Elevated ASO Titre: What It Means and How to Treat It

Understanding an Elevated ASO Titre

• Normal: < 200 Todd units in adults
• Positive/elevated: > 200 Todd units (rises ~1 week after infection, peaks at 3-5 weeks)
• The test is positive in only 80-85% of GAS infections, so a negative result does not exclude infection

Treatment Based on the Underlying Condition

1. Acute Streptococcal Pharyngitis (Primary Prevention of ARF)

Note: ASO titres are NOT recommended to diagnose acute tonsillitis/pharyngitis as they only indicate prior infection, not active disease - K.J. Lee's Essential Otolaryngology

2. Acute Rheumatic Fever (ARF)

• Benzathine Penicillin G 1.2 million units IM (single dose)
• Or Penicillin V orally for 10 days
• Erythromycin for penicillin-allergic patients

• Arthritis: Aspirin 80-100 mg/kg/day in divided doses (max 4-8 g/day) for 1-2 weeks, or Naproxen 10-20 mg/kg/day twice daily. Continue NSAIDs until all symptoms resolve - not just joint symptoms.
• Carditis with heart failure: Diuretics, ACE inhibitors/ARBs, fluid restriction, bed rest. Systemic glucocorticoids may be considered in severe cases (evidence is limited).
• Valve surgery: Reserved for acute rupture of valve leaflet or severe hemodynamic compromise - should not be delayed for anti-inflammatory trials.
• Sydenham's Chorea: Usually resolves without treatment in weeks to months. Antipsychotics or anticonvulsants for symptomatic management; IVIG/plasmapheresis in refractory cases.

3. Post-streptococcal Glomerulonephritis (PSGN)

• Bed rest
• Management of hypertension (antihypertensives)
• Fluid and salt restriction
• Diuretics for edema
• Dialysis in severe acute kidney injury

4. PANDAS

• Antibiotics when a streptococcal infection is confirmed by culture or elevated ASO/anti-DNase B
• Antibiotic prophylaxis is recommended in some cases to prevent recurrences
• Immunomodulatory therapy (IVIG, plasma exchange) in severe cases

Key Points to Remember

• An elevated ASO titre by itself does not require treatment - treat the underlying condition it points to
• Always combine ASO with anti-DNase B for better sensitivity (using both increases detection of prior GAS infection)
• IM benzathine penicillin is superior to oral regimens for secondary prophylaxis due to compliance issues
• About 35-70% of ARF patients progress to chronic rheumatic heart disease despite treatment, making prophylaxis essential

Treatment of Vaginal Discharge

Quick Diagnostic Comparison

1. Bacterial Vaginosis (BV) - Most Common Cause

• Suppressive therapy: Metronidazole gel 0.75% twice weekly for 16 weeks
• Vaginal probiotics with Lactobacillus crispatus (LACTIN-V) have shown ~1/3 reduction in recurrence in trials

• Metronidazole 500 mg twice daily x 7 days (safe in all trimesters)
• Avoid clindamycin cream in the second trimester and beyond (associated with adverse events)
• Treatment reduces symptoms but does NOT consistently reduce risk of preterm delivery

Partner treatment: Not recommended - no benefit shown

2. Vulvovaginal Candidiasis (VVC)

Partner treatment: Not routinely needed - treat male partners only if symptomatic candidal balanitis is present

3. Trichomoniasis

• Pregnancy: Metronidazole is the drug of choice in all trimesters (tinidazole is FDA category C - avoid in first trimester)
• HIV-positive women: Treat with metronidazole 500 mg twice daily x 7 days (not single dose, due to higher treatment failure rate)

Partner treatment: MANDATORY - all sexual partners must be treated regardless of symptoms. Test-of-cure at 3 months is recommended.

4. Mucopurulent Cervicitis (Gonorrhea / Chlamydia)

5. Other Causes

Syndromic Approach (Where Lab Testing Is Unavailable)

• Oral metronidazole (covers BV and trichomoniasis)
• Topical antifungal azole (covers candidiasis)

Low Back Pain with Tingling and Numbness in the Lower Limb - Management

Step 1: Initial Assessment - Red Flags and Neurological Grading

Step 2: Dermatomal Localization of the Radiculopathy

Step 3: Investigations

• Plain X-ray lumbar spine: First-line; shows disc space narrowing, osteophytes, spondylolisthesis, fractures
• MRI lumbar spine (gold standard): Indicated when symptoms persist >4-6 weeks, neurological deficit is present, or surgery is being considered. Best for soft tissue (disc, nerves, cord)
• CT scan: Better for bony canal stenosis, foraminal narrowing, calcified discs; use when MRI is contraindicated
• EMG/Nerve conduction studies: Helpful in confirming radiculopathy vs. peripheral neuropathy, and in selecting surgical candidates
• CT myelography: For complex cases when MRI is unavailable or contraindicated

Step 4: Conservative (Non-Surgical) Management

A. Pharmacological Treatment

Note: Avoid prolonged opioid use given risks of dependence. Avoid NSAIDs in elderly with renal impairment, peptic ulcer disease, or cardiovascular risk.

B. Physical and Rehabilitative Treatment

• Physiotherapy: Core of conservative management
  • McKenzie exercises (extension-based therapy for disc herniation)
  • Lumbar stabilization exercises
  • Stretching of hamstrings and piriformis
  • Postural correction
• Encourage activity: Bed rest is not recommended - early mobilization speeds recovery
• Heat therapy: For muscle spasm relief
• TENS (Transcutaneous Electrical Nerve Stimulation): Adjunct for pain
• Spinal manipulation (chiropractic/osteopathy): Recommended by multiple guidelines for subacute and chronic LBP; avoid with progressive neurological deficit
• Traction: Limited evidence; not routinely recommended
• Acupuncture: Recommended by NICE and BMJ guidelines for chronic LBP

C. Interventional (Minimally Invasive) Procedures

Step 5: Surgical Management

Indications for Surgery

1. Absolute (urgent): Cauda equina syndrome - bilateral motor/sensory loss, sphincteric dysfunction
2. Relative (elective):
   • Failure of 6-12 weeks of adequate conservative treatment
   • Disabling, progressive neurological deficit (e.g., foot drop)
   • Severe pain significantly impairing quality of life
   • Imaging findings consistent with the clinical picture

Surgical Options

Outcomes of Surgery vs. Conservative Care

• Early microdiscectomy provides faster pain relief vs. conservative care
• At 1 year follow-up, outcomes are similar between early surgery and conservative care for disc herniation
• Surgery is superior for pain relief at 6 and 12 months when sciatica has persisted for 4-12 months
• Patients with foot drop or progressive weakness benefit from early surgical decompression

Step 6: Management of Chronic Low Back Pain with Radiculopathy

• Structured physiotherapy and graded exercise programs
• Multidisciplinary pain management programs
• Cognitive behavioural therapy (CBT) - addresses pain catastrophizing and disability
• Long-term neuropathic agents (pregabalin, duloxetine)
• Spinal cord stimulation (SCS) for refractory radicular pain
• Re-evaluation for surgery if not previously considered

Practical Summary Algorithm

LBP + tingling/numbness lower limb
           |
   Screen for RED FLAGS
           |
   ┌───────┴───────┐
Urgent (cauda   No red flags
equina/progressive   |
deficit)         Investigate (MRI if indicated)
   |                    |
Surgical         Conservative x 6-12 weeks
emergency        (NSAIDs + pregabalin + physio)
                        |
                ┌───────┴───────┐
           Improving        No improvement
                        Epidural steroid injection
                                |
                        Still no improvement
                        Surgical referral
                        (Microdiscectomy / Laminectomy)

Treatment for Increased IgE Levels

Key Principle: Treat the Underlying Cause

Step 1: Identify the Cause

Treatment by Underlying Condition

1. Allergic Rhinitis (IgE-mediated)

• Subcutaneous immunotherapy (SCIT): Weekly injections escalating to monthly; 3-5 years duration; reduces specific IgE and symptoms; durable effect; anaphylaxis risk requires 30-min post-injection observation
• Sublingual immunotherapy (SLIT): Tablet dissolved under tongue at home; comparable efficacy to SCIT for dust mite, timothy grass, and short ragweed allergens; lower systemic reaction risk but transient oral pruritus common
• Contraindicated in significant cardiovascular disease or unstable asthma; caution with beta-blockers (anaphylaxis harder to treat)

2. Allergic Asthma

Omalizumab reduces exacerbations requiring hospitalization by 88% and allows reduction in corticosteroid dose. Patients must be monitored 30-60 minutes after injection due to anaphylaxis risk.

3. Atopic Dermatitis (Eczema)

Note: Omalizumab has not shown significant clinical benefit in atopic dermatitis despite elevated IgE.

4. Parasitic Infections (Helminthic/Protozoal)

5. Allergic Bronchopulmonary Aspergillosis (ABPA)

• Oral prednisolone: 0.5 mg/kg/day x 2 weeks, then taper
• Itraconazole or Voriconazole: Antifungal to reduce fungal burden
• Omalizumab: Used adjunctively in refractory cases to allow steroid reduction
• Monitor with serial IgE levels (IgE should fall >35% with treatment response)

6. Hyper-IgE Syndrome (HIES) - STAT3 or DOCK8 mutations

• Antibiotic prophylaxis: TMP-SMX (trimethoprim-sulfamethoxazole) for recurrent skin and airway infections
• Antifungal prophylaxis: For Candida and Aspergillus
• IVIG replacement: For patients with poor antibody responses
• Hematopoietic stem cell transplantation (HSCT): Considered in severe or refractory DOCK8-deficiency cases (curative for autosomal recessive form)
• Wound care: Incision and drainage of skin abscesses

Summary: Approach to Elevated IgE

Elevated serum IgE
        |
   History + Examination
        |
  ┌─────┴──────────────────┐
Atopic history?         Eosinophilia?     Recurrent infections from childhood?
(asthma, eczema,        (parasites, ABPA, (Hyper-IgE syndrome)
rhinitis)               eosinophilic disorders)
        |                    |                      |
Treat specific          Identify pathogen      Genetic testing
allergic condition      Antiparasitic /        Prophylactic Abx
+ Allergen IT           antifungal Rx          HSCT if severe
+ Omalizumab if
severe/refractory