Group A Streptococcus virulence and host factors in two toddlers with rheumatic fever following toxic shock syndrome

Inactivation of the lysine binding sites of human plasminogen (hPg) reveals novel structural requirements for the tight hPg conformation, M-protein binding, and rapid activation

Accelerated activation of the human plasminogen zymogen (hPg) to two-chain active plasmin (hPm) is achieved following conformational changes induced by ligand-binding at the lysine-binding sites (LBSs) in four of the five hPg kringle domains. In this manner, pattern D skin-trophic strains of Group A streptococci (GAS), through the expression of surface plasminogen-binding M-protein (PAM), immobilize surface hPg, thereby enabling rapid hPg activation by GAS-secreted streptokinase (SK). Consequently, GAS enhances virulence by digesting extracellular and tight cellular junctional barriers using hPm activity. Many studies have demonstrated the singular importance of the kringle-2 domain of hPg (K2hPg) to PAM-binding using hPg fragments. Recently, we showed, using full-length hPg, that K2hPg is critical for PAM binding. However, these studies did not eliminate any modulatory effects of the non-K2hPg LBS on this interaction. Moreover, we sought to establish the significance of the intramolecular interaction between Asp219 of the LBS of K2hPg and its serine protease domain binding partner, Lys708, to conformational changes in hPg. In the current study, selective inactivation of the LBS of K1hPg, K4hPg, and K5hPg revealed that the LBS of these kringle domains are dispensable for hPg binding to PAM. However, the attendant conformational change upon inactivation of K4hPg LBS increased the affinity of hPg for PAM by an order of magnitude. This finding suggests that the native hPg conformation encloses PAM-binding exosites or sterically hinders access to K2hPg. While simultaneous inactivation of the LBS of K1hPg, K4hPg, and K5hPg inhibited hPg/SK association alongside hPg activation, the replacement of Lys708 generated a slight conformational change that optimally accelerated hPg activation. Thus, we accentuate disparate functions of hPg LBS and conclude, using intact proteins, that K2hPg plays a central role in regulating hPg activation.

Streptococcal Pyrogenic Exotoxin A-Stimulated Monocytes Mediate Regulatory T-Cell Accumulation through PD-L1 and Kynurenine

Bacterial superantigens (SAgs) are exotoxins that promote a fulminant activation of the immune system. The subsequent intense release of inflammatory cytokines often results in hypotension, shock, and organ failure with high mortality rates. In the current paradigm, the direct and simultaneous binding of SAgs with T-cell receptor (TCR)-bearing Vβ regions and conserved structures on major histocompatibility complex class II (MHC class II) on antigen-presenting cells (APCs) induces the activation of both cell types. However, by crosslinking MHC class II molecules, APCs can be activated by SAgs independently of T lymphocytes. Recently, we showed that streptococcal pyrogenic exotoxin A (SPEA) of Streptococcus pyogenes stimulates an immunogenic APC phenotype with upregulated costimulatory molecules and inflammatory cytokines. Additionally, we revealed that SPEA triggers immunosuppressive programs in monocytes that facilitate the accumulation of regulatory T cells (Tregs) in in vitro monocyte/CD4⁺ T-cell cocultures. Immunosuppressive factors include anti-inflammatory interleukin 10 (IL-10), co-inhibitory surface molecule programmed cell death 1 ligand 1 (PD-L1), and the inhibitory indoleamine 2,3-dioxygenase (IDO)/kynurenine effector system. In the present study, we investigated the underlying mechanism of SPEA-stimulated monocyte-mediated accumulation of Tregs. Blood-derived monocytes from healthy donors were stimulated with SPEA for 48 h (SPEA-monocytes). For the evaluation of SPEA-monocyte-mediated modulation of CD4⁺ T lymphocytes, SPEA was removed from the culture through extensive washing of cells before adding allogeneic CD3/CD28-activated T cells. Results: In coculture with allogeneic CD4⁺ T cells, SPEA-monocytes mediate apoptosis of CD4⁺Foxp3⁻ lymphocytes and accumulation of CD4⁺Foxp3⁺ Tregs. PD-L1 and kynurenine are critically involved in the mediated cell death because blocking both factors diminished apoptosis and decreased the proportion of the CD25⁺/Foxp3⁺ Treg subpopulation significantly. Upregulation of PD-L1 and kynurenine as well as SPEA-monocyte-mediated effects on T cells depend on inflammatory IL-1β. Our study shows that monocytes activated by SPEA mediate apoptosis of CD4⁺Foxp3⁻ T effector cells through PD-L1 and kynurenine. CD4⁺Foxp3⁺ T cells are resistant to apoptosis and accumulate in SPEA-monocyte/CD4⁺ T-cell coculture.

Management of Contacts of Patients With Severe Invasive Group A Streptococcal Infection

BACKGROUND

Conflicting recommendations regarding antibiotic prophylaxis for contacts of patients with invasive group A streptococcal (GAS) infection exist. Close contacts of patients with such severe and rapidly progressive disease often strongly appeal to the treating clinicians for antimicrobial treatment to prevent additional cases. We aimed to use an approach based on pharyngeal culture testing of contacts and targeted antibiotic prophylaxis.

METHODS

A large throat swab survey including 105 contacts was undertaken after a fulminant and fatal case of GAS necrotizing fasciitis. GAS strains were characterized by emm typing and antimicrobial susceptibility to 7 antibiotics. The presence of 30 virulence determinants was determined by polymerase chain reaction and sequencing.

RESULTS

The GAS isolate recovered from the index patient was an M1T1 GAS clone susceptible to all antimicrobial agents tested. The same clone was present in the throat of 36% of close contacts who had exposure to the index patient (family households and classroom contacts) for >24 hours/week, whereas the strain was present in only 2% of the other contacts.

CONCLUSIONS

Although the study does not allow firm conclusions to be drawn as to whether antibiotic prophylaxis is effective, we describe a practical approach, including an educational campaign and targeted antibiotic treatment to close contacts who have been exposed to an index patient for > 24 hours/week before the initial disease onset.

Geoepidemiological hints about Streptococcus pyogenes strains in relationship with acute rheumatic fever

Group A Streptococcus (GAS) strains are lately classified on the basis of sequence variations in the emm gene encoding the M protein, but despite the high number of distinct emm genotypes, the spectrum of phenotypes varying from invasive suppurative to non-suppurative GAS-related disorders has still to be defined. The relationship of GAS types with the uprising of acute rheumatic fever (ARF), a multisystemic disease caused by misdirected anti-GAS response in predisposed people, is also obscure. Studies published over the last 15 years were retrieved from PubMed using the keywords: "Streptococcus pyogenes" or "group A Streptococcus" and "acute rheumatic fever": the prevalence of peculiar emm types across different countries of the world is highly variable, depending on research designs, year of observation, country involved, patients' age, and gender. Most studies revealed that a relatively small number of specific emm/M protein types can be considered "rheumatogenic", as potentially characterized by the possibility of inducing ARF, with remarkable differences between developing and developed countries. The association between emm types and post-streptococcal manifestations is challenging, however surveillance of disease-causing variants in a specific community with high rate of ARF should be reinforced with the final goal of developing a potential primary prophylaxis against GAS infections.

Streptococcal superantigens: categorization and clinical associations

Superantigens are key virulence factors in the immunopathogenesis of invasive disease caused by group A streptococcus. These protein exotoxins have also been associated with severe group C and group G streptococcal infections. A number of novel streptococcal superantigens have recently been described with some resulting confusion in their classification. In addition to clarifying the nomenclature of streptococcal superantigens and proposing guidelines for their categorization, this review summarizes the evidence supporting their involvement in various clinical diseases including acute rheumatic fever.

Group A streptococcus colonies from a single throat swab can have heterogeneous antimicrobial susceptibility patterns

This study describes for the first time heterogeneity of antibiotic resistance profiles among group A Streptococcus isolates originating from a single throat swab in patients with acute pharyngitis. For each throat swab, 10 group A Streptococcus colonies were randomly selected from the primary plate and subcultured to a secondary plate. These isolates were characterized by various phenotypic and genotypic methods. Our results demonstrated that differing antibiotic resistance profiles were present in 19% of pediatric patients with acute pharyngitis before antimicrobial treatment. This heterogeneity likely resulted from horizontal gene transfer among streptococcal isolates sharing the same genetic background. As only a minority of colonies displayed antibiotic resistance among these heterogeneous samples, a classical diagnostic antibiogram would have classified them in most instances as "susceptible," although therapeutic failure could be caused by the proliferation of resistant strains after initiation of antibiotic treatment.

Group A streptococcus meningitis in children

OBJECTIVE

To characterize the epidemiologic burden and the molecular determinants of group A streptococcal (GAS) meningitis among the pediatric population of the state of Paraná, Brazil.

METHODS

Clinical and epidemiologic data were gathered by a compulsory notification system during the period 2003 to 2011. Bacterial identification, antibiotic resistance profile, emm-typing, pulsed-field gel electrophoresis typing and virulence profile were analyzed by a central reference laboratory. A review of published pediatric cases of GAS meningitis from the last 45 years was undertaken and compared with the Brazilian series.

RESULTS

The incidence of GAS meningitis among the pediatric population was 0.06 cases per 100,000 children per year and was associated with a case fatality rate of 43%. Neonatal age and the presence of an associated toxic shock syndrome were identified as risk factors for death. A distant focus of infection was present in more than half of the patients in the literature and in 36% in the Brazilian case series. A high diversity of emm-types was associated with GAS meningitis in Brazil. No single virulence determinant could be associated with death.

CONCLUSIONS

GAS meningitis is associated with high mortality and with a high diversity of GAS emm-types and virulence determinants in Brazil.

Current insights in invasive group A streptococcal infections in pediatrics

A rising incidence of invasive group A Streptococcus infections (IGASI) has been noted in children in the past three decades. The relative frequency of the infection types showed marked differences to IGASI in adults, and severity of the disease resulted in a mortality rate usually comprising between 3.6% and 8.3%. The emm1-type group A Streptococcus (GAS) subclone displaying a particular pattern of virulence factors was widely disseminated and prevalent in children with IGASI while the emm3-type GAS subclone appeared as a recent emerging genotype. However, the implication of these hypervirulent clones in the increase of IGASI in children is still controversial. Recent advances in our knowledge on pathogenesis of IGASI underlined that deregulation of virulence factor production, individual susceptibility, as well as exuberant cytokine response are important factors that may account for the severity of the disease in children. Future changes in IGASI epidemiology are awaited from current prospects for a safe and effective vaccine against GAS. IGASI are complex infections associating septic, toxic, and immunological disorders. Treatment has to be effective on both the etiologic agent and its toxins, due to the severity of the disease associated to the spread of highly virulent bacterial clones. More generally, emergence of virulent clones responsible for septic and toxic disease is a matter of concern in pediatric infectiology in the absence of vaccination strategy.

Identification and antibacterial evaluation of bioactive compounds from Garcinia kola (Heckel) seeds

We assessed the bioactivity of G. kola seeds on Streptococcus pyogenes, Staphylococcus aureus, Plesiomonas shigelloides and Salmonella typhimurium. The crude ethyl acetate, ethanol, methanol, acetone and aqueous extracts were screened by the agar-well diffusion method and their activities were further determined by Minimum Inhibitory Concentration (MIC) and Minimum Bactericidal Concentration (MBC) assays. The extracts were fractionated by Thin Layer Chromatography (TLC). Bioautography was used to assess the activity of the possible classes of compounds present in the more active extracts. Column chromatography was used to purify the active compounds from the mixture, while GC-MS was used to identify the phytocomponents of the fractions. The inhibition zone diameters of the extracts ranged from 0–24 ± 1.1 mm, while MIC and MBC values ranged between 0.04–1.25 mg/mL and 0.081–2.5 mg/mL, respectively. The chloroform/ethyl acetate/formic acid (CEF) solvent system separated more active compounds. The MIC of the fractions ranged between 0.0006–2.5 mg/mL. CEF 3 (F3), CEF 11 (F11) and CEF 12 (F12) revealed the presence of high levels of linoleic acid, 1,2-benzenedicarboxylic acid and 2,3-dihydro-3,5-dihydroxy-6-methyl ester, respectively. The results obtained from this study justify the use of this plant in traditional medicine and provide leads which could be further exploited for the development of new and potent antimicrobials.

DQB1*06:02 allele-specific expression varies by allelic dosage, not narcolepsy status

The association of narcolepsy-cataplexy, a sleep disorder caused by the loss of hypocretin/orexin neurons in the hypothalamus, with DQA1*01:02-DQB1*06:02 is one of the tightest known single-allele human leukocyte antigen (HLA) associations. In this study, we explored genome-wide expression in peripheral white blood cells of 50 narcolepsy versus 47 controls (half of whom were DQB1*06:02 positive) and observed the largest differences between the groups in the signal from HLA probes. Further studies of HLA-DQ expression (mRNA and protein in a subset) in 125 controls and 147 narcolepsy cases did not reveal any difference, a result we explain by the lack of proper control of allelic diversity in Affymetrix HLA probes. Rather, a clear effect of DQB1*06:02 allelic dosage on DQB1*06:02 mRNA levels (1.65-fold) and protein (1.59-fold) could be demonstrated independent of disease status. These results indicate that allelic dosage is transmitted into changes in heterodimer availability, a phenomenon that may explain the increased risk for narcolepsy in DQB1*06:02 homozygotes versus heterozygotes.

Pragmatic scoring system for pharyngitis in low-resource settings

OBJECTIVE

Our objective was to develop an easy, safe, pragmatic, clinical scoring system that would allow decreases in unnecessary treatment with antimicrobial agents in low-resource settings.

METHODS

Children with pharyngitis were enrolled prospectively from 2 public hospitals and 1 medical unit in Brasilia, Brazil, over 17 months. Attending clinicians completed a questionnaire and a previously published scoring system for pharyngitis before performing throat swabs and group A streptococcus (GAS) rapid antigen-detection tests. Data from this study were added to those collected in 2004, to assess the performance of each item of the scoring system. The performance of the new clinical decision rule was determined with a receiver operating characteristic curve. The final outcome of the model was assessed on the basis of sensitivity, specificity, and positive likelihood ratio for non-GAS infections with the clinical approach, compared with throat culture or rapid antigen-detection test results.

RESULTS

A total of 576 children were included, among whom 400 had non-GAS pharyngitis. The use of our new clinical decision rule would allow for 35% to 55% antibiotic reduction, with 88% specificity.

CONCLUSIONS

This clinical decision rule could reduce unnecessary antibiotic treatment significantly in low-resource settings.