Roles of the alternative complement pathway and C1q during innate immunity to Streptococcus pyogenes

Complement is important for innate immunity to the common bacterial pathogen Streptococcus pyogenes, but the relative importance of the alternative and classical pathways has not been investigated. Using mice and human serum deficient in either C1q, the first component of the classical pathway, or factor B, an important component of the alternative pathway, we have investigated the role of both pathways for innate immunity to S. pyogenes. C3b deposition on four different strains of S. pyogenes was mainly dependent on factor B. As a consequence opsonophagocytosis of S. pyogenes was reduced in serum from factor B-deficient mice, and these mice were very susceptible to S. pyogenes infection. In contrast, C3b deposition was not dependent on C1q for two of the strains investigated, H372 and H305, yet opsonophagocytosis of all four S. pyogenes strains was impaired in serum deficient in C1q. Furthermore, infection in C1q-deficient mice with strain H372 resulted in a rapidly progressive disease associated with large numbers of bacteria in target organs. These results demonstrate the important role of the alternative pathway and C1q for innate immunity to S. pyogenes and suggest that C1q-mediated innate immunity to at least some strains of S. pyogenes may involve mechanisms that are independent of C3b on the bacteria.

One-off streptococcal serologic testing in young children with recurrent tonsillitis

OBJECTIVES

Recurrent acute tonsillitis in children under 4 years of age is usually viral, making antibiotic therapy inappropriate and the indication for tonsillectomy uncertain. Identifying those young children with bacterial infections is therefore important. The purpose of this study was to determine whether one-off streptococcal serologic testing is a useful tool in assessing recurrent acute tonsillitis in young children.

METHODS

We performed a retrospective study of 45 children (35 male and 10 female) under the age of 4 years who were found by a staff otolaryngologist to have recurrent acute tonsillitis over a 5-year period and had one-off serologic testing for anti-streptolysin O titers and anti-deoxyribonuclease B levels. Data were collected by chart review.

RESULTS

Three children (6.7%) had clearly positive titers for either one or both streptococcal antibodies. Children with negative serologic results were significantly less likely to have shown a significant response to antibiotic therapy for their acute episodes (26% versus 100%; p = .026). Nine children (20%) eventually underwent tonsillectomy, all of whom had negative serologic results.

CONCLUSIONS

Anti-streptolysin O and anti-deoxyribonuclease B levels may aid clinical evaluation of recurrent acute tonsillitis in young children in differentiating between those cases due to group A beta-hemolytic Streptococcus and those that are viral in origin.

Immunization with a tetraepitopic lipid core peptide vaccine construct induces broadly protective immune responses against group A streptococcus

BACKGROUND

The development of a vaccine to prevent infection with group A streptococcus (GAS) is hampered by the widespread diversity of circulating GAS strains and M protein types, and it is widely believed that a multivalent vaccine would provide better protective immunity.

METHODS

We investigated the efficacy of incorporating 3 M protein serotypic amino-terminal epitopes from GAS isolates that are common in Australian Aboriginal communities and a conformational epitope from the conserved carboxy-terminal C-repeat region into a single synthetic lipid core peptide (LCP) vaccine construct in inducing broadly protective immune responses against GAS after parenteral delivery to mice.

RESULTS

Immunization with the tetraepitopic LCP vaccine construct led to high titers of systemic, antigen-specific IgG responses and the induction of broadly protective immune responses, as was demonstrated by the ability of immune serum to opsonize multiple GAS strains. Systemic challenge of mice with a lethal dose of GAS given 60 or 300 days after primary immunization showed that, compared with the control mice, the vaccinated mice were significantly protected against GAS infection, demonstrating that the vaccination stimulated long-lasting protective immunity.

CONCLUSIONS

These data support the efficacy of the LCP vaccine delivery system in the development of a synthetic, multiepitopic vaccine for the prevention of GAS infection.

Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help?

BACKGROUND

Rapid streptococcal tests (RSTs) for streptococcal pharyngitis have made diagnosis at once simpler and more complicated. The American Academy of Pediatrics recommends that all RSTs be confirmed by a follow up throat culture unless local validation has proved the RST to be equally sensitive.

AIMS

To evaluate (a) RST as a single diagnostic tool, compared with RST with or without throat culture; (b) clinical diagnosis and the relative contribution of different symptoms.

METHODS

The study included 213 patients with clinical signs of pharyngitis. Throat swabs were analysed using Quickvue+ Strep A Test; negative RSTs were backed up by throat culture. Thirteen clinical features commonly associated with strep throat were analysed using backward stepwise logistic regression.

RESULTS

Positive results (RST or throat culture) were obtained in 33 patients; RST correctly identified 21. Eleven samples were false negative on RST. At a strep throat prevalence of 15.9%, sensitivity of RST was 65.6% (95% CI 46.8% to 81.4%) and specificity 99.4% (96.7% to 99.9%). Sensitivity of clinical diagnosis alone was 57% (34% to 78%) and specificity 71% (61% to 80%). Clinically, only history of sore throat, rash, and pyrexia contributed to the diagnosis of strep throat (p<0.05).

CONCLUSION

The high specificity of RST facilitates early diagnosis of strep throat. However, the low sensitivity of RST does not support its use as a single diagnostic tool. The sensitivity in the present study is markedly different from that reported by the manufacturer. Clinical examination is of limited value in the diagnosis of strep throat. It is important to audit the performance of new diagnostic tests, previously validated in different settings.

[Rapid antigen tests in acute pharyngitis]

Acute pharyngitis is one of the most common illnesses for which adults seek medical help from primary care physicians. Approximately 15% of cases in adults are caused by group A beta-hemolytic Streptococcus. Strategies of management should aim at identifying the latter with a view to prevent the development of complications. Rapid Antigen tests have a reported specificity of more than 95%. Antibiotic therapy is only recommanded for patients with positive rapid antigen test results and those with risk factors.

Peripheral blood mononuclear cells proliferation and Th1/Th2 cytokine production in response to streptococcal M protein in psoriatic patients

BACKGROUND

Psoriasis is a chronic skin disease that is probably a T cell-mediated autoimmune condition which is strongly associated with streptococcal throat infections. Although some groups have associated the involved response with different streptococcal antigens, M protein has been described as the major virulence factor of Streptococcus pyogenes. Thus, it is necessary to describe some features of the cellular responses to this streptococcal antigen.

METHODS

Proliferation and Th1/Th2 cytokine production of peripheral blood mononuclear cells (PBMC) in response to total soluble extracts from type M5 S. pyogenes with (TSE37Sp) and without (M(-)TSESp) M protein were analyzed in 10 psoriatic patients and 10 healthy controls.

RESULTS

PBMC from both patients and controls proliferated to both extracts. Responses to M(-)TSESp were significantly lower than those to TSE37Sp (P < 0.05). PBMC IL-2 and gammaIFN production after TSE37Sp stimulus was much higher than after M(-)TSESp antigenic stimulation in both groups (P < 0.05). Meanwhile, IL-4 production was quite low in both groups and in response to both extracts. We found a differential production of IL-10 between groups. PBMC from healthy controls responded to TSE37Sp with a much higher production of this cytokine as compared to the responses showed to M(-)TSESp while the cells from psoriatic patients responded without differences in the production of IL-10.

CONCLUSION

Results obtained suggest an important Th1 response to M protein in psoriatic patients which could be associated with the cellular responses involved in psoriasis, while healthy subjects respond in a probably non-Th2 IL-10 producing regulatory T cells fashion.

The efficacy of CpG oligodinucleotides, in combination with conventional adjuvants, as immunological adjuvants to swine streptococcic septicemia vaccine in piglets in vivo

Oligodinucleotides containing CpG motifs (CpG ODN) are strong adjuvants for immune responses, particularly in mice, the immunostimulatory effects of CpG in combination with aluminum hydroxide (alum) or Emulsigen (Em) were investigated in cattle, rabbits or mice, but not piglets. In this report, using the swine streptococcus as model bacteria, the efficacy of CpG ODN as an adjuvant for piglets was assessed alone and in combination with alum (CpG/alum) or Em (CpG/Em). The CpG/alum or CpG/Em combination elicited greater immune responses to swine streptococcic septicemia killed vaccine (SSSK vaccine) compared with CpG alone, or alum or Em. A GpC/alum or GpC/Em combination did not have the same effects as CpG/alum or CpG/Em suggesting that the adjuvanticity was related to the CpG motifs. In addition, we also found that the 10% Em in combination with CpG ODN had similar immunological effects as 30% Em combination. Our results demonstrate that the addition of CpG ODN to alum or to Em significantly improves the efficiency of the adjuvants in piglets.

Anti-phagocytic mechanisms of Streptococcus pyogenes: binding of fibrinogen to M-related protein

A key attribute of invasive Streptococcus pyogenes is their ability to resist phagocytosis and multiply in human blood. M-related protein (Mrp) is a major anti-phagocytic factor but the mechanism whereby it helps streptococci to evade phagocytosis has not been demonstrated. We investigated phagocytosis resistance in a strain of serotype M4 by inactivating the mrp gene and also the emm, enn, sof and sfbX genes and by analysing the effect on streptococcal growth in blood and on complement deposition on the bacterial surface. Inactivation of enn4 and sfbX4 had little impact on growth in blood, but ablation of mrp4, emm4 or sof4 reduced streptococcal growth in human blood, confirming that Mrp and Emm are required for optimal resistance to phagocytosis and providing the first indication that Sof may be an anti-phagocytic factor. Moreover, antisera against Mrp4, Emm4 and Sof4 promoted the killing of S. pyogenes, but anti-SfbX serum had no effect. Growth of S. pyogenes in blood was dependent on the presence of fibrinogen and in the absence of fibrinogen there was a twofold increase in complement deposition. Inactivation of mrp4 resulted in a loss of fibrinogen-binding and caused a twofold increase in the binding of C3b that was inhibited by Mg-EGTA. Mrp contained two fibrinogen-binding sites, one of which is within a highly conserved region. These findings indicate that Mrp-fibrinogen interactions prevent surface deposition of complement via the classical pathway, thereby contributing to the ability of these streptococci to resist phagocytosis. This may be a common mechanism for evasion of phagocytosis because Mrp is expressed by approximately half of the clinical isolates of S. pyogenes.

Antibodies against Four Proteins from a Streptococcus pyogenes Serotype M1 Strain and Levels of Circulating Mannan-Binding Lectin in Acute Poststreptococcal Glomerulonephritis

BACKGROUND

Responses against antigens from the potentially nephritogenic Streptococcus pyogenes serotype M1 in patients with acute poststreptococcal glomerulonephritis (AGN) were studied to seek indications of expression of these antigens during the preceding infection. Also, the question was asked whether the complement protein mannan-binding lectin (MBL) is required for development of the hypocomplementemia associated with AGN. Hypothetically, the lectin pathway might trigger the alternative pathway, which is consistently activated in AGN.

METHODS

Antibodies against three proteins associated with M1, M1 protein, streptococcal inhibitor of complement (SIC) and protein H, an IgG-binding protein, were determined by ELISA in 56 children and 17 adults with AGN. Antibodies against streptococcal cysteine proteinase, which is produced by all serotypes of S. pyogenes, were also examined. MBL concentrations were measured in the same 71 patients by a sandwich ELISA.

RESULTS

Increased concentrations of antibodies were found against all four streptococcal proteins, albeit not uniformly distributed between different subgroups of patients. The prevalence of low MBL concentrations (<100 microg/l) including 2 patients with undetectable MBL (<10 microg/l) was similar in AGN (11%) and in controls (16%).

CONCLUSIONS

Our results give evidence of exposure to SIC and protein H in conjunction with AGN. This implies that SIC and protein H and/or cross-reacting proteins may have a role in the pathogenesis of AGN or that streptococci expressing SIC or protein H are nephritogenic for other reasons. The finding of MBL-deficient individuals among the patients demonstrates that MBL is not necessary for the recruitment of complement in AGN.

Domains of group A streptococcal M protein that confer resistance to phagocytosis, opsonization and protection: implications for vaccine development

Streptococcus pyogenes (group A streptococcus) colonizes skin and throat tissues resulting in a range of benign and serious human diseases. Opsonization and phagocytosis are important defence mechanisms employed by the host to destroy group A streptococci. Antisera against the cell-surface M protein, of which over 150 different types have been identified, are opsonic and contribute to disease protection. In this issue of Molecular Microbiology, Sandin and colleagues have comprehensively analysed the regions of M5 protein that contribute to phagocytosis resistance and opsonization. Human plasma proteins bound to M5 protein B- and C-repeats were shown to block opsonization, an observation that needs to be carefully considered for the development of M protein-derived vaccines. While safe and efficacious human group A streptococcal vaccines are not commercially available, candidate M protein-derived vaccines have shown promise in murine vaccine models and a recent phase 1 human clinical trial.

Binding of human plasma proteins to Streptococcus pyogenes M protein determines the location of opsonic and non-opsonic epitopes

Antibodies directed against a pathogenic microorganism may recognize either protective or non-protective epitopes. Because antibodies elicited by a vaccine must be directed against protective epitopes, it is essential to understand the molecular properties that distinguish the two types of epitope. Here we analyse this problem for the antiphagocytic M protein of Streptococcus pyogenes, using the opsonizing capacity of antibodies to estimate their ability to confer protection in vivo. Our studies were focused on the M5 protein, which has three surface-exposed regions: the amino-terminal hypervariable region (HVR) and the B- and C-repeat regions. We first analysed the role of different M5 regions in phagocytosis resistance under non-immune conditions, employing chromosomal mutants expressing M5 proteins with internal deletions, and demonstrate that only the B-repeat region is essential for phagocytosis resistance. However, only antibodies to the HVR were opsonic. This apparent paradox could be explained by the ability of fibrinogen and albumin to specifically bind to the B- and C-repeats, respectively, causing inhibition of antibody binding under physiological conditions, while antibodies to the HVR could bind and promote deposition of complement. These data indicate that binding of human plasma proteins plays an important role in determining the location of opsonic and non-opsonic epitopes in streptococcal M protein.

Otomicroscopic findings and systemic interleukin-6 levels in relation to etiologic agent during experimental acute otitis media

The aim of the present study was to explore whether it was possible to differentiate the clinical course and the otomicroscopic appearance of acute otitis media (AOM) caused by common otitis pathogens in an animal model. Systemic interleukin (IL)-6 levels as early markers for bacterial AOM were also studied. Four groups of rats were inoculated with either Streptococcus pneumoniae, Streptococcus pyogenes, non-typeable Haemophilus influenzae or Moraxella catarrhalis. The animals were monitored by otomicroscopy, photos of the tympanic membrane, cultures and IL-6 detection in serum the following 4 days. The gram-positive S. pneumoniae and S. pyogenes induced severe AOM with opaque effusion behind the tympanic membrane, pronounced dilation of the vessels and spontaneous perforations. The gram-negative H. influenzae and M. catarrhalis induced a less severe infection with cloudy, sometimes foamy effusion, and no spontaneous perforations. With the otomicroscopic findings it was possible to distinguish between infections induced by gram-positive bacteria and gram-negative bacteria. Detection of interleukin-6 in serum appeared to be of limited use for all infections except the pneumococcal AOM, but this needs to be further investigated.

Development of serum IgM antibodies against superantigens of Staphylococcus aureus and Streptococcus pyogenes in Kawasaki disease

To serologically determine the association of microbial superantigens and the pathogenesis of Kawasaki disease (KD), we conducted a case-control study. Serum IgG and IgM antibodies against staphylococcal enterotoxin A (SEA), SEB, SEC, toxic shock syndrome toxin-1 (TSST-1), and streptococcal pyrogenic exotoxin A (SPEA) were measured by an enzyme-linked immunosorbent assay in 293 serum samples from 65 KD patients on clinical days 1-28 and 120 control samples. The administration of immunoglobulin products, which contain high concentrations of IgG antibodies against all the superantigens, directly elevated antitoxin IgG antibodies in KD patients. In contrast, antitoxin IgM antibodies were not detected in immunoglobulin products. Actually, we found a significant elevation of IgM antibodies against SEA in KD patients in the first (median titre: 0.020, P < 0.01 versus control), second (0.024, P < 0.001), third (0.030, P < 0.001) and fourth (0.038, P < 0.001) weeks, compared to the controls (0.015). Significant differences of IgM antibodies were also true for SEB, TSST-1, and SPEA throughout the first to fourth weeks, and for SEC throughout the second to fourth weeks. The prevalence of KD patients having high IgM titres (> mean + 2SD of control values) to the 5 superantigens was increased with the clinical weeks, and reached 29-43% of KD subjects at the fourth week. This is the first study that describes kinetics of IgM antibodies against superantigens and clarifies the serological significance throughout the clinical course of KD. Our results suggest that multiple superantigens involve in the pathogenesis of KD.

Skin basement membrane zone: a depository for circulating microbial antigen evoking psoriasis and autoimmunity

BACKGROUND

Elevated levels of antibody to streptococcal exoenzymes have been found in patients with psoriasis or psoriatic arthritis. Research on the role of streptococcal antigen in psoriasis has been hampered by a potential molecular mimicry between streptococcal epitopes and human epidermal keratin.

OBJECTIVE AND METHODS

Evidence of microbial product was sought in skin biopsies of psoriasis patients thought clinically to have either streptococcal carrier state or gastrointestinal candidal colonization. A polyclonal antibody to streptococcal-derived exoenzymes unlikely to share antigenic structures with normal human skin, and an anticandidal antibody, were used with linked streptavidin biotin amplification stain.

RESULTS

The predicted microbial product appeared heavily in lesional epidermis, but unexpectedly also as a thin deposit along the skin basement membrane zone (SBMZ) of apparently unaffected skin. Staining was negative for nonpsoriatic subjects.

CONCLUSIONS

The findings support a direct effect of microbial antigen in psoriasis. They also suggest an important role for SBMZ as a very large adhesive surface in the first step of a process of percutaneous epidermal elimination of foreign antigens and microbial toxins. The many autoimmune phenomena seen so often at the SBMZ are probably a physiologic part of this important immune function. Efforts to enhance the adhesive properties of SBMZ should be exploitable for both diagnostic and therapeutic benefit.

Intranasal immunization with serum opacity factor (SOF) of Streptococcus pyogenes fails to protect mice against lethal mucosal challenge with a heterologous strain

Streptococcus pyogenes is a human pathogen causing invasive and non-invasive diseases, as well as severe sequels, such as rheumatic fever. Several bacterial factors have been proposed as candidate vaccine antigens. Among them, the serum opacity factor (SOF), which was able to confer protective immunity against an intraperitoneal challenge after vaccination by the parenteral route. In an attempt to develop more efficient vaccines, we combined SOF with an additional well-known protective antigen, namely, the fibronectin-binding protein I (SfbI). Intranasal immunization of mice with SOF and SfbI stimulates strong systemic and mucosal immune responses against both antigens. Animals vaccinated with SfbI, alone or in combination with SOF, were also efficiently protected against a lethal challenge with a SOF/SfbI-positive virulent S. pyogenes strain (80% survival). In contrast, those vaccinated with SOF alone were not protected against a mucosal challenge (100% lethality), which mimics more closely natural infections. These results highlight the importance of developing adequate experimental animal models to evaluate vaccine efficiency, according to the selected antigen.

IdeS, a highly specific immunoglobulin G (IgG)-cleaving enzyme from Streptococcus pyogenes, is inhibited by specific IgG antibodies generated during infection

IdeS, a recently discovered cysteine proteinase secreted by the important human pathogen Streptococcus pyogenes, interferes with phagocytic killing by specifically cleaving the heavy chain of immunoglobulin G. The fact that the enzyme targets one of the key molecules of the adapted immune response raised the question of whether an antibody response against IdeS could inhibit, i.e., neutralize, enzyme activity. Paired acute- and convalescent-phase serum samples from patients with pharyngotonsillitis (n = 10), bacteremia (n = 7), and erysipelas (n = 4) were analyzed. Antibodies with the ability to neutralize IdeS enzymatic activity were already found in two-thirds of acute-phase sera. However, patients who seroconverted to IdeS, in particular patients with pharyngotonsillitis and erysipelas, developed specific antibodies during convalescence with an increased capability to efficiently neutralize the enzymatic activity of IdeS. Also, the presence of neutralizing antibodies decreased the ability of IdeS to mediate bacterial survival in human immune blood. In patients with bacteremia, several acute-phase sera contained neutralizing antibodies, but no correlation was found to severity or outcome of invasive infections. Still, the fact that the human immune response targets the enzymatic activity of IdeS supports the view that the enzyme plays an important role during streptococcal infection.

StreptAvax (ID Biomedical)

ID Biomedical, under license from the University of Tennessee, is developing StreptAvax, a potential subunit vaccine against group A streptococcal infection. By January 2005, analysis of data from phase II clinical trials conducted in adults was completed. Pediatric trials are not expected to begin before 2007.

Characterization and identification of vaccine candidate proteins through analysis of the group A Streptococcus surface proteome

We describe a proteomic approach for identifying bacterial surface-exposed proteins quickly and reliably for their use as vaccine candidates. Whole cells are treated with proteases to selectively digest protruding proteins that are subsequently identified by mass spectrometry analysis of the released peptides. When applied to the sequenced M1_SF370 group A Streptococcus strain, 68 PSORT-predicted surface-associated proteins were identified, including most of the protective antigens described in the literature. The number of surface-exposed proteins varied from strain to strain, most likely as a consequence of different capsule content. The surface-exposed proteins of the highly virulent M23_DSM2071 strain included 17 proteins, 15 in common with M1_SF370. When 14 of the 17 proteins were expressed in E. coli and tested in the mouse for their capacity to confer protection against a lethal dose of M23_DSM2071, one new protective antigen (Spy0416) was identified. This strategy overcomes the difficulties so far encountered in surface protein characterization and has great potential in vaccine discovery.

Is the nephritogenic antigen in post-streptococcal glomerulonephritis pyrogenic exotoxin B (SPE B) or GAPDH?

BACKGROUND

Acute glomerulonephritis can follow infection by group A streptococci. An immune-complex pathogenesis is accepted, but the causative antigen(s) is still controversial. In recent years, 2 streptococcal antigens, the cationic cysteine proteinase exotoxin B (SPE B) and the plasmin receptor, a glyceraldehyde phosphate dehydrogenase (Plr, GAPDH) have attracted attention because: (1) they were localized in glomeruli in patients with acute post-streptococcal glomerulonephritis (APSGN); and (2) serum antibody to these antigens was associated with nephritogenic streptococcal infections. To date, putative nephritogens were always tested independently. Here, the relevance of SPE B and GAPDH was evaluated in the same renal biopsies and serum samples of well-defined APSGN patients.

METHODS

Renal biopsies (17 patients) and serum samples (53 patients) with APSGN and appropriate controls were examined. Immunofluorescent staining of frozen sections was performed using specific antibodies to SPE B and GAPDH. Serum antibodies were investigated by both enzyme-linked immunosorbent assay (ELISA) and Western blot methodology.

RESULTS

Glomerular deposits of SPE B were demonstrated in 12/17 APSGN biopsies, and 2 cases were borderline; circulating antibodies were found in all instances (53/53 patients). Glomerular deposition of GAPDH was detected in 1/17 biopsies, and 2 cases were borderline; circulating antibodies were found in 5/47 patients. In 31 control biopsies, only weak staining for each antigen was found in 2 cases.

CONCLUSION

In this study, glomerular deposits of and antibody response to zymogen/SPE B are more consistently present in APSGN than deposits and antibody response to GAPDH. Zymogen/SPE B is likely to be the major antigen involved in the pathogenesis of most cases of APSGN.

Active and passive intranasal immunizations with streptococcal surface protein C5a peptidase prevent infection of murine nasal mucosa-associated lymphoid tissue, a functional homologue of human tonsils

C5a peptidase, also called SCPA (surface-bound C5a peptidase), is a surface-bound protein on group A streptococci (GAS), etiologic agents for a variety of human diseases including pharyngitis, impetigo, toxic shock, and necrotizing fasciitis, as well as the postinfection sequelae rheumatic fever and rheumatic heart disease. This protein is highly conserved among different serotypes and is also expressed in human isolates of group B, C, and G streptococci. Human tonsils are the primary reservoirs for GAS, maintaining endemic disease across the globe. We recently reported that GAS preferentially target nasal mucosa-associated lymphoid tissue (NALT) in mice, a tissue functionally analogous to human tonsils. Experiments using a C5a peptidase loss-of-function mutant and an intranasal infection model showed that this protease is required for efficient colonization of NALT. An effective vaccine should prevent infection of this secondary lymphoid tissue; therefore, the potential of anti-SCPA antibodies to protect against streptococcal infection of NALT was investigated. Experiments showed that GAS colonization of NALT was significantly reduced following intranasal immunization of mice with recombinant SCPA protein administered alone or with cholera toxin, whereas a high degree of GAS colonization of NALT was observed in control mice immunized with phosphate-buffered saline only. Moreover, administration of anti-SCPA serum by the intranasal route protected mice against streptococcal infection. These results suggest that intranasal immunization with SCPA would prevent colonization and infection of human tonsils, thereby eliminating potential reservoirs that maintain endemic disease.

Role of rapid antigen detection test for the diagnosis of group-A ß-hemolytic streptococcus in patients with pharyngotonsillitis

Group A ß-hemolytic streptococcus (GAS) is an important pharyngotonsillitis etiologic agent. Correct etiologic diagnosis and early treatment prevent suppurative and non-suppurative complications of streptococcal pharyngotonsillitis, however, clinical diagnostic methods are not reliable. Within this context, rapid detection methods of GAS antigen are useful to diagnose this agent.

Aim

The objective of the present study was to determine the sensitivity and specificity of rapid GAS antigen detection tests used in Brazil.

Study Design

Clinical prospective.

Methods

Eighty-one patients with clinical diagnosis of acute pharyngotonsillitis seen at the otorhinolaryngology emergency department of University Hospital, FMUSP, between May 2001 and April 2002, were submitted to two simultaneous collections of oropharyngeal material using swabs. Rapid GAS antigen detection test was compared to culture on blood agar, the gold standard for the diagnosis of this etiologic agent.

Results

Among the 81 studied patients, the rapid test was positive in 56% and negative in 44%. GAS growth in culture was observed for 40.7% of the patients. The sensitivity and specificity of the rapid test were, respectively, 93.9% and 68.7%, and the negative and positive predictive values were 94.2 and 67.4%, respectively.

Conclusions

We concluded that the high sensitivity of the test permits its use for the identification of patients with GAS. Rapid streptococcal antigen detection tests have been shown to be an important supporting tool in the etiologic diagnosis of pharyngotonsillitis.

[Investigation of bactericidal effect and cytokine response of the oral epithelial cells against different antigenic doses of Streptococcus pyogenes]

Epithelial cells (EC) have an important role in the constitution of both innate and acquired immune responses. The aim of this study was to investigate the alterations of bactericidal effects and cytokine production patterns of human oral epithelial cells (OEC) against different doses of Streptococcus pyogenes. For this purpose, OEC have been stimulated with S. pyogenes with an effector/target (E/T) cell ratio of 1/1, 1/100, 1/1.000 and 1/10.000, and bactericidal effects and interleukin (IL)-6, IL-8 and IL-10 levels were detected in the first and sixth hours of incubation. The mean rates of bactericidal effect detected in the first and sixth hours were 38.7% and 54.5%, respectively. The bactericidal effects observed at 1/1 E/T cell ratio in the first hour, and at 1/1 and 1/100 E/T cell ratio in the the sixth hour were found significantly higher then the other cells ratios (p<0.05). Time- and dose-depended differences were detected in the cytokine responses of OEC for different S. pyogenes concentrations. IL-6 levels produced by stimulated OEC were found higher, and IL-8 levels were found lower then the levels which were produced by unstimulated OEC (p<0.05, p<0.001, respectively) in the first hour, while there were no change in IL-10 levels after stimulation with different bacterial concentrations (p>0.05). At the sixth hour there were no differences in the IL-6 levels produced by stimulated and unstimulated cells, while the levels of IL-8 produced by stimulated cells were found lower then the levels produced by unstimulated cells in the E/T cell ratio of 1/100, 1/1000 and 1/10.000 (p<0.05, p<0.01, p<0.01, respectively). Nevertheless IL-10 levels in the E/T cell ratio of 1/100 and 1/1.000 were statistically higher then the levels produced by unstimulated cells (p<0.05, p<0.05). As a result OEC stimulated with S. pyogenes showed dose dependent manner in bactericidal effect and cytokine production. It is suggested that epithelial cells stimulation with different doses of antigen contributed to the immune system activation or tolerance.

Molecular pathogenesis of rheumatic fever and rheumatic heart disease

Molecular mimicry between streptococcal and human proteins has been proposed as the triggering factor leading to autoimmunity in rheumatic fever (RF) and rheumatic heart disease (RHD). This article summarises studies on genetic susceptibility markers involved in the development of RF/RHD. It also focuses on the molecular mimicry in RHD mediated by the responses of B and T cells of peripheral blood, and T cells infiltrating heart lesions, against streptococcal antigens and human tissue proteins. The molecular basis of T-cell recognition is assessed through the definition of heart-crossreactive antigens. The production of cytokines from peripheral and heart-infiltrating mononuclear cells suggests that T helper 1 (Th1)-type cytokines are the mediators of RHD heart lesions. An insufficiency of interleukin 4 (IL-4)-producing cells in the valvular tissue might contribute to the maintenance and progression of valve lesions.

Asymptomatic infection by Streptococcus pyogenes in schoolchildren and diagnostic usefulness of antideoxyribonuclease B

This study is designed to evaluate the immune status of schoolchildren with respect to Streptococcus pyogenes, and to ascertain the usefulness of antideoxyribonuclease B (ADNase B). Antistreptolysin O (ASO) and ADNase B concentrations were measured quantitatively in 266 serum samples from healthy elementary school children in Seoul. Simultaneously, throat cultures were taken in order to isolate S. pyogenes and other beta-hemolytic streptococci (BHS). The upper limits of the normal (ULN) concentration of ASO and ADNase B were 326 IU/mL, and 362 IU/mL, respectively. The correlation between ADNase B (y) and ASO (x) was y = 0.4x+173 (r = 0.46). Mean ADNase B level (392 IU/mL) was significantly higher in children with S. pyogenes than in those with non-group A BHS (236 IU/mL) or no BHS (234 IU/ mL). Some schoolchildren were proven, via ASO and ADNase B tests, to be harboring asymptomatic S. pyogenes infections. The high ULN of ASO and ADNase B in schoolchildren should be carefully considered, in order to interpret the data collected from the patients. We could add the ADNase B test to our set of diagnostic tools, which would allow us to more accurately detect and diagnose streptococcal infections, as ADNase B was more specifically related to the results of throat cultures, and there was little correlation between ASO and ADNase B.

The role of the MHC on resistance to group a streptococci in mice

The severity of infection with Streptococcus pyogenes is strongly influenced by the host's genetics. This observation extends to the murine model of streptococcal infection, where the background of the mouse strain determines the infection outcome (BALB/c are resistant, whereas C3H/HeN are susceptible). To determine the extent to which the MHC complex (H2) contributed to diseases susceptibility, the response to S. pyogenes of congenic BALB mice from a resistant background (BALB/c), but carrying the H2(k) region of susceptible C3H/HeN mice (BALB/k), was examined. BALB/k were as susceptible as the H2 donor strain (C3H/HeN). Linkage analysis performed in F(2) backcross ([BALB/c x C3H/HeN] x BALB/c) mice confirmed the presence of a susceptibility locus within the H2 region on proximal chromosome 17. The possibility that modulation of T cell responses to streptococcal superantigens (GAS-SAgs) by different H2 haplotypes may influence disease severity was examined. BALB/k exhibited a significantly stronger response at the level of cell proliferation and cytokine production to GAS-SAgs than did BALB/c mice. However, the fact that T cell-deficient SCID-C3H/HeN mice also exhibited a susceptible phenotype suggests a more important contribution of innate effector cells to disease susceptibility. Lower transcriptional levels of certain inflammation-related regulatory genes located on chromosome 17 were detected in macrophages from susceptible than in those from resistant mice in response to infection. These results suggest that susceptibility to S. pyogenes may be associated with an altered transcription of specific genes that may compromise the endogenous regulatory processes controlling the inflammatory cascade and favor the progression to sepsis.

Group A streptococcus (GAS) carbohydrate as an immunogen for protection against GAS infection

Previous studies have shown that human serum containing anti-group A streptococcus carbohydrate (GAS CHO) antibodies were opsonic for different M protein-carrying serotypes. To investigate the role that anti-GAS CHO antibodies play in passive and active protection, mice were immunized subcutaneously or intranasally with GAS CHO conjugated to tetanus toxoid, and mortality and oral colonization were monitored after challenge with live GAS. Compared with control mice, immunized mice were significantly protected against systemic or nasal challenge with GAS. Furthermore, studies of serum samples and throat cultures from Mexican children revealed an inverse relationship between high serum titers of anti-GAS CHO antibodies and the presence of GAS in the throat. Anti-GAS CHO antibodies were also tested for cross-reactivity with human tissues and cytoskeletal proteins. No cross-reactivity was observed in either assay. The present study demonstrates that GAS CHO is both immunogenic and protective against GAS infections.

Protective immunity against Streptococcus pyogenes challenge in mice after immunization with fibronectin-binding protein

BACKGROUND

Surface-associated fibronectin (Fn)-binding proteins of Streptococcus pyogenes play an important role in the bacterial invasion of epithelial cells. We examined the functional domain and protective antigenicity of the Fn-binding protein FbaA.

METHODS

To investigate the functional domain of FbaA and its localization on S. pyogenes, a series of recombinant glutathione S-transferase (GST)-truncated FbaA proteins was used for immunofluorescent microscopy, ligand blotting, and Biacore analyses. Mice were immunized with the truncated proteins for the determination of the immunogenic domains that contribute to protection against S. pyogenes infection.

RESULTS

Ligand-blotting and Biacore analyses revealed that the FbaA fragments harboring a proline-rich repeat domain (RD), but not the N- and C-terminal regions, possessed Fn-binding activity. Immunofluorescent microscopy findings showed that the N terminus and RD were exposed to external regions, which suggests that the RD serves as a Fn-binding element on live organisms. Specific antibodies were efficiently induced in N terminus- and RD-immunized mice and demonstrated bactericidal activity against S. pyogenes in vitro. FbaA-immunized mice survived significantly longer than GST-immunized mice after infection with serotype M1 and M49 strains expressing FbaA.

CONCLUSION

The Fn-binding RD and N terminus of FbaA are potential vaccine candidates for M1 strains of S. pyogenes infection.

An adult with acute poststreptococcal glomerulonephritis complicated by hemolytic uremic syndrome and nephrotic syndrome

We report the case of a 47-year-old man with the simultaneous occurrence of clinical and laboratory features consistent with acute poststreptococcal glomerulonephritis (APSGN), hemolytic uremic syndrome (HUS), and nephrotic syndrome. Acute nephritic syndrome occurred 3 weeks after having pharyngeal pain and diarrhea. He presented with edema and hypertension on admission. Laboratory evaluation showed hemolytic anemia with fragmentation, thrombocytopenia, elevated lactic dehydrogenase level, low haptoglobin level, low complement C3 level, and elevated antistreptolysin-O titer. Serum creatinine level was 1.22 mg/dL (108 micromol/L), and urinalysis showed marked proteinuria, with protein of 8.7 g/d, and hematuria. The renal biopsy specimen was characteristic of APSGN, but not HUS. Moderate expansion of the mesangial matrix, moderate proliferation of epithelial and endothelial cells, and marked infiltration of neutrophils was seen by means of light microscopy, and many subepithelial humps were seen by means of electron microscopy. Neither fibrin deposition nor evidence of thrombotic microangiopathy was found. Complement C3 deposition along the capillary wall and tubules was seen in an immunofluorescence study. The patient was administered plasma infusion at 320 mL/d and antihypertensive drugs. Serum complement C3 and haptoglobin levels returned to normal within 3 weeks. This is a rare case of the simultaneous occurrence of APSGN, HUS, and nephrotic syndrome.

Adult Kawasaki disease unrelated to epstein-barr virus and group A Streptococcus

A 23-year-old Japanese woman with a fever and generalized skin eruptions was referred to our hospital in July 1999. At admission, her temperature was 38.9 degrees C, and she had fluctuating symptoms including erythema of the extremities, conjunctival hyperemia, strawberry tongue, and generalized skin eruptions, but lymphadenopathy was not verified. An initially elevated urine leukocyte count (more than 100 per high power field) later returned to normal range without antibiotic therapy. Adult Kawasaki disease was diagnosed on the basis of the above symptomology. Echocardiograph showed transient effusion in the pericardium. Using the Harada scoring system for treatment of Kawasaki disease, we gave the patient aspirin and did not administer intravenous immunoglobulin. The clinical course was uneventful, and on the day of discharge (day 22 after onset), the laboratory test results were nearly normal. Laboratory test results were negative for both Epstein-Barr virus and group A Streptococcus.

Counts of stromal precursor cells in heterotopic bone marrow transplants in mice immunized with group a streptococcus antigens

The count of stromal precursor cells in bone marrow transplants from CBA mice, transplanted to animals immunized with killed type 5 group A streptococcus vaccine, decreased 4.5-6.5 times (depending on the transplant age) in comparison with the grafts transplanted to normal recipients. The counts of stromal precursor cells in 1.5-3-month bone marrow transplants from animals immunized with killed streptococcal vaccine transplanted to normal mice were virtually the same, while in 7-month transplants they decreased 2-fold in comparison with their counts in bone marrow transplants from normal CBA mice transplanted to normal animals. The content of stromal precursor cells in the femoral bone marrow of animals immunized with killed streptococcal vaccine was appreciably (3.5 times) higher than in the bone marrow of normal mice. The results attest to an appreciable effect of streptococcal antigens on the bone marrow stromal tissue and suggest that not all stromal precursor cells, whose count increases after injection of antigens, are responsible for transplantability of the stromal tissue in case of its heterotopic transplantation.

D-alanylation of teichoic acids promotes group a streptococcus antimicrobial peptide resistance, neutrophil survival, and epithelial cell invasion

Group A streptococcus (GAS) is a leading cause of severe, invasive human infections, including necrotizing fasciitis and toxic shock syndrome. An important element of the mammalian innate defense system against invasive bacterial infections such as GAS is the production of antimicrobial peptides (AMPs) such as cathelicidins. In this study, we identify a specific GAS phenotype that confers resistance to host AMPs. Allelic replacement of the dltA gene encoding d-alanine-d-alanyl carrier protein ligase in an invasive serotype M1 GAS isolate led to loss of teichoic acid d-alanylation and an increase in net negative charge on the bacterial surface. Compared to the wild-type (WT) parent strain, the GAS DeltadltA mutant exhibited increased susceptibility to AMP and lysozyme killing and to acidic pH. While phagocytic uptake of WT and DeltadltA mutants by human neutrophils was equivalent, neutrophil-mediated killing of the DeltadltA strain was greatly accelerated. Furthermore, we observed the DeltadltA mutant to be diminished in its ability to adhere to and invade cultured human pharyngeal epithelial cells, a likely proximal step in the pathogenesis of invasive infection. Thus, teichoic acid d-alanylation may contribute in multiple ways to the propensity of invasive GAS to bypass mucosal defenses and produce systemic infection.

Group A Streptococcus produce pilus-like structures containing protective antigens and Lancefield T antigens

Although pili have long been recognized in Gram-negative pathogens as important virulence factors involved in adhesion and invasion, very little is known about extended surface organelles in Gram-positive pathogens. Here we report that Group A Streptococcus (GAS), a Gram-positive human-specific pathogen that causes pharyngitis, impetigo, invasive disease, necrotizing fasciitis, and autoimmune sequelae has long, surface-exposed, pilus-like structures composed of members of a family of extracellular matrix-binding proteins. We describe four variant pili and show that each is recognized by a specific serum of the Lancefield T-typing system, which has been used for over five decades to characterize GAS isolates. Furthermore, we show that immunization of mice with a combination of recombinant pilus proteins confers protection against mucosal challenge with virulent GAS bacteria. The data indicate that induction of a protective immune response against these structures may be a useful strategy for development of a vaccine against disease caused by GAS infection.

Safety and Immunogenicity of 26-Valent Group A Streptococcus Vaccine in Healthy Adult Volunteers

BACKGROUND

Group A streptococcus (GAS) causes illness ranging from uncomplicated pharyngitis to life-threatening necrotizing fasciitis, toxic shock, and rheumatic fever. Attempts to develop an M protein-based vaccine have been hindered by the fact that some M proteins elicit both protective antibodies and antibodies that cross-react with human tissues. New molecular techniques have allowed the previous obstacles to be largely overcome.

METHODS

The vaccine is comprised of 4 recombinant proteins adsorbed to aluminum hydroxide that contain N-terminal peptides from streptococcal protective antigen and M proteins of 26 common pharyngitis, invasive, and/or rheumatogenic serotypes. Thirty healthy adult subjects received intramuscular 26-valent GAS vaccine (400 microg) at 0, 1, and 4 months, with clinical and laboratory follow-up for safety and immunogenicity using assays for tissue cross-reactive antibodies, type-specific M antibodies to 27 vaccine antigens, and functional (opsonization) activity of M protein antibodies.

RESULTS

The incidence of local reactogenicity was similar to that for other aluminum hydroxide-adsorbed vaccines in adults. No subject developed evidence of rheumatogenicity or nephritogenicity, and no induction of human tissue-reactive antibodies was detected. Overall, 26 of 27 antigenic peptides evoked a >4-fold increase in the geometric mean antibody titer over baseline. The mean log2 fold-increase in serum antibody titer (+/- standard error of the mean) for all 27 antigens was 3.67 +/- 0.21. A significant mean log2 reduction in streptococcal bacterial counts in serum samples obtained after immunization was seen in opsonization assays for all M serotypes.

CONCLUSIONS

On the basis of epidemiological data demonstrating that the majority of cases of pharyngitis, necrotizing fasciitis, and other invasive streptococcal infections are caused by a limited number of serotypes, this 26-valent vaccine could have significant impact on the overall burden of streptococcal disease.

Identification of group A Streptococcus antigenic determinants upregulated in vivo

Group A Streptococcus (GAS) causes a range of diseases in humans, from mild noninvasive infections to severe invasive infections. The molecular basis for the varying severity of disease remains unclear. We identified genes expressed during invasive disease using in vivo-induced antigen technology (IVIAT), applied for the first time in a gram-positive organism. Convalescent-phase sera from patients with invasive disease were pooled, adsorbed against antigens derived from in vitro-grown GAS, and used to screen a GAS genomic expression library. A murine model of invasive GAS disease was included as an additional source of sera for screening. Sequencing DNA inserts from clones reactive with both human and mouse sera indicated 16 open reading frames with homology to genes involved in metabolic activity to genes of unknown function. Of these, seven genes were assessed for their differential expression by quantitative real-time PCR both in vivo, utilizing a murine model of invasive GAS disease, and in vitro at different time points of growth. Three gene products-a putative penicillin-binding protein 1A, a putative lipoprotein, and a conserved hypothetical protein homologous to a putative translation initiation inhibitor in Vibrio vulnificus-were upregulated in vivo, suggesting that these genes play a role during invasive disease.

Toward the development of an antidisease, transmission-blocking intranasal vaccine for group a streptococcus

Infection with group A streptococcus (GAS) may result in a number of clinical conditions, including the potentially life-threatening postinfectious sequelae of rheumatic fever and rheumatic heart disease. As part of the search for a vaccine to prevent GAS infection, a conformationally constrained and minimally conserved peptide, J14, from the M protein of GAS has been defined. In the present study, J14 was formulated with bacterial outer membrane proteins (proteosomes) and then intranasally administered to outbred mice without additional adjuvant. Such immunization led to high titers of J14-specific serum immunoglobulin (Ig) G and mucosal IgA. After upper respiratory tract GAS challenge, immunized mice demonstrated increased survival and reduced GAS colonization of the throat.

Systemic immunization with streptococcal immunoglobulin-binding protein Sib35 induces protective immunity against group A Streptococcus challenge in mice

The streptococcal immunoglobulin (Ig)-binding protein Sib 35 binds to IgG, IgM and IgA in human, mouse and bovine. Since all group A Streptococcus pyogenes (GAS) strains examined express the sib 35 gene, we evaluated the Sib 35 as a vaccine candidate against GAS infections. We detected significantly higher anti-Sib 35 IgG antibody titers in sera from patients with GAS infections than from healthy volunteers. Immunization of mice with Sib 35 induced antigen-specific IgG antibodies in their sera, and rabbit Sib 35-specific antiserum showed opsonic activity. Immunization with Sib 35 enhanced survival rates in mice challenged with a GAS strain, while exhibiting no toxicity in hosts. We conclude that Sib 35 is a promising vaccine for prevention of GAS infections.

A toll-like receptor 2-responsive lipid effector pathway protects mammals against skin infections with gram-positive bacteria

flake (flk), an N-ethyl-N-nitrosourea-induced recessive germ line mutation of C57BL/6 mice, impairs the clearance of skin infections by Streptococcus pyogenes and Staphylococcus aureus, gram-positive pathogens that elicit innate immune responses by activating Toll-like receptor 2 (TLR2). Positional cloning and sequencing revealed that flk is a novel allele of the stearoyl coenzyme A desaturase 1 gene (Scd1). flake homozygotes show reduced sebum production and are unable to synthesize the monounsaturated fatty acids (MUFA) palmitoleate (C(16:1)) and oleate (C(18:1)), both of which are bactericidal against gram-positive (but not gram-negative) organisms in vitro. However, intradermal MUFA administration to S. aureus-infected mice partially rescues the flake phenotype, which indicates that an additional component of the sebum may be required to improve bacterial clearance. In normal mice, transcription of Scd1-a gene with numerous NF-kappaB elements in its promoter--is strongly and specifically induced by TLR2 signaling. Similarly, the SCD1 gene is induced by TLR2 signaling in a human sebocyte cell line. These observations reveal the existence of a regulated, lipid-based antimicrobial effector pathway in mammals and suggest new approaches to the treatment or prevention of infections with gram-positive bacteria.

Role of rapid antigen detection test for the diagnosis of group A beta-hemolytic streptococcus in patients with pharyngotonsillitis

Group A β -hemolytic streptococcus (GAS) is an important pharyngotonsillitis etiologic agent. Correct etiologic diagnosis and early treatment prevent suppurative and non-suppurative complications of streptococcal pharyngotonsillitis; however, clinical diagnosis is not reliable. Within this context, rapid detection methods of GAS antigen are useful to diagnose this agent.

Aim

The objective of the present study was to determine sensitivity and specificity of rapid GAS antigen detection tests used in Brazil.

Study design

Clinical prospective. Method: Eighty-one patients with clinical diagnosis of acute pharyngotonsillitis seen at the otorhinolaryngology emergency department of the University Hospital, FMUSP, between May 2001 and April 2002 were submitted to two simultaneous collections of oropharyngeal material using swabs. The rapid GAS antigen detection test was compared to culture on blood agar, the gold standard for the diagnosis of this etiologic agent.

Results

Among the 81 patients studied, the rapid test was positive in 56% and negative in 44%. GAS growth in culture was observed in 40.7% of the patients. Sensitivity and specificity of the rapid test were, respectively, 93.9% and 68.7%, and the negative and positive predictive values were 94.2 and 67.4%, respectively. Conclusions: We concluded that high sensitivity of the test allows its use in the identification of patients with GAS. Rapid streptococcal antigen detection tests have been shown to be an important adjuvant tool in the etiologic diagnosis of pharyngotonsillitis.

Streptococcal pyrogenic exotoxin B causes mitochondria damage to polymorphonuclear cells preventing phagocytosis of group A streptococcus

The streptococcal pyrogenic exotoxin B (SpeB) is known to be involved in group A streptococcus (GAS) survival in blood, but the detailed mechanism is not clear. For clarification of this issue, speB isogenic mutants of strains M6 and M49 were constructed by using an integrational plasmid and confirmed by Southern blot analysis. The resistance to phagocytosis of wild-type strains and their speB isogenic mutants was analyzed. The results demonstrated a five-fold increase in phagocytosis of speB mutants compared to that of wild-type strains in whole blood, but no significant difference in plasma. To further clarify whether this effect is due to a functional SpeB protein, recombinant SpeB (r-SpeB) and a SpeB mutant protein lacking proteinase activity (r-C192S) were purified and incubated with a speB mutant in whole blood. The results showed a two- to threefold increase in resistance to phagocytosis when the M6 speB mutant was incubated with r-SpeB, but not with r-C192S. Incubation with the wild-type strain, speB mutant, or the r-SpeB protein did not affect the total cell number of polymorphonuclear (PMN) cells in whole blood under laboratory conditions. However, the PMN cells' mitochondria showed decreasing dehydrogenase activity and loss of membrane potential after r-SpeB treatment. These data indicate that SpeB could cause the mitochondria damage to the PMN cells, preventing immune clearance at an early infectious stage.

Specific C-terminal cleavage and inactivation of interleukin-8 by invasive disease isolates of Streptococcus pyogenes

Lethal necrotizing fasciitis caused by Streptococcus pyogenes is characterized by a paucity of neutrophils at the site of infection. Interleukin (IL)-8, which is important for neutrophil transmigration and activation, can be degraded by S. pyogenes. Blood isolates of S. pyogenes were better able to degrade human IL-8 than throat isolates. Degradation of IL-8 was the result of a single specific cleavage between 59glutamine and 60arginine within the IL-8 C-terminal alpha helix. Cleaved IL-8 reduced neutrophil activation and migration. IL-8-cleaving activity was found in partially purified supernatant of a necrotizing fasciitis isolate, and this activity was associated with an approximately 150-kDa fraction containing S. pyogenes cell envelope proteinase (SpyCEP). IL-8-cleaving activity corresponded with the presence of SpyCEP in the supernatant. Cleavage of IL-8 by S. pyogenes represents an unprecedented mechanism of immune evasion, effectively preventing IL-8 C-terminus-mediated endothelial translocation and subsequent recruitment of neutrophils.

Host-pathogen interactions in Streptococcus pyogenes infections, with special reference to puerperal fever and a comment on vaccine development

Streptococcus pyogenes (group A streptococcus) causes a variety of diseases, including acute pharyngitis, impetigo, rheumatic fever and the streptococcal toxic shock syndrome. Moreover, S. pyogenes was responsible for the classical example of a nosocomial infection, the epidemics of puerperal fever (childbed fever) that caused the death of numerous women in earlier centuries. The most extensively studied virulence factor of S. pyogenes is the surface M protein, which inhibits phagocytosis and shows antigenic variation. Recent data indicate that many M proteins confer phagocytosis resistance because the variable N-terminal region has non-overlapping sites that specifically bind two components of the human immune system, the complement inhibitor C4b-binding protein (C4BP) and IgA-Fc. Concerning puerperal fever, molecular and epidemiological analysis suggests that the S. pyogenes surface protein R28 may have played a pathogenetic role in these epidemics. This article summarizes the properties of M protein and the R28 protein and considers a potential problem encountered in connection with the use of animal models for vaccine development.

Induction of a Regulatory Phenotype in Human CD4+ T Cells by Streptococcal M Protein

Regulatory T cells (Tregs) participate in the control of the immune response. In the human system, an IL-10-secreting, T regulatory type 1 cell (Tr1)-like subset of Tregs can be induced by concurrent cross-linking of the TCR and CD46 on naive CD4(+) T cells. Because many viral and bacterial pathogens, including the major human pathogen Streptococcus pyogenes, bind to CD46, we asked whether this bacterium can directly induce Tr1-like cells through the streptococcal ligand for CD46, the M protein. The M5 and M22 proteins were found to induce T cells to develop into the IL-10-producing Tr1-like phenotype. Moreover, whole M5-expressing bacteria, but not isogenic M-negative bacteria, led to proliferation and IL-10 secretion by T cells. The interaction between the M5 protein and T cells was dependent on CD46 and the conserved C repeat region of M5. Supernatants derived from T cells stimulated with M proteins or M protein-expressing bacteria suppressed bystander T cell proliferation through IL-10 secretion. In addition, activation of CD46 through streptococcal M protein induced the expression of granzyme B, providing a second means for these cells to regulate an immune response. These findings suggest that binding to CD46 and exploiting its signaling pathway may represent a strategy employed by a number of important human pathogens to induce directly an immunosuppressive/regulatory phenotype in T cells.

Variations in the protective immune response against streptococcal superantigens in populations of different ethnicity

Superantigens (SAgs) from group A streptococcus (GAS) are potent T cell mitogens, and have been suggested to play a role in severe streptococcal disease. Neutralizing antibodies protect against SAg-mediated disease and their levels should therefore be inversely related to severe streptococcal infection. Neutralizing anti-SAg titers in patients with severe GAS infection and patients without disease were compared in two separate groups. The first group comprised patients with invasive GAS disease from New Zealand European, Maori, and Pacific Island descent. The second group comprised Aboriginal Australian individuals with rheumatic heart disease and/or a past history of acute rheumatic fever. Patients sera were tested for their ability to neutralize T cell mitogenicity of recombinant streptococcal SAgs as a measure of functional SAg-neutralizing antibody concentration. In both studies, no inverse correlation was observed between disease and the level of serum SAg-neutralizing activity. Notably, much higher levels of natural immunity to all streptococcal SAgs were found in New Zealand Maori, New Zealand Pacific Island, and Aboriginal Australian individuals, suggesting a high degree of natural exposure and seroconversion in these groups compared to the New Zealand European cohort. Levels of serum antibodies against SAgs could not be used to predict disease susceptibility in groups with existing high levels of SAg-neutralizing antibodies.

Critical role for complement receptor 3 (CD11b/CD18), but not for Fc receptors, in killing of Streptococcus pyogenes by neutrophils in human immune serum

During phagocytosis, surface receptors on neutrophils interact with pathogens opsonized with complement factor C3b/iC3b and in some cases with antibodies. In human immune sera antibodies directed against surface-bound M proteins mediated killing of Streptococcus pyogenes by neutrophils. Surprisingly, blocking of the Fc receptors had little effect on the killing. In contrast, inhibition of C3b/iC3b generation, or blocking of the major neutrophil iC3b receptor CD11b/CD18, enabled S. pyogenes to grow efficiently in immune sera. Inhibition of CD11b/CD18, but not of CD32, the major neutrophil signaling Fc receptor, prevented Streptococcus-induced NADPH oxidase-dependent respiratory burst, and blocking of C3b/iC3b formation inhibited Streptococcus-induced activation of Cdc42, a small GTPase critically involved in transmitting pro-inflammatory signals to the cytoskeleton. Consequently, ligation of CD11b/CD18 by bacteria-bound iC3b is necessary for inducing a neutrophil response leading to elimination of S. pyogenes in immune human serum.

Reemergence of emm1 and a changed superantigen profile for group A streptococci causing invasive infections: results from a nationwide study

Between 1999 and 2002, 496 invasive group A streptococcal (GAS) isolates from clinical microbiological departments in Denmark and subsequently 487 (98%) questionnaires from the clinicians treating the patients were received as part of a national surveillance. emm types and streptococcal superantigen (SAg) genes were determined. The incidence of invasive GAS infections was on average 2.3 per 100,000 per year. Bacteremia with no focal symptoms (27%) was together with erysipelas (20%) the most prevalent clinical diagnoses. Streptococcal toxic shock syndrome occurred in 10% of patients, of which 56% died. The overall case fatality rate within 30 days was 23%. In total, 47 different emm types were identified, of which emm1, emm3, emm4, emm12, emm28, and emm89 were identified in 72% of the 493 available isolates. During the 4-year period the presence of emm1 increased from 16% in 1999 to 40% in 2002. Concurrently, the presence of emm3 decreased from 23% in 1999 to 2% in 2002. The emm1 isolates predominantly carried speA, although the frequency decreased from 94% in 1999 to 71% in 2002, whereas the emm1-specific prevalence of speC increased from 25 to 53%. In a historical perspective, this could be interpreted as a reemergence of emm1 and could indicate a possible introduction of a new emm1 subclone. However, this reemergence did not result in any significant changes in the clinical manifestations during the study period. Our results show the complexity of invasive GAS infections, with time-dependent variations in the incidence and distribution of emm and SAg genes, which emphasizes the need for continuous epidemiological and molecular investigations.

Acute guttate psoriasis patients have positive streptococcus hemolyticus throat cultures and elevated antistreptococcal M6 protein titers

To further study the role of Streptococci hemolyticus infection and streptococcal M6 protein in the pathogenesis of acute guttate psoriasis, streptococcal cultures were taken from the throats of 68 patients with acute guttate psoriasis. PCR technique was applied to detect M6 protein encoding DNA from those cultured streptococci. Pure M6 protein was obtained by Sephacry/S-200HR and Mono-Q chromatography from proliferated Streptococcus hemolyticus. Antistreptococcal M6 protein titers were measured in the serum of patients with acute guttate psoriasis, plaque psoriasis and healthy controls by ELISA. A high incidence of Streptococcus hemolyticus culture was observed in the guttate psoriatic group compared with the plaque psoriasis and control groups. Fourteen strains of Streptococcus hemolyticus were cultured from the throats of 68 acute guttate psoriasis patients. Of these, 5 strains contain DNA encoding the M6 protein gene as confirmed by PCR technique. More than 85% purification of M6 protein was obtained from Streptococcus pyogenes. Applying our pure M6 protein with the ELISA methods, we found that the titer of antistreptococcal M6 protein was significantly higher in the serum of guttate psoriasis patients than in the control or plaque psoriasis groups (P < 0.01). We verified that patients of acute guttate psoriasis have a high incidence of Streptococcus hemolyticus in their throats and raised titers of antistreptococcal M6 protein in their sera.

Surface analyses and immune reactivities of major cell wall-associated proteins of group a streptococcus

A proteomic analysis was undertaken to identify cell wall-associated proteins of Streptococcus pyogenes. Seventy-four distinct cell wall-associated proteins were identified, 66 of which were novel. Thirty-three proteins were immunoreactive with pooled S. pyogenes-reactive human antisera. Biotinylation of the GAS cell surface identified 23 cell wall-associated proteins that are surface exposed.