First reported case of Streptococcus pyogenes infection with toxic shock-like syndrome in Italy

Streptococcal mitogenic exotoxin, SmeZ, is the most susceptible M1T1 streptococcal superantigen to degradation by the streptococcal cysteine protease, SpeB

Superantigens (SAgs) play an important role in the pathogenesis of severe invasive infections caused by Group A Streptococcus (GAS). We had shown earlier that the expression of streptococcal cysteine protease SpeB results in partial loss of the immune-stimulating activity of the native secreted GAS SAgs, namely the streptococcal pyrogenic exotoxins produced by the globally disseminated M1T1 GAS strain, associated with invasive infections worldwide. In this study, we examined the susceptibility of each of the M1T1 recombinant SAgs to degradation by rSpeB. Whereas SmeZ was degraded completely within 30 min of incubation with rSpeB, SpeG, and SpeA were more resistant and SpeJ was completely unaffected by the proteolytic effects of this protease. Proteomic analyses demonstrated that the order of susceptibility of the M1T1 SAgs to SpeB proteolysis is unaltered when they are present in a mixture that reflects their native physiological status. As expected, the degradation of SmeZ abolished its immune stimulatory activity. In silico sequence disorder and structural analyses revealed that SmeZ, unlike the three other structurally related SAgs, possesses a putative SpeB cleavage site within an area of the protein likely to be exposed to the surface. The study provides evidence for the effect of subtle structural differences between highly similar SAgs on their biological activity.

[Necrotizing fasciitis caused by group A streptococcus]

The first case of the confirmed necrotizing fasciitis caused by Group A Streptococcus in Yugoslavia was presented. Male patient, aged 28, in good health, suddenly developed symptoms and signs of severe infective syndrome and intensive pain in the axillary region. Parenteral antibiotic, substitutional and supportive therapy was conducted along with the radical surgical excision of the necrotizing tissue. The patient did not develop streptococcal toxic shock syndrome thanks to the early established diagnosis and timely applied aggressive treatment. He was released from the hospital as completely cured two months after the admission.

Toxic shock syndrome due to group C streptococci. A case report

BACKGROUND

Streptococcal toxic shock-like syndrome is a life-threatening illness which is on the increase. In early reports, only group A beta-hemolytic streptococcus was associated with the disease, but recent evidence indicates non-A streptococci groups are also involved.

OBSERVATIONS

We describe the first reported case of streptococcal toxic shock-like syndrome caused by a group C strain in Italy. Prior to the disease, the patient, a 46-year-old man, had been in good health and had only a 3-day history of sore throat, low grade fever, vomiting, diarrhea, and myalgia before admission. Initially, diagnosis was based only on clinical evidence: shock, multiorgan failure, profound hypothermia, and no apparent signs of infection. Toxic cardiomyopathy was also present.

RESULTS

Positive throat swab and blood culture confirmed a "definite case" following established criteria. Anamnesis showed a diagnosis of monoclonal gammopathy. Antibiotic treatment was begun immediately on admission of the patient, who was discharged 20 days later in good health.

CONCLUSIONS

This case illustrates how an early diagnosis and prompt antibiotic therapy can determine a more favorable outcome.

Streptococcal toxic shock syndrome in a postpartum woman. Case report and review of the literature

A case of streptococcal toxic shock syndrome in a 29-year-old postpartum woman is described. The patient presented with hypotension, coagulation defects, adult respiratory distress syndrome and scarlet exanthema as a complication of hemolytic group A streptococcal endometritis. One hundred and twenty-two other cases of streptococcal toxic shock syndrome in the literature are reviewed and the criteria of the syndrome discussed. Streptococcal toxic shock syndrome seems to be increasing along with more frequent invasive streptococcal infections in several countries. It is therefore important to recognize and treat the infection as early as possible to minimize the risk of mortality.

Streptococcal toxic shock-like syndrome. Report of two cases from Italy

Two cases of streptococcal toxic shock-like syndrome that occurred at our hospital are described. They represent the second and third cases reported from Italy. Both patients were women, had a portal of entry from cutaneous infection of a limb and suddenly developed high degree fever, severe hypotension, necrotizing fasciitis, acute renal failure, hepatic damage, thrombocytopenia and bleeding from a stress-related duodenal ulcer. One patient was leukopenic. The first patient needed resuscitation in the intensive care unit and emergency surgical debridement of the affected limb, whereas the second improved with medical therapy, but needed duodenal surgery for uncontrolled bleeding. Both patients slowly recovered and survived. Finally, a short update on the pathogenesis of the syndrome is also presented.