Invasive group A streptococcus infections

Group A streptococcal myositis

Myositis is a relatively uncommon presentation of group A streptococcal infection. We present a case of a 3-year-old girl with group A streptococcal myositis primarily involving the soleus muscle. Magnetic resonance imaging was valuable in localizing the affected muscle and avoiding surgical exploration.

Relative avidities of human immunoglobulin G antibodies for streptococcal pyrogenic exotoxins A and B

In this pilot study, we investigated the relative avidities for streptococcal pyrogenic exotoxin A (SPE-A) and SPE-B of antibodies in sera from patients with fatal streptococcal toxic shock-like syndrome and from healthy individuals and in intravenous immunoglobulin (IVIG) preparations. We observed a great variation in the relative avidities of patient, control, and IVIG immunoglobulin G (IgG) (values estimated to be between 10(-7) and 10(-11) M), with mean values for patient IgG about 10-fold lower than those of control IgG.

Acquired streptococcal necrotizing fasciitis following excision of malignant melanoma

Necrotizing fasciitis is an uncommon condition which may complicate any surgical procedure, including 'minor' dermatological procedures. However, it may arise de novo in the absence of any discernible trauma. We report a patient who acquired a fulminant form of this condition following excision of a malignant melanoma. The development of necrotizing fasciitis in association with melanoma has not previously been reported.

Growth-phase-dependent expression of virulence factors in an M1T1 clinical isolate of Streptococcus pyogenes

The effect of growth phase on expression of virulence-associated factors was studied by Northern hybridization in an M1T1 clinical isolate of Streptococcus pyogenes. Expression of M protein, C5a peptidase, and capsule was maximal in the exponential phase of growth, while streptococcal pyrogenic exotoxins A and B and mitogenic factor were maximally expressed in later phases of growth.

Comparison of pathogenic factors expressed by group A Streptococci isolated from patients with streptococcal toxic shock syndrome and scarlet fever

Streptococcal toxic shock syndrome (STSS) is an illness with high mortality. To obtain clues to understanding the pathogenesis of STSS, we investigated the expression of several pathogenic factors in ten group A streptococcus (GAS) isolates from ten patients with STSS in Japan, in comparison with ten GAS isolates from children with scarlet fever. The ten scarlet fever-derived GAS isolates were equally low in lethality and anti-phagocytic activity in mice and in the production of streptolysin O (SLO), and equally high in production of superantigenic exotoxins (SAGTs) and cysteine proteinase. By comparison, the ten STSS-derived GAS isolates were heterogeneous in the expression of the above pathogenic factors, which ranged from low to high values. Most of the ten STSS-derived isolates were higher in lethality and anti-phagocytic activity and production of SLO, and lower in the production of SAGTs and cysteine proteinase than the ten scarlet fever-derived isolates. The results suggest that the lethality and anti-phagocytic activity examined in mice and SLO may be involved mainly in the development of most of the ten STSS cases.

Fc-Mediated Nonspecific Binding Between Fibronectin-Binding Protein I of Streptococcus pyogenes and Human Immunoglobulins

Fibronectin-binding protein I (SfbI) from Streptococcus pyogenes plays a key role in bacterial adhesion to, and invasion of, eukaryotic cells. In addition, SfbI exhibits a considerable potential as mucosal adjuvant and can trigger polyclonal activation of B cells. Here, we report that SfbI is also capable of binding human IgG in a nonimmune fashion. SfbI was reactive with IgG1, IgG2, IgG3, and IgG4 isotypes (type IIo IgG-binding profile). The affinity constant (Kd) of the SfbI-IgG interaction was in the range of 1–2 × 10−5 M. Further studies demonstrated that the SfbI binding was mediated by the Fc component of the IgG molecule. Experiments performed using purified recombinant proteins spanning different domains of SfbI showed that the IgG-binding activity was restricted to the fibronectin-binding domains, and in particular to the fibronectin-binding repeats. Finally, the presence of recombinant SfbI resulted in an impairment of both phagocytosis of IgG-coated RBCs and Ab-dependent cell cytotoxicity by macrophages. These results demonstrated for the first time that, in addition to its major role during the colonization process, SfbI may also favor bacterial immune evasion after the onset of the infection by interfering with host clearance mechanisms.

Molecular analysis of the role of streptococcal pyrogenic Exotoxin A (SPEA) in invasive soft-tissue infection resulting from Streptococcus pyogenes

Epidemiological studies strongly implicate the bacterial superantigen, streptococcal pyrogenic exotoxin A (SPEA), in the pathogenesis of necrotizing soft-tissue infection and toxic shock syndrome resulting from Streptococcus pyogenes. SPEA can act as a superantigen and cellular toxin ex vivo, but its role during invasive streptococcal infection is unclear. We have disrupted the wild-type spea gene in an M1 streptococcal isolate. Supernatants from toxin-negative mutant bacteria demonstrated a 50% reduction in pro-mitogenic activity in HLA DQ-positive murine splenocyte culture, and up to 20% reduction in activity in human PBMC culture. Mutant and wild-type bacteria were then compared in mouse models of bacteraemia and streptococcal muscle infection. Disruption of spea was not associated with attenuation of virulence in either model. Indeed, a paradoxical increase in mutant strain-induced mortality was seen after intravenous infection. Intramuscular infection with the SPEA-negative mutant led to increased bacteraemia at 24 h and a reduction in neutrophils at the site of primary muscle infection. Purified SPEA led to a dose-dependent increase in peritoneal neutrophils 6 h after administration. SPEA is not a critical virulence factor in invasive soft-tissue infection or bacteraemia caused by S. pyogenes, and it could have a protective role in murine immunity to pyogenic infection. The role of this toxin may be different in hosts with augmented superantigen responsiveness.

Capsular hyaluronic acid of group A streptococci hampers their invasion into human pharyngeal epithelial cells

Group A streptococci (GAS) cause various diseases, from uncomplicated noninvasive, to severe invasive infections. Capsular hyaluronic acid (HA) is known to resist phagocytosis, however, interaction between HA and epithelial cells have not been clearly understood. In this study, both HA-producing wild strains and HA-nonproducing mutants were employed to examine their invasiveness into confluent cultures of HEp-2, a nonphagocytic human epithelial cell line. Invasion of HEp-2 cells by GAS strains increased over time. The hasA gene encoding hyaluronate synthase of GAS strains was inactivated by allelic replacement. It was found that hasA-inactivated mutants were internalized into HEp-2 cells more efficiently than their parent strains under various conditions in terms of incubation time and inoculum size. Taken together, these findings indicate that GAS can be internalized into HEp-2 cells with considerably high frequencies and that the presence of HA of GAS decreased the invasion efficiency.

Survival of Streptococcus pyogenes under stress and starvation

The ability of Streptococcus pyogenes to enter a quiescent state, similar to the stationary phase of lab cultures, is believed to be an important factor in its ability to persist within the host and to subsequently cause disease. Using a model broth system, we determined that after entering the stationary phase, there was a 99.99% reduction in cell viability over a 4-day period, following which the cells appeared to enter a resistant starvation state where cell numbers remained constant over the subsequent 3-4 weeks. This starvation response was induced by carbon or phosphorous limitation, but not by nitrogen limitation in the form of amino acids where cells became non-culturable after 4 days. Amino acid utilization in the absence of a carbon source may be an essential factor for the long-term survival of this bacterium in the stationary phase. Early stationary phase cells showed a greater resistance to oxidative and pH stress compared to 24-h-starved cultures. There was evidence for the formation of a viable but non-culturable state as indicated by a comparison of the numbers of cells with a functional membrane potential (rhodamine 123) against culturable cells on either Todd Hewitt broth agar or sheep blood agar. Long-term survival of S. pyogenes was dependent on both cell wall and protein synthesis, suggesting that starving cultures are a dynamic cell population.

Susceptibility of group A beta-hemolytic streptococci in the lower St Lawrence region, Quebec

OBJECTIVE

To determine the susceptibility of group A beta-hemolytic streptococci (GABHS) in the lower St Lawrence region, Quebec to different antibiotics, particularly macrolides, and to compare different antibiogram methods (disk diffusion, E-test and microdilution) and incubation atmospheres (ambient air and 5% carbon dioxide).

METHODS

A total of 384 strains of GABHS isolated from 377 patients (throat 335; other sites 49) from three hospitals in the lower St Lawrence region were analyzed for their susceptibility to erythromycin, clarithromycin, azithromycin, penicillin, clindamycin, cephalothin, rifampin and vancomycin by disk diffusion on Mueller-Hinton (MH) agar supplemented with 5% defibrinated sheep blood (MHB) at 35ºC in 5% carbon dioxide. Strains that were found to be intermediately resistant or resistant to one of the antibiotics by disc diffusion, strains from sites other than throat, and a sample of 97 pharyngeal strains were evaluated by E-test on MHB (35ºC, 5% carbon dioxide) for their susceptibility to the antibiotics erythromycin, clarithromycin, azithromycin, penicillin, clindamycin and ceftriaxone. In addition, minimum inhibitory concentrations (MICs) were determined for erythromycin and azithromycin by broth microdilution using MH broth supplemented with 2.5 % of lysed horse blood (35ºC, ambient air) on strains that were resistant or intermediately resistant to the macrolides (erythromycin, clarithromycin, azithromycin). An evaluation was also carried out on these strains to determine the influence of the incubating atmosphere (ambient air versus 5% carbon dioxide) on susceptibility results obtained by disk diffusion (erythromycin, clarithromycin and azithromycin) and E-test (erythromycin and azithromycin) methods.

RESULTS

Nine strains (2%) from nine patients (throat eight, pus one) were resistant to all macrolides as tested by three different techniques (disk diffusion, E-test and microdilution). All strains were susceptible to all the other antibiotics tested. For the strains intermediately resistant or resistant to macrolides, incubation in a 5% carbon dioxide atmosphere was associated with a reduction in the diameter of inhibition determined by disk diffusion (P<0.001) with frequent minor variations in interpretation, and with an increase in the MIC by E-test (P<0.001), which had no impact on interpretation.

CONCLUSIONS

Resistance of GABHS to macrolides was not common (2%) in the lower St Lawrence Region. GABHS susceptibility to erythromycin seemed to predict the susceptibility to the other macrolides. Significant variation in antibiogram results (disk diffusion and E-test) of GABHS susceptibility to macrolides was related to the incubation atmosphere and may have an impact on the interpretation of disk diffusion results.

High-resolution genotyping of Streptococcus pyogenes serotype M1 isolates by fluorescent amplified-fragment length polymorphism analysis

We have used fluorescent amplified-fragment length polymorphism (FAFLP) analysis to subtype clinical isolates of Streptococcus pyogenes serotype M1. Established typing methods define most M1 isolates as members of a clone that has a worldwide distribution and that is strongly associated with invasive diseases. FAFLP analysis simultaneously sampled 90 to 120 loci throughout the M1 genome. Its discriminatory power, precision, and reproducibility were compared with those of other molecular typing methods. Irrespective of disease symptomatology or geographic origin, the majority of the clinical M1 isolates shared a single ribotype, pulsed-field gel electrophoresis macrorestriction profile, and emm1 gene sequence. Nonetheless, among these isolates, FAFLP analysis could differentiate 17 distinct profiles, including seven multi-isolate groups. The FAFLP profiles of M1 isolates reproducibly exhibited between 1 and more than 20 amplified fragment differences. The high discriminatory power of genotyping by FAFLP analysis revealed genetic microheterogeneity and differentiated otherwise "identical" M1 isolates as members of a clone complex.

A Streptococcus pyogenes outbreak caused by an unusual serotype of low virulence: the value of typing techniques in outbreak investigations

OBJECTIVES

To investigate and stop the spread of an outbreak of Streptococcus pyogenes infection in a district general hospital, involving 19 patients and two nurses over a 20-day period.

METHODS

All suspected persons were investigated using conventional bacteriological techniques, followed by M, T and exotoxin gene-typing of the isolates in a national reference laboratory.

RESULTS

11 patients and both nurses were associated with the acute surgical ward on one floor of the hospital. They were infected with serotype M 9/T B3264, a strain with apparently low virulence, which has not been previously associated with outbreaks. Two other patients on the same floor each had different types and there were two clusters of another S. pyogenes serotype on other floors, each involving two patients. Two (unrelated) patients yielded other types of S. pyogenes. The patients were not seriously ill but had some delay in wound healing.

CONCLUSIONS

The value of typing the isolates of S. pyogenes in this outbreak was in defining which patients were involved. No added value could be ascribed to the exotoxin gene-typing results.

Extracellular cysteine protease produced by Streptococcus pyogenes participates in the pathogenesis of invasive skin infection and dissemination in mice

The role of an extracellular cysteine protease encoded by the speB gene in group A Streptococcus (GAS) skin infection was studied with a mouse model. Mice were injected subcutaneously with a wild-type GAS serotype M3 strain or a cysteine protease-inactivated isogenic derivative grown to stationary phase. The mortality rate of mice injected with the M3 speB mutant strain was significantly decreased (P < 0.0008) compared to that of animals injected with the wild-type parental organism. The abscesses formed in animals infected with the cysteine protease mutant strain were significantly smaller (P < 0.0001) than those caused by the wild-type organism and slowly regressed over 3 to 4 weeks. In striking contrast, infection with the wild-type GAS isolate generated necrotic lesions, and in some animals the GAS disseminated widely from the injection site and produced extensive cutaneous damage. All of these animals developed bacteremia and died. GAS dissemination was accompanied by severe tissue and blood vessel necrosis. Cysteine protease expression in the infected tissue was identified by immunogold electron microscopy. These data demonstrate that cysteine protease expression contributes to soft tissue pathology, including necrosis, and is required for efficient systemic dissemination of the organism from the initial site of skin inoculation.

Risk factors in the pathogenesis of invasive group A streptococcal infections: role of protective humoral immunity

An impressive change in the epidemiology and severity of invasive group A streptococcal infections occurred in the 1980s, and the incidence of streptococcal toxic shock syndrome cases continues to rise. The reason for the resurgence of severe invasive cases remains a mystery-has there been a change in the pathogen or in host protective immunity? To address these questions, we have studied 33 patients with invasive infection caused by genotypically indistinguishable M1T1 strains of Streptococcus pyogenes who had different disease outcomes. Patients were classified as having severe (n = 21) and nonsevere (n = 12) invasive infections based on the presence or absence of shock and organ failure. Levels of anti-M1 bactericidal antibodies and of anti-streptococcal superantigen neutralizing antibodies in plasma were significantly lower in both groups than in age- and geographically matched healthy controls (P < 0.01). Importantly, the levels of these protective antibodies in plasma samples from severe and nonsevere invasive cases were not different. Together the data suggest that low levels of protective antibodies may contribute to host susceptibility to invasive streptococcal infection but do not modulate disease outcome. Other immunogenetic factors that regulate superantigen responses may influence the severity of systemic manifestations associated with invasive streptococcal infection.

Fatal group A Streptococcal toxic shock-like syndrome in a child with varicella: report of the first well documented case with detection of the genetic sequences that code for exotoxins spe A and B, in São Paulo, Brazil

A previously healthy seven-year-old boy was admitted to the intensive care unit because of toxaemia associated with varicella. He rapidly developed shock and multisystem organ failure associated with the appearance of a deep-seated soft tissue infection and, despite aggressive treatment, died on hospital day 4. An M-non-typable, spe A and spe B positive Group A Streptococcus was cultured from a deep soft tissue aspirate. The criteria for defining Streptococcal toxic shock-like syndrome were fulfilled. The authors discuss the clinical and pathophysiological aspects of this disease as well as some unusual clinical findings related to this case.

Streptococcal pyrogenic exotoxin B induces apoptosis and reduces phagocytic activity in U937 cells

Treatment of U937 human monocyte-like cells with Streptococcus pyogenes led to an induction of apoptosis in these cells. A comparison between the wild-type strain and its isogenic protease-negative mutant indicated that the production of streptococcal pyrogenic exotoxin B (SPE B), a cysteine protease, caused a greater extent of apoptosis in U937 cells. Further study using purified SPE B showed that this protease alone could induce U937 cells to undergo apoptosis, which was characterized by morphologic changes, DNA fragmentation laddering on the gel, and an increase in the percentages of hypodiploid cells. The protease activity of SPE B was required for apoptosis to proceed, since treatment with cysteine protease inhibitor E64 or heat inactivation abrogated this death-inducing effect. The SPE B-induced apoptosis pathway was interleukin-1beta converting enzyme (ICE) family protease dependent. Further experiments showed that the phagocytic activity of U937 cells was reduced by SPE B. Treatment with E64 and heat inactivation both abrogated this phagocytosis-inhibitory effect. Taken together, the present data show that SPE B not only possesses the ability to induce apoptosis in monocytic cells but also helps bacteria to resist phagocytosis by host cells.

Puerperal and intrapartum group A streptococcal infection

OBJECTIVE

To determine the demographic and clinical variables characteristic of non-epidemic intrapartum or puerperal group A streptococcal (GAS) infection.

METHODS

The records of 47 patients diagnosed with intrapartum or puerperal GAS infection over a 6 1/2 year period at Hadassah-University Hospital-Mt. Scopus, Jerusalem were reviewed. Data regarding 25,811 women, the general population of women that delivered during that period, were obtained from their computerized medical records. Frequency distributions, t-test, chi-square, and Spearman's Rank Correlation were used, as appropriate, to analyze and compare demographic and clinical variables associated with development of GAS infection, its clinical course and subsequent development of septic shock.

RESULTS

Mean age of mothers with GAS infection was higher than that of our general pregnant population (30.4 versus 27.4 years, P = 0.0019), and a higher proportion of GAS infected patients (30% versus 12%, P < 0.005) experienced PROM. Thirty-one (66%) women had fever as their sole presenting symptom, eight (17%) had fever and abdominal pain, seven (15%) had fever and abnormal vaginal bleeding, and one patient (2%) presented with a rash. Three patients (6%) developed a septic shock. Two of these patients presented with symptoms more than 14 days after delivery.

CONCLUSIONS

We describe the characteristics of non-epidemic intrapartum or puerperal GAS infection. Data from our study and review of the literature suggest that some patients who develop septic shock may present later in the puerperium than patients with an uncomplicated GAS infection.

Lactobacilli and streptococci induce interleukin-12 (IL-12), IL-18, and gamma interferon production in human peripheral blood mononuclear cells

Human peripheral blood mononuclear cells (PBMC) were stimulated with three nonpathogenic Lactobacillus strains and with one pathogenic Streptococcus pyogenes strain, and cytokine gene expression and protein production were analyzed. All bacteria strongly induced interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor alpha mRNA expression and protein production. S. pyogenes was the most potent inducer of secretion of IL-12 and gamma interferon (IFN-gamma), and two of three Lactobacillus strains induced IL-12 and IFN-gamma production. All strains induced IL-18 protein production. IL-10 and IL-4 production was induced weakly and not at all, respectively. Our data show that nonpathogenic lactobacilli and pathogenic streptococci can induce Th1 type cytokines IL-12, IL-18, and IFN-gamma in human PBMC.

Roles of integrins and fibronectin in the entry of Streptococcus pyogenes into cells via protein F1

Entry of group A streptococcus (GAS) into cells has been suggested as an important trait in GAS pathogenicity. Protein F1, a fibronectin (Fn) binding protein, mediates GAS adherence to cells and the extracellular matrix, and efficient cell internalization. We demonstrate that the cellular receptors responsible for protein F1-mediated internalization of GAS are integrins capable of Fn binding. In HeLa cells, bacterial entry is blocked by anti-beta1 integrin monoclonal antibody. In the mouse cell line GD25, a beta1 null mutant, the alphavbeta3 integrin promotes GAS entry. Internalization of these cells by GAS is blocked by a peptide that specifically binds to alphavbeta3 integrin. In both cell lines, entry of GAS requires the occupancy of protein F1 by Fn. Neither the 29 kDa nor the 70 kDa N-terminal fragments or the 120 kDa cell-binding fragment of Fn promote bacterial entry. Fn-coated beads are taken up efficiently by HeLa cells. Both the entry of GAS via protein F1 and the uptake of Fn-coated beads are blocked by anti-beta1 antibody but are unaffected by a large excess of soluble Fn. Internalization of HeLa cells by bacteria bearing increasing amounts of prebound Fn to protein F1 reveals a sigmoidal ultrasensitive curve. These suggest that the ability of particles to interact via Fn with multiple integrin sites plays a central role in their ability to enter cells.

Role of the Hypervariable Region in Streptococcal M Proteins: Binding of a Human Complement Inhibitor

Antigenic variation allows pathogenic microorganisms to evade the immune system of the infected host. The variable structure must play an important role in pathogenesis, but its function is in most cases unknown. Here, we identify a function for the surface-exposed hypervariable region of streptococcal M5 protein, a virulence factor that inhibits phagocytosis. The hypervariable region of M5 was found to bind the human complement inhibitor FHL-1 (factor H-like protein 1), a 42-kDa plasma protein. Plasma absorption experiments with M5-expressing bacteria showed that the interaction with FHL-1 occurs also under physiologic conditions. Studies of another extensively characterized M protein, M6, indicated that this protein also has a binding site for FHL-1 in the hypervariable region. The complement-inhibitory function of FHL-1 was retained after binding to streptococci, suggesting that bound FHL-1 protects bacteria against complement attack. All available data now indicate that FHL-1, or another human complement inhibitor, binds to the hypervariable region of M proteins. These findings provide insights into the forces that drive antigenic variation and may explain why the hypervariable region of M protein is essential for phagocytosis resistance. Moreover, these data add to a growing body of evidence that human complement inhibitors are major targets for pathogenic microorganisms.

Rapid diagnosis of varicella zoster virus infection in acute facial palsy

Patients with zoster sine herpete and Ramsay Hunt syndrome without pathognomonic vesicles at the initial visit are often misdiagnosed with Bell's palsy and treated without antiviral agents. With PCR, we found that varicella zoster virus genomes were frequently detectable in auricular skin exudate from patients with zoster sine herpete or Ramsay Hunt syndrome before the appearance of vesicles.

Toxin-mediated streptococcal and staphylococcal disease

After several decades of seemingly decreasing virulence, streptococcal and staphylococcal infections have reemerged as a major source of morbidity and mortality. Within the past 2 decades, not only have well-established diseases such as rheumatic fever begun to reappear. but also many new entities, such as toxic shock syndrome, streptococcal toxic shock syndrome, recurrent toxin-mediated perineal erythema, and recalcitrant erythematous desquamating disorder have been described. Central to the renewed importance of these bacteria has been the production of circulating toxins, which often function as superantigens in causing the clinical manifestations, morbidity and mortality associated with these diseases.

Role of streptococcal pyrogenic exotoxin B in the mouse model of group A streptococcal infection

Streptococcal pyrogenic exotoxin B (SPE B) is a cysteine protease produced by Streptococcus pyogenes. In this study, the differences in virulence between protease-positive clinical isolates and their protease-negative mutants were examined in a mouse model. Isogenic protease-negative mutants were constructed by homologous recombination, using integrational plasmids to disrupt the speB gene. These mutants caused less mortality and tissue damage than protease-positive strains when inoculated into BALB/c mice via air pouch, suggesting that SPE B cysteine protease plays an important role in the pathogenesis of S. pyogenes infection. Reconstitution of SPE B in the air pouches increased the mortality of mice receiving the speB mutant strain. Infiltrated cell numbers in the exudates from the air pouches of mice infected with SPE B-producing S. pyogenes were higher than those from mice infected with protease-negative mutants at 12 h. However, despite pretreatment with vinblastine to deplete neutrophils, injection of protease-positive bacteria still resulted in severe tissue injury, indicating that neutrophil infiltration may not be the major factor involved in SPE B-enhanced tissue damage. The role of SPE B was further confirmed by demonstrating that SPE B immunization of mice conferred protection from challenge with a lethal dose of protease-positive bacteria.

Magnetic resonance imaging in the early diagnosis of group A beta streptococcal necrotizing fasciitis: a case report

Early diagnosis of invasive group A beta streptococcal (GABS) infection has been achieved in a patient using magnetic resonance imaging (MRI) complemented by needle aspiration. Life-saving treatments of GABS infection that include immediate surgical debridement along with the administration of i.v. antibiotics, gamma globulin, and hyperbaric oxygen were then implemented successfully to prevent the development of streptococcal toxic shock syndrome. While MRI is valuable in making early diagnosis of GABS, it should not delay surgical intervention.

Opsonic antibodies to the surface M protein of group A streptococci in pooled normal immunoglobulins (IVIG): potential impact on the clinical efficacy of IVIG therapy for severe invasive group A streptococcal infections

The surface M protein of group A streptococci (GAS) is one of the major virulence factors for this pathogen. Antibodies to the M protein can facilitate opsonophagocytosis by phagocytic cells present in human blood. We investigated whether pooled normal immunoglobulin G (IVIG) contains antibodies that can opsonize and enhance the phagocytosis of type M1 strains of GAS and whether the levels of these antibodies vary for different IVIG preparations. We focused on the presence of anti-M1 antibodies because the M1T1 serotype accounts for the majority of recent invasive GAS clinical isolates in our surveillance studies. The level of anti-M1 antibodies in three commercial IVIG preparations was determined by enzyme-linked immunosorbent assay (ELISA), and the opsonic activity of these antibodies was determined by neutrophil-mediated opsonophagocytosis of a representative M1T1 isolate. High levels of opsonic anti-M1 antibodies were found in all IVIG preparations tested, and there was a good correlation between ELISA titers and opsonophagocytic activity. However, there was no significant difference in the levels of opsonic anti-M1 antibodies among the various IVIG preparations or lots tested. Adsorption of IVIG with M1T1 bacteria removed the anti-M1 opsonic activity, while the level of anti-M3 opsonophagocytosis was unchanged. Plasma was obtained from seven patients with streptococcal toxic shock syndrome who received IVIG therapy, and the level of anti-M1 antibodies was assessed before and after IVIG administration. A significant increase in the level of type M1-specific antibodies was found in the plasma of all patients who received IVIG therapy (P < 0.006). The results reveal another potential mechanism by which IVIG can ameliorate severe invasive group A streptococcal infections.

Immunoglobulins to group A streptococcal surface molecules decrease adherence to and invasion of human pharyngeal cells

The M protein is one of the most important virulence factors of group A streptococci (Streptococcus pyogenes) and may play an important role in the first steps of streptococcal infection. Since acute pharyngitis is a frequently occurring infectious disease caused by these bacteria, we wished to know whether antibodies to the M protein or other surface components inhibit adherence and internalization of streptococci to pharyngeal cells. We investigated the role of whole human secretory immunoglobulin A (sIgA), M6 protein-specific sIgA, and M6 protein-specific serum IgG in the inhibition of streptococcal adherence and internalization to cultured human pharyngeal cells. S. pyogenes D471, which produces a type 6 M protein (M+), and its isogenic M-negative (M-) derivative JRS75 were tested. Purified whole sIgA, M protein-specific sIgA, and sIgA preabsorbed with M protein were able to decrease significantly the adherence of streptococci to pharyngeal cells. Purified IgG against the M6 protein did not diminish the attachment of streptococci to the pharyngeal cells but did reduce internalization. Thus, our data suggest that secretory IgA may play a key role in preventing streptococcal infection at mucosal surfaces by blocking adherence while affinity-purified anti-M protein-specific IgG blocks epitopes responsible for invasion.

Limb salvage for streptococcal gangrene of the extremity

BACKGROUND

Extremity soft tissue infections from group A, beta-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.

METHODS

Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.

RESULTS

Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.

CONCLUSIONS

Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.

Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature

The clinical features, essential laboratory findings, management, and outcome of all 23 cases of septic arthritis caused by different serogroups of beta-hemolytic streptococcus (BHS) seen at the Stanford Medical Center, Stanford, CA, from July 1, 1985, through October 31, 1996, were reviewed and compared to those found in the literature. Group A streptococci (GAS) accounted for 9 (40%) of our cases; group B (GBS), for 7 (30%); and Group G (GGS), for 7 (30%). No cases were caused by Group C (GCS) or F (GFS) during this period. During the same period, GAS accounted for 66 (33%) of 200 cases of bacteremia due to BHS, GBS, for 98 (49%); GCS, for 12 (6%); GFS, for 4 (2%); and GGS, for 20 (10%). A review of potential risk factors revealed that, with the exception of GGS, male and female patients were almost equally distributed among each of the serogroups. Patients aged 50 years and older comprised 56%-77% of each group. Associated conditions and risk factors were present among most patients (19/23, 83%); autoimmune diseases and a chronic skin wound or trauma were notably present among patients with GAS, while diabetes mellitus and malignancy were more common among patients with GBS. Infected prosthetic implants were present in 7 patients, including 4/7 patients with GGS. All patients had positive cultures of synovial fluid, and 11/23 (49%) had positive blood cultures (GAS, 5/9; GBS, 6/7; and GGS, 0/7). The clinical presentation and hospital course of patients infected with the different serogroups varied. Patients infected with GAS had the most severe disease and those with GGS the least severe. Necrotizing fascitis, shock, DIC, and admission to the intensive care unit were found only among patients infected with GAS. Despite aggressive management with antimicrobial therapy and surgery, 4/23 patients died (3 patients with GAS; 1 with GBS). The isolates from our patients were not available for study; investigations by others of the biology of BHS suggest that the production of 1 or more of the streptococcal pyrogenic exotoxins by isolates of GAS may account for the differences in the severity of disease among our patients with septic arthritis caused by different serogroups of BHS. Although septic arthritis due to BHS is uncommon, such patients provide a valuable model to study features of the host-parasite interaction that may contribute to the observed differences in severity of disease.

Group A streptococcal toxic shock syndrome with severe necrotizing fasciitis following hysterectomy--a case report

In the last 10 years an increasing number of cases of group A streptococcal toxic shock syndrome have appeared in various clinical settings. The manifestation of this syndrome includes rapidly progressive multiorgan failure and soft-tissue necrosis. This report presents a case of streptococcal toxic shock syndrome caused by Streptococcus pyogenes with severe necrotizing fasciitis of the abdominal wall following hysterectomy. Aggressive surgical intervention with debridement of all necrotic tissue necessitated resection of the complete abdominal wall (skin, subcutaneous tissue, muscle and peritoneum). The abdominal wall defect was covered with free myocutaneous flaps and split-skin grafts. Optimal treatment, including adequate antibiotic therapy and radical surgical intervention, is an indispensable prerequisite of successful outcome.

Necrotizing fasciitis caused by Staphylococcus aureus

Two patients with rapidly progressive necrotizing fasciitis of a lower extremity due to Staphylococcus aureus as a single pathogen are described. In both patients the portal of entry was attributed to needle puncture (intra-articular injection and intravenous catheter, respectively), followed by bacteremia. Necrotizing fasciitis occurred in a site remote from the needle puncture, suggesting metastatic infection. One patient developed toxic shock syndrome and the other a sunburn-like rash and erythematous mucosae with strawberry tongue. One patient died, and the other required above-knee amputation due to secondary infectious complications. Staphylococcus aureus may mimic the presentation of invasive group A streptococcal infections. A history of needle puncture should alert the physician to the possibility of Staphylococcus aureus infection.

Emerging and reemerging infectious diseases: a multidisciplinary perspective

Predictions that infectious diseases would be eliminated as a major threat to human health have been shattered by emerging and reemerging infections, among them acquired immunodeficiency syndrome (AIDS), hemorrhagic fevers, marked increases in infections caused by antimicrobial-resistant bacteria, and the resurgence of tuberculosis and malaria. Understanding the dynamics of emerging and reemerging infections is critical to efforts to reduce the morbidity and mortality of such infections, to establish policy related to preparedness for infectious threats, and for decisions on where to use limited resources in the fight against infections. In order to offer a multidisciplinary perspective, 23 infectious disease specialists, epidemiologists, geneticists, microbiologists, and population biologists participated in an open forum at Emory University on emerging and reemerging infectious diseases. As summarized below, the group addressed questions about the definition, the identification, the factors responsible for, and multidisciplinary approaches to emerging and reemerging infections.

Group A streptococcal meningitis: report of two cases

Group A streptococcus (GAS) is a very uncommon cause of bacterial meningitis, with less than 30 cases reported in the last quarter of a century. A recent worldwide increase in the incidence and severity of disease due to Streptococcus pyogenes has been observed. Although a rise of incidence of cases of GAS meningitis has not been shown, severe and fulminant cases have been reported in the literature in the last few years. We performed a retrospective analysis of the computer data of cerebrospinal fluid cultures from July 1987 to December 1995 at the Hadassah University Medical Center in Jerusalem, and report two cases of GAS meninigitis: one with a primary infection acquired through bacteraemia, in a 2-month-old child, and another with meninigitis secondary to cranial surgery in a 75-year-old patient. The cases are discussed and a literature review is presented.

Differentiation of cultured keratinocytes promotes the adherence of Streptococcus pyogenes

Based on a consideration of the histopathology of nonbullous impetigo that shows localization of Streptococcus pyogenes to highly differentiated, subcorneal keratinocytes, we hypothesized that adherence of an impetigo strain of S. pyogenes would be promoted by terminal differentiation of keratinocytes. An assay was developed in which S. pyogenes adhered via pilus-like projections from the cell wall to the surface of cultured human keratinocytes in a time- and inoculum-dependent manner suggestive of a receptor-mediated process. Terminal differentiation of keratinocytes was induced by increasing the calcium concentration in the growth medium, and was confirmed by morphologic analysis using electron microscopy. Adherence of S. pyogenes was three and fourfold greater to keratinocytes differentiated in 1.0 and 1.5 mM calcium, respectively, compared with undifferentiated keratinocytes in 0.15 mM calcium. The presence of calcium during the adherence assay further enhanced adherence nearly twofold. Adherence occurred preferentially to sites of contact between adjacent keratinocytes, suggesting that the keratinocyte receptor may be a molecule involved in cell-to-cell adhesion. In contrast, nonpathogenic Streptococcus gordonii adhered poorly to keratinocytes regardless of their state of terminal differentiation, and adherence of a pharyngeal strain of S. pyogenes was twofold greater to undifferentiated than differentiated keratinocytes. This is the first report of in vitro adherence of S. pyogenes to keratinocytes in a manner that emulates human impetigo. Adherence of only the impetigo strain, and not the pharyngeal strain of S. pyogenes or the nonpathogenic S. gorgonii isolate, was promoted by keratinocyte differentiation. This result provides a model system for investigating the molecular pathogenesis of streptococcal skin infections.

Differential induction of Th1 versus Th2 cytokines by group A streptococcal toxic shock syndrome isolates

The majority of group A streptococcal (GAS) isolates from patients with streptococcal toxic shock syndrome (STSS) and necrotizing fasciitis (NF) express numerous virulence factors, including several superantigens (SAgs). Purified SAgs are potent inducers of inflammatory (Th1) cytokines that contribute to the pathogenesis of severe infections. However, GAS-infected individuals are likely to be exposed to a mixture of GAS SAgs as well as other virulence factors produced by the bacteria, and therefore, our goal was to characterize the mitogenic and cytokine induction profiles of this mixture. All GAS isolates tested had brisk mitogenic activity and induced potent cytokine responses, with higher frequencies of Th1 than Th2 cytokine-producing cells. The mitogenic activity produced in culture supernatants of three selected clinical GAS isolates was significantly different, but no marked difference was found in their overall cytokine induction profiles. However, significant differences (P < 0.0062) were noted in the induction of Th2 cytokines between GAS supernatants and recombinant streptococcal pyrogenic exotoxin A (rSpeA), suggesting that the presence of other SAgs and/or the production of additional virulence factors may alter the overall cytokine induction profile of SAgs. A significant individual variation in the level of proliferative and cytokine responses to the same GAS culture supernatants or to rSpeA was noted. Individuals with higher frequencies of cells producing Th2 cytokines mounted lower levels of Th1 cytokine responses, and vice versa. Furthermore, quantification of the intensity and cell area of interleukin-1beta (IL-1beta)-producing cells by image analysis revealed that individuals with higher Th2 responses had significantly lower IL-1beta production (P < 0.0001) than the individual with a strong Th1 response. Differences in the ability to induce Th1 versus Th2 cytokines, as well as the individual variations in cytokine responses to streptococcal SAgs, may play a central role in determining the severity of invasive GAS infections.

Periocular necrotizing fasciitis: a review of five cases

OBJECTIVE

The purpose of the study is to display a spectrum of clinical presentations of periocular necrotizing fasciitis caused by group A streptococci and to discuss recent trends and treatment of this disease.

DESIGN AND INTERVENTION

A case series of five patients (four female and one male) was seen between July 1990 and January 1995 in four university centers. All had clinical evidence of periocular necrotizing fasciitis and grew group A streptococci on wound cultures or had serologic evidence of streptococcal infection. Details of patient presentation, treatment, and outcome are examined.

RESULTS

The five patients showed a spectrum of clinical severity from a necrotizing infection confined to the eyelid to a potentially fatal, severe shock-like syndrome characterized by sepsis and multiorgan system failure. A history of trauma often was absent. Patients were treated successfully by a combination of appropriate antibiotics and surgical debridement.

CONCLUSIONS

Group A streptococci can cause severe necrotizing infections of the eyelids. Early recognition and prompt treatment can be essential to these patients' survival.

Toxic shock syndrome and necrotizing fasciitis complicating neglected sacrococcygeal pilonidal sinus disease: report of a case

PURPOSE

This study was conducted to report the rare combination of necrotizing fasciitis and toxic shock syndrome, which both complicated neglected sacrococcygeal pilonidal sinus disease.

METHODS

A case report is presented.

RESULTS

We describe the rare case of a previously healthy adult male patient who developed necrotizing fasciitis and toxic shock syndrome associated with Streptococcus pyogenes and Bacteroides fragilis. Patient's response to emergency surgery followed by repeated debridements of necrotic tissue, together with aggressive fluid resuscitation, broad-spectrum antibiotic coverage, and hyperbaric oxygenation was good.

CONCLUSION

This case serves again as a clear reminder that neglected pilonidal sinus disease can lead to unusual and life-threatening consequences.