Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A

Toxic shock-like syndrome due to severe hemolytic group A streptococcal infection

A 33-year-old woman suffering from anal erosions developed severe illness with fever, diarrhea, ischalgia, hypotension, acute abdominal pain, dyspnea, renal and hepatic impairment, myalgia, desquamation of the skin, leukocytosis, anemia, hypocalcemia, decreased serum albumin, and cholesterol levels. Exploratory laparotomy did not reveal pathologic findings. Hemolytic group A streptococci were grown from peritoneal swabs and pleural exudate in bacteriologic cultures. The patient slowly recovered after intense penicillin and tobramycin therapy.

The staphylococcal enterotoxins and their relatives

Staphylococcal enterotoxins and a group of related proteins made by Streptococci cause food poisoning and shock in man and animals. These proteins share an ability to bind to human and mouse major histocompatibility complex proteins. The complex ligand so formed has specificity for a particular part of T cell receptors, V beta, and by engaging V beta can stimulate many T cells. It is likely that some or all of the pathological effects of these toxins are caused by their ability to activate quickly so many T cells. It is also possible that encounters with such toxins have caused mice, at least, to evolve mechanisms for varying their T cell V beta repertoires, such that they are less susceptible to attack by the toxins.

Fulminant group A streptococcal infections. Report of two cases

We describe two female patients presenting with spontaneous peritonitis and fulminant Streptococcus pyogenes (Strep. pyogenes) septicemia and shock. Both patients recovered completely upon immediate antibiotic therapy, initially with broad range combination therapy effective against Strep. pyogenes, which was switched to penicillin G when culture results became available. This isolated strain in case 1 was M-type 28, which is the M-type most often isolated from vaginal swabs (as commensal) and from blood from patients with puerperal sepsis. Patient 1 had signs and symptoms of a toxic shock-like syndrome, including rapid onset of fever and shock, skin rash, desquamation of palms and soles, and multisystem involvement with vomiting, diarrhea, myalgia, renal failure, and severe disorientation without focal neurological deficits.

[Fatal maternal streptococcus A infection after cesarean section]

A case is reported of an infection with Streptococcus pyogenes, occurring 24 hours after an elective Caesarean section in a 30 year old woman. She worsened during the first 48 h, with shock (Pasys less than 70 mmHg, pH 7.28) as well as abdominal tenderness and guarding. Laparotomy revealed peritonitis, and subtotal hysterectomy was carried out. Gram positive cocci were found in the peritoneal exudate, with bacterial cultures yielding Streptococcus pyogenes. Histopathological examination of the specimen revealed necrosing endomyometritis with septic thrombophlebitis. During the immediate post-operative period, there were several prolonged episodes of circulatory arrest treated with dobutamine, adrenaline, and noradrenaline. Multiple organ failure occurred during the next five days, despite antibiotic therapy (vancomycin, tienamycin, amikacin) and intensive care. It included jaundice, thrombocytopaenia (10 G.l(-1] adult respiratory distress syndrome (ARDS). A further laparotomy was carried out because of abdominal and thigh cellulitis, with completion of the hysterectomy and bilateral salpingo-oophorectomy. Streptococcus pyogenes was still present in the peritoneal cavity. There followed an improvement, with a return to normal of the platelet count, haemodynamic stability such that vasoactive drugs were no longer needed, and a decrease in the degree of jaundice. However, the ARDS worsened, and the patient died 15 days after the Caesarean section. There have been recent reports of similar cases, suggesting an increase in the virulence of group A streptococci linked to a re-emergence of exotoxin A.

Staphylococcal and streptococcal pyrogenic toxins involved in toxic shock syndrome and related illnesses

Toxic-shock syndrome (TSS) is an acute onset, multiorgan illness which resembles severe scarlet fever. The illness is caused by Staphylococcus aureus strains that express TSS toxin-1 (TSST-1), enterotoxin B, or enterotoxin C. TSST-1 is associated with menstrual TSS and approximately one-half of nonmenstrual cases; the other two toxins cause nonmenstrual cases, 47% and 3%, respectively. The three toxins are expressed in culture media under similar environmental conditions. These conditions may explain the association of certain tampons with menstrual TSS. Biochemically, the toxins are all relatively low molecular weight and fairly heat and protease stable. Enterotoxins B and C, share nearly 50% sequence homology with streptococcal scarlet fever toxin A; they share no homology with TSST-1 despite sharing numerous biological properties. Numerous animal models for development of TSS have suggested mechanisms of toxin action, though the exact molecular action is not known. The toxins are all potent pyrogens, induce T lymphocyte proliferation, requiring interleukin 1 release from macrophages, suppress immunoglobulin production, enhance endotoxin shock, and enhance hypersensitivity skin reactions. The genetic control of the toxins has been studied and suggests the exotoxins are variable traits. Some additional properties of TSS S. aureus which facilitate disease causation have been clarified.

Streptococcal serogroup A epidemic in Norway 1987-1988

A nationwide outbreak of Lancefield group A streptococcal (GAS) infections in Norway during the season 1987-88 is described. Data were collected from the Norwegian infectious disease notification system and supplemented by active search for cases of bacteraemia and other serious infections in addition to serotyping of selected clinical bacterial isolates. The number of reported cases of non-invasive GAS infections from week 29/1987 to week 28/1988 was 60% higher than expected. Between 1 Jan. and 30 June 1988, 84 cases of bacteraemia were notified, several with fulminant septicaemia and shock. The case fatality rate was 25%. Six cases of neonatal GAS septicaemia were seen. There was a nearly 3-fold total increase in occurrence of GAS bacteraemia compared with previous years, and the increase was marked particularly in cases among older children and adults 30-50 years old. Additional culture-confirmed diagnoses included unusual cases compared to recent decades such as pneumonia with empyema, necrotising fasciitis and primary peritonitis. Serotyping of strains collected consecutively from localized infections revealed a marked predominance of T-type 1, opacity factor negative strains (T-1 OF-), ranging from 41% in North Norway to 87% in Mid-Norway. M-typing confirmed that these strains were M-1, as were 87% of the preserved bacteraemia strains from the period described. Although most of the M-1 strains were distinctly mucoid only one case of acute rheumatic fever was reported during the first half of 1988. We conclude that an epidemic of GAS infections caused by M-1 strains has occurred in Norway resulting in an increase in both incidence and seriousness of disease.