Short Communication 299 Results
Perianale Streptokokken-Dermatitis ist keine wesentliche Ursache der chronischen Obstipation zerebralparetischen Kinder Introduction
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Painful defecation and constipation, as well as perianal itch and erythema, are the main clinical symptoms of perianal dermatitis, frequently caused by a streptococcus infection, mainly Streptococcus pyogenes. (Meury SN et al., J Pediatr 2008; 153: 799–802). Constipation is also a frequently observed relevant comorbidity in children with cerebral palsy (CP) with a prevalence of upto > 50 % (Veugelers R, et al., Dev Med Child Neurol 2010; 52: e216–e221). The definitive causes of an increased frequency of constipation in children with CP are unknown. In some patients with CP, the need for swaddling clothes or continuous spastic adduction of the legs can cause poor perianal hygiene. With these conditions, one can assume a possible higher risk for perianal infections, which can cause or compound constipation. The aim of this study was to determine the frequency of perianal dermatitis and the frequency of perianal streptococcus colonization and infection in a convenience sample of children, adolescents, and young adults with cerebral palsy under our center’s care.
Patients and Methods
▼
This study was conducted as a single-center cross-sectional study in the outpatient clinic of the Division of Neuropediatrics and Developmental Medicine of the University Childrenʼs Hospital of Basel. During the 4-month study period from January to April, all parents and, if possible, patients who were diagnosed as having a CP (inclusion criteria) were eligible to participate in this study as a convenience cohort. After informed consent had been obtained from parents and patients (depending on the age and developmen▶ Table 1, the tal level), as documented in ●
patients’ parents filled out a standardized questionnaire about perianal signs and symptoms during the previous 4 weeks. The questions about the stool habits requested information about frequency (classified as “daily”, “2–6 times/week”, and “ < 2 times/week”), consistency (classified in accordance with the Bristol stool form charts (Rubin et al. BMJ 2006; 333: 1051–1055) as “separate hard lumps” (type 1), “sausage-like but lumpy or with cracks” (type 2 and 3), “like a sausage” (type 4), and “soft” (type 5 and 6)), and special procedures to regulate the stool (no special procedure, intake of special nutrients, or intake of oral or rectal drugs). In a further analysis, types 1–3 of the stool form were combined into “hard stool”, types 4–6 into “normal stool”. Intake of an antibiotic drug during the previous 4 weeks was an exclusion criterion. The study was approved by the local ethics committee as an amendment (EKBB – 251/00)to a previous study (Landolt et al., Praxis 2005; 94: 1467–1471). After filling out the questionnaire, local inspection of the perianal region was performed by a physician (E.N. or P.W.) to assess the presence of streptococcus infection or perianal dermatitis, respectively. Thereafter an anal swab for bacterial culture was obtained and analyzed as previously described (Landolt et al., Praxis 2005; 94: 1467–1471). Statistics: Statistical analyses were performed with the SPSS 21.0 program. Mann-Whitney-U-test was used to calculate associations between GMFCS level and stool frequency and consistency, clinical scores 1 and 2 and clinical signs and history of perianal dermatitis. Pearsonʼs Chi-Quadrate was used to calculate associations between stool frequency and consistency and clinical scores 1 and 2, perianal erythema and rhagades, and anal swab result.
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A total of 96 patients (55 male) with a mean age of 11.4 years ( ± 5.1) were included in the study. 22.9 % suffered from hypotone-atactic, 60.4 % from spastic bilateral, and 16.7 % from spastic unilateral CP. 65.6 % had a Gross Motor Function Classification System (GMFCS) (Palisano R et al., Dev Med Child Neurol 1997; 39: 214–223) level from I–III, 34.4 % a level of IV–V. 37.5 % of the patients were treated with anticonvulsive drugs. ▶ Table 1 documents the reports about ● the frequency and form of stools, as well as the reports about special procedures to regulate the stools. According to Meury et al. (2008), a weighted clinical score (score 1) including a history of perianal erythema, perianal itch, painful defecation, and constipation was calculated. Also, a modified clinical score (score 2) was calculated, in which a history of blood-streaked stools was assigned 3 points and a history of pus was assigned 5 points in addition to the score by Meury et al. (2008). Both ▶ Table 1. scores are documented in ● No significant association was found between score 1 and stool frequency. In addition, all 9 patients with a stool frequency of less than 2 times/week had a value of 0 as score 2. However a significant association exists between stool consistency and score 1 (p < 0.001) and stool consistency and score 2 (p < 0.018). Patients with hard stools show a more frequent history of perianal symptoms, blood-streaks, and pus. In our cohort, the mobility as expressed by the GMFCS level showed neither a significant association to stool consistency or frequency, nor to scores 1 or 2. We found no differences between the groups of children with CP who are able to walk (GMFCS levels I–III) as compared with those who are unable to walk (GMFCS levels IV–V), neither in consistency (p = 0.740) or in frequency (p = 0.618) of stools, nor in the history or clinical findings suggesting perianal dermatitis (differences in score 1 [p = 0.216] and score 2 [p = 0.195] are not significant between the GMFCS levels I–III vs. IV–V). Positive streptococcus cultures were found in 2 patients with GMFCS level V, in one patient with GMFCS level II, and in 3 patients with GMFCS level I. Besides these scores, the frequency of clinical findings
Nava E et al. Perianal Streptococcal Dermatitis is … Klin Padiatr 2014; 226: 299–300 · DOI 10.1055/s-0034-1371842
Downloaded by: University of Pittsburgh. Copyrighted material.
Perianal Streptococcal Dermatitis is not a Major Cause of Constipation in Pediatric Patients with Cerebral Palsy
Table 1 Stool characteristics, history of perianal signs and symptoms, clinical scores (mean and standard deviation), and clinical findings indicating possible perianal Streptococcus infection in 96 patients. Stool characteristics stool frequency – daily – ≥ 2–6/week − < 2/week stool consistency − normal − hard anti-constipation procedure − none − dietary − medication History of perianal symptoms and clinical scores perianal erythema (N) perianal itch (N) painful defecation (N) perianal pus (N) Score 1 (mean ± standard deviation; maximum: 13 points) blood-streaked stool (N) pus Score 2 (mean ± standard deviation; maximum: 8 points) Clinical findings perianal erythema perianal rhagades perianal blood perianal pus vaginitis/balanitis
indicating a possible streptococcus infec▶ Table 1). tion was documented (● None of the patients showed blood or pus. No association was found between perianal erythema and stool consistency (p = 0.81) or stool frequency (p = 0.055). Similarly, no association was found between perianal rhagades and stool consistency (p = 0.446) nor stool frequency (p = 0.415). In 94 of 96 patients (98 %) an anal swab was performed. A positive streptococcus culture was detected in 6 cases (6.4 %): colonization with Group A β-hemolytic Streptococcus (GABHS) was found in 2 cases, Group G Streptococcus in 2 cases, co-colonization with Group G and Group C Streptococcus in one case, and colonization with Group B Streptococcus was found in one case. The last patient suffered from bilateral spastic CP GMFCS level V, wears swaddling clothes, but without any special perianal findings
N ( %) 52 (54.2 %) 35 (36.5 %) 9 (9.4 %) 61 (63.6 %) 35 (36.4 %) 63 (65.6 %) 10 (10.4 %) 23 (24.0 %) N 14 7 17 37 2.25 ( ± 3.3) 7 1 2.52 ( ± 3.8) 12 1 0 0 1
(scores 1 and 2 are 0) with daily, formed stools, and without clinical findings on the perianal examination. Neither a significant association was found between a positive swab finding and stool frequency (p = 0.830), nor between a positive swab finding and stool consistency (p = 0.881). No significant association was found between perianal streptococcus colonization and score 1 (p = 0.427), however we found a clear association between streptococcus colonization and score 2 (p = 0.001). The patient with the maximal sum value of scores 1 and 2 (18 points) showed a colonization with GABHS.
Discussion
▼
leading to perianal dermatitis, possibly causing an additional condition for developing constipation or its aggravation. In our cohort we found perianal dermatitis with positive culture for GABHS in merely 1 of 94 patients (prevalence of 1.1 %) indicating that children and adolescents with CP show a prevalence of perianal dermatitis in the same range as clinical admission groups with no neurological disorders (Mogielnicki NP et al., Pediatrics 2000; 106: 276–281; Meury SN et al. 2008). In addition, 5 patients showed perianal streptococcus colonization without clear clinical signs of perianal dermatitis. In our study cohort, 9.4 % of patients showed severe constipation and 34.4 % used some kind of anti-constipation treatment. This lower rate of constipation, compared with other studies is probably associated with the lower rate of children with severe mobility limitations, as indicated by the lower rate of children with GMFCS level IV and V. The 2 cases in which we could detect GABHS by culture are patients with GMFCS level III and GMFCS level V. Both are incontinent and wear swaddling clothes, which could be a risk factor for a perianal infection. The most important limitation of this study is its small sample size, but since recruitment was unselected it correctly reflects our practice. In summary, perianal dermatitis caused by GABHS does not appear to occur more frequently in children with CP than in otherwise healthy children. Moreover perianal dermatitis does not seem to be a frequent organic cause for constipation in children with CP.
Conflict of interest: The authors have no conflict of interest to disclose.
E. Nava, U. Heininger, P. Weber; Basel, Switzerland
Children and adolescents with cerebral palsy do not appear to have an increased risk of perianal infection with GABHS
Nava E et al. Perianal Streptococcal Dermatitis is … Klin Padiatr 2014; 226: 299–300 · DOI 10.1055/s-0034-1371842
Downloaded by: University of Pittsburgh. Copyrighted material.
300 Short Communication
Perianale Streptokokken-Dermatitis ist keine wesentliche Ursache der chronischen Obstipation zerebralparetischen Kinder Introduction
▼
Painful defecation and constipation, as well as perianal itch and erythema, are the main clinical symptoms of perianal dermatitis, frequently caused by a streptococcus infection, mainly Streptococcus pyogenes. (Meury SN et al., J Pediatr 2008; 153: 799–802). Constipation is also a frequently observed relevant comorbidity in children with cerebral palsy (CP) with a prevalence of upto > 50 % (Veugelers R, et al., Dev Med Child Neurol 2010; 52: e216–e221). The definitive causes of an increased frequency of constipation in children with CP are unknown. In some patients with CP, the need for swaddling clothes or continuous spastic adduction of the legs can cause poor perianal hygiene. With these conditions, one can assume a possible higher risk for perianal infections, which can cause or compound constipation. The aim of this study was to determine the frequency of perianal dermatitis and the frequency of perianal streptococcus colonization and infection in a convenience sample of children, adolescents, and young adults with cerebral palsy under our center’s care.
Patients and Methods
▼
This study was conducted as a single-center cross-sectional study in the outpatient clinic of the Division of Neuropediatrics and Developmental Medicine of the University Childrenʼs Hospital of Basel. During the 4-month study period from January to April, all parents and, if possible, patients who were diagnosed as having a CP (inclusion criteria) were eligible to participate in this study as a convenience cohort. After informed consent had been obtained from parents and patients (depending on the age and developmen▶ Table 1, the tal level), as documented in ●
patients’ parents filled out a standardized questionnaire about perianal signs and symptoms during the previous 4 weeks. The questions about the stool habits requested information about frequency (classified as “daily”, “2–6 times/week”, and “ < 2 times/week”), consistency (classified in accordance with the Bristol stool form charts (Rubin et al. BMJ 2006; 333: 1051–1055) as “separate hard lumps” (type 1), “sausage-like but lumpy or with cracks” (type 2 and 3), “like a sausage” (type 4), and “soft” (type 5 and 6)), and special procedures to regulate the stool (no special procedure, intake of special nutrients, or intake of oral or rectal drugs). In a further analysis, types 1–3 of the stool form were combined into “hard stool”, types 4–6 into “normal stool”. Intake of an antibiotic drug during the previous 4 weeks was an exclusion criterion. The study was approved by the local ethics committee as an amendment (EKBB – 251/00)to a previous study (Landolt et al., Praxis 2005; 94: 1467–1471). After filling out the questionnaire, local inspection of the perianal region was performed by a physician (E.N. or P.W.) to assess the presence of streptococcus infection or perianal dermatitis, respectively. Thereafter an anal swab for bacterial culture was obtained and analyzed as previously described (Landolt et al., Praxis 2005; 94: 1467–1471). Statistics: Statistical analyses were performed with the SPSS 21.0 program. Mann-Whitney-U-test was used to calculate associations between GMFCS level and stool frequency and consistency, clinical scores 1 and 2 and clinical signs and history of perianal dermatitis. Pearsonʼs Chi-Quadrate was used to calculate associations between stool frequency and consistency and clinical scores 1 and 2, perianal erythema and rhagades, and anal swab result.
▼
A total of 96 patients (55 male) with a mean age of 11.4 years ( ± 5.1) were included in the study. 22.9 % suffered from hypotone-atactic, 60.4 % from spastic bilateral, and 16.7 % from spastic unilateral CP. 65.6 % had a Gross Motor Function Classification System (GMFCS) (Palisano R et al., Dev Med Child Neurol 1997; 39: 214–223) level from I–III, 34.4 % a level of IV–V. 37.5 % of the patients were treated with anticonvulsive drugs. ▶ Table 1 documents the reports about ● the frequency and form of stools, as well as the reports about special procedures to regulate the stools. According to Meury et al. (2008), a weighted clinical score (score 1) including a history of perianal erythema, perianal itch, painful defecation, and constipation was calculated. Also, a modified clinical score (score 2) was calculated, in which a history of blood-streaked stools was assigned 3 points and a history of pus was assigned 5 points in addition to the score by Meury et al. (2008). Both ▶ Table 1. scores are documented in ● No significant association was found between score 1 and stool frequency. In addition, all 9 patients with a stool frequency of less than 2 times/week had a value of 0 as score 2. However a significant association exists between stool consistency and score 1 (p < 0.001) and stool consistency and score 2 (p < 0.018). Patients with hard stools show a more frequent history of perianal symptoms, blood-streaks, and pus. In our cohort, the mobility as expressed by the GMFCS level showed neither a significant association to stool consistency or frequency, nor to scores 1 or 2. We found no differences between the groups of children with CP who are able to walk (GMFCS levels I–III) as compared with those who are unable to walk (GMFCS levels IV–V), neither in consistency (p = 0.740) or in frequency (p = 0.618) of stools, nor in the history or clinical findings suggesting perianal dermatitis (differences in score 1 [p = 0.216] and score 2 [p = 0.195] are not significant between the GMFCS levels I–III vs. IV–V). Positive streptococcus cultures were found in 2 patients with GMFCS level V, in one patient with GMFCS level II, and in 3 patients with GMFCS level I. Besides these scores, the frequency of clinical findings
Nava E et al. Perianal Streptococcal Dermatitis is … Klin Padiatr 2014; 226: 299–300 · DOI 10.1055/s-0034-1371842
Downloaded by: University of Pittsburgh. Copyrighted material.
Perianal Streptococcal Dermatitis is not a Major Cause of Constipation in Pediatric Patients with Cerebral Palsy
Table 1 Stool characteristics, history of perianal signs and symptoms, clinical scores (mean and standard deviation), and clinical findings indicating possible perianal Streptococcus infection in 96 patients. Stool characteristics stool frequency – daily – ≥ 2–6/week − < 2/week stool consistency − normal − hard anti-constipation procedure − none − dietary − medication History of perianal symptoms and clinical scores perianal erythema (N) perianal itch (N) painful defecation (N) perianal pus (N) Score 1 (mean ± standard deviation; maximum: 13 points) blood-streaked stool (N) pus Score 2 (mean ± standard deviation; maximum: 8 points) Clinical findings perianal erythema perianal rhagades perianal blood perianal pus vaginitis/balanitis
indicating a possible streptococcus infec▶ Table 1). tion was documented (● None of the patients showed blood or pus. No association was found between perianal erythema and stool consistency (p = 0.81) or stool frequency (p = 0.055). Similarly, no association was found between perianal rhagades and stool consistency (p = 0.446) nor stool frequency (p = 0.415). In 94 of 96 patients (98 %) an anal swab was performed. A positive streptococcus culture was detected in 6 cases (6.4 %): colonization with Group A β-hemolytic Streptococcus (GABHS) was found in 2 cases, Group G Streptococcus in 2 cases, co-colonization with Group G and Group C Streptococcus in one case, and colonization with Group B Streptococcus was found in one case. The last patient suffered from bilateral spastic CP GMFCS level V, wears swaddling clothes, but without any special perianal findings
N ( %) 52 (54.2 %) 35 (36.5 %) 9 (9.4 %) 61 (63.6 %) 35 (36.4 %) 63 (65.6 %) 10 (10.4 %) 23 (24.0 %) N 14 7 17 37 2.25 ( ± 3.3) 7 1 2.52 ( ± 3.8) 12 1 0 0 1
(scores 1 and 2 are 0) with daily, formed stools, and without clinical findings on the perianal examination. Neither a significant association was found between a positive swab finding and stool frequency (p = 0.830), nor between a positive swab finding and stool consistency (p = 0.881). No significant association was found between perianal streptococcus colonization and score 1 (p = 0.427), however we found a clear association between streptococcus colonization and score 2 (p = 0.001). The patient with the maximal sum value of scores 1 and 2 (18 points) showed a colonization with GABHS.
Discussion
▼
leading to perianal dermatitis, possibly causing an additional condition for developing constipation or its aggravation. In our cohort we found perianal dermatitis with positive culture for GABHS in merely 1 of 94 patients (prevalence of 1.1 %) indicating that children and adolescents with CP show a prevalence of perianal dermatitis in the same range as clinical admission groups with no neurological disorders (Mogielnicki NP et al., Pediatrics 2000; 106: 276–281; Meury SN et al. 2008). In addition, 5 patients showed perianal streptococcus colonization without clear clinical signs of perianal dermatitis. In our study cohort, 9.4 % of patients showed severe constipation and 34.4 % used some kind of anti-constipation treatment. This lower rate of constipation, compared with other studies is probably associated with the lower rate of children with severe mobility limitations, as indicated by the lower rate of children with GMFCS level IV and V. The 2 cases in which we could detect GABHS by culture are patients with GMFCS level III and GMFCS level V. Both are incontinent and wear swaddling clothes, which could be a risk factor for a perianal infection. The most important limitation of this study is its small sample size, but since recruitment was unselected it correctly reflects our practice. In summary, perianal dermatitis caused by GABHS does not appear to occur more frequently in children with CP than in otherwise healthy children. Moreover perianal dermatitis does not seem to be a frequent organic cause for constipation in children with CP.
Conflict of interest: The authors have no conflict of interest to disclose.
E. Nava, U. Heininger, P. Weber; Basel, Switzerland
Children and adolescents with cerebral palsy do not appear to have an increased risk of perianal infection with GABHS
Nava E et al. Perianal Streptococcal Dermatitis is … Klin Padiatr 2014; 226: 299–300 · DOI 10.1055/s-0034-1371842
Downloaded by: University of Pittsburgh. Copyrighted material.
300 Short Communication
