.

 

Streptococci are catalase-negative. In ideal conditions, S. pyogenes has an incubation period of approximately 10 days.

 

http://en.wikipedia.org/wiki/Streptococcus_pyogenes

 

 

Markers Consistent with Rheumatic Fever for Adrian

 

Confirmed Strep Grp A diagnosis: 11/8/07

Abnormal Lab findings - elevated

 

RESULT RANGE

WBC 18.5 5.0 - 14.5

Neutrophilis 74 30 – 49

C-Reactive Protein 25.9 0 - 8

ESR 20 0 - 15

Anti-DNase B titer 680 <170

 

PNEUMOCOCCAL AB TITER 14 SUBTYPES

 

STREP PNEUMO 2/14/08 11/12/09

TYPE 1 <1.00 0.26

TYPE 3 10.27 3.93

TYPE 4 <1.00 0.20

TYPE 8 <1.00 0.43

TYPE 9 <1.00 0.16

TYPE 12 <1.00 0.21

TYPE 14 1.43 0.81

TYPE 19 1.40 1.00

TYPE 23 1.47 0.59

TYPE 26 9.00 5.16

TYPE 51 1.49 1.00

TYPE 56 <1.00 0.24

TYPE 57 1.43 1.85

TYPE 68 <1.00 0.36

 

ECHOCARDIOGRAM INTERPRETATION SUMMARY 11/12/09: Normal with exception of mild (1+) tricuspid regurgitation present in right heart.

 

 

 

 

 

Hi Wendy,

 

I'm pretty sure Dr. Lewis won't value comments off the internet by parents even if backed with good scientific data. It just doesn't seem to be the nature of immunologists :-)

 

Usually a good paper on a topic, particularly one in a notable journal (like JNI or Nature), is more effective.

 

If it's not a paper he's already read, he'll scan it in the 15 min before the appointment. I think he, like many specialists, are looking for a reason to treat --but they want to have a reason and not just be experimenting. Unfortunately, the science (and funding) here is still 5-10 years away from the conclusive evidence that is really needed.

 

I think you've met with with him before, right? He is extremely well versed in Kawasaki's disease and has his own research around T cells. My strongest recommendation would be to consider what you want done, and why you think it will help, and then ask him what he'd need to see in tests or otherwise to support you? I presume he's already done his own lab work, discovered nothing particularly unusual, so he's not finding a way yet to support you.

 

My memory is that you have a ~3 year old diagnosed and treated for Kawasaki's. A ~6 year old diagnosed and treated with IVIG (Sept 21) for PANDAS and a playmate who had peeling hands and lymph issues of KD but likely has PANDAS. So, just wondering if you are trying to dangle a good research direction in front of Lewis (i.e., a good topic for one of his grad students to work on) or trying to get him to do something?

 

Best wishes and hopes,

 

Buster

[Buster]

Confirmed Strep Grp A diagnosis: 11/8/07

Abnormal Lab findings - elevated

RESULT RANGE

WBC 18.5 5.0 - 14.5

Neutrophilis 74 30 – 49

C-Reactive Protein 25.9 0 - 8

ESR 20 0 - 15

Anti-DNase B titer 680 <170

 

That's a really significant C-Reactive protein level, ESR and neutrophil level. He is having significant inflammation going on. It would be consistent with RF (especially with the CRP and Anti-DNAse . Wow!

 

I see now why you are taking these three cases in together given the RF and KD... wish they had done an emm-typing.

 

Buster

[sf_mom]

You know Buster, they completely over looked the results back in 2007 - Immunologist in SF out of CPMC. It took Dr. Lewis mentioning it to me to get the formal diagnosis.... The problem is RF is not on anyones radar. The poor kid has been complaining of joint pain for two years..... lately looking like he could be diagnosed with Asperger's, held back in Kindergarten, etc. Thankfully, he was treated by Dr. K last week. Lewis said he would have treated him but my friend was unwilling to wait to see him. I think she will following up with Lewis in the next couple of months for similar reasons.

 

Dr. K, as well as, Madeleine are very interested in the connection. Plus there might be a fourth boy at play date who is now also PANDAS. They are still testing him so won't know for the next couple of months. Currently, I've got an e-mail out to Madeleine to determine if its RF in one person can the EXOTOXIN produce the disease in another.... i.e. Kawasaki's. Not sure she'll know the answer.

 

-Wendy

 

 

 

Confirmed Strep Grp A diagnosis: 11/8/07

Abnormal Lab findings - elevated

RESULT RANGE

WBC 18.5 5.0 - 14.5

Neutrophilis 74 30 – 49

C-Reactive Protein 25.9 0 - 8

ESR 20 0 - 15

Anti-DNase B titer 680 <170

 

That's a really significant C-Reactive protein level, ESR and neutrophil level. He is having significant inflammation going on. It would be consistent with RF (especially with the CRP and Anti-DNAse . Wow!

 

I see now why you are taking these three cases in together given the RF and KD... wish they had done an emm-typing.

 

Buster

[Buster]

You know Buster, they completely over looked the results back in 2007 - Immunologist in SF out of CPMC.

Are you kidding me? With CRP at almost 26 and an ESR at 20? They should either have been immediately looking for lyme disease or RF. The Anti-DNAseB should have driven them to RF. Amazing.

 

I'm not sure whether it is the exotoxins, certainly some of them act as super-antigens and recruit/activate 20+% of T-cells. With that many activated T-cells all sorts of things can go wrong. Why I'm asking about the emm-type is I think this is likely a key that may even help us determine the right exotoxins to track. I wonder if we could recruit Ed Kaplan at WHO to run emm-types on culture samples... He was the one who found that GABHS changed its M protein expression when moved from person to person. Perhaps there is something going on there.

 

Buster

[sf_mom]

I KNOW!!!!!!!!!! AND, they spent 8 months trying to eradicate the strep from Adrian to NO avail... they finally pulled his adenoids and called him cured when the swollen neck gland finally resolved. They never ever investigated the RF possibility. AND, basically that is what Madeleine stated.... 'all sorts of things can go wrong'. Apparently, they really haven't studied the underlying immunological issue of RF either. I've been hounding them that its the bacteria/exotoxin that attacks the host and basically wipes out the immune system (look at strep antibody titers results from 2007 to 2009 in Adrian) and not a disposition, maybe weak immune system due to age but that is all. THE ODDS OF FOUR OUT OF FIVE children getting sick at time of playdate, 3 children currently have very similar labs and all PANDAS range CaM Kinase, awaiting to test the fourth child. The only child who did not get sick was Romy's twin sister (only female at playdate) and I've also offered to run labs on her as a comparative.

 

There is something obviously going on and why I'm heading back to Lewis. I also think its the key to why we are not seeing raised ASO or Anti-DNase-B in many children. They DO NOT RISE in Kawasaki's so similar. Happy to run any tests and to recruit whoever. Dr. K called Madeleine to see how he could test for the S. pyogenes exotoxin but he is in Europe this week and don't know if they finally talked. Dr. K also wanted to call the people from the Japan study on Kawasaki's and S. pyrogenes exotoxin, he was walking around with the entire study while we were there (http://www.springerlink.com/content/l34qj830548q4q46/). He really wants to keep Romy in a holding pattern until we run further tests so we have him on 125 m.g. Azithromycin at the moment and we've seen improvement in his behavior. Madeleine latest comments were....... 'very interesting', its hard for her to dispute anything at this point. WE HAVE ALL THE LABS AND MEDICAL RECORDS. Corsa was never a sick child prior to exposure/illnesses... first time he was on an antibiotic was six months post illness when he got his first TICs (so, he was able to fight it off for a little bit). Adrian's mother never communicated positive strep at the time when my children got extremely ill.... She just didn't make the connection at the time and I didn't know enough. I had never even heard of Kawasaki's prior to Romy getting sick. I also hounded the Dr.'s while in the hospital saying my other son 'CORSA' had the same symptoms the week prior. Probably 4 Dr.'s told me Kawasaki's wasn't contagious!

 

 

 

 

 

 

 

 

 

You know Buster, they completely over looked the results back in 2007 - Immunologist in SF out of CPMC.

Are you kidding me? With CRP at almost 26 and an ESR at 20? They should either have been immediately looking for lyme disease or RF. The Anti-DNAseB should have driven them to RF. Amazing.

 

I'm not sure whether it is the exotoxins, certainly some of them act as super-antigens and recruit/activate 20+% of T-cells. With that many activated T-cells all sorts of things can go wrong. Why I'm asking about the emm-type is I think this is likely a key that may even help us determine the right exotoxins to track. I wonder if we could recruit Ed Kaplan at WHO to run emm-types on culture samples... He was the one who found that GABHS changed its M protein expression when moved from person to person. Perhaps there is something going on there.

 

Buster