Streptococcus zooepidemicus (group C) pneumonia in a human

7-Year (2015-21) longitudinal surveillance of lefamulin in vitro activity against bacterial pathogens collected worldwide from patients with respiratory tract infections including pneumonia and characterization of resistance mechanisms

OBJECTIVES

Lefamulin (Xenleta™), a pleuromutilin antibiotic, was approved for the oral and IV treatment of community-acquired bacterial pneumonia (CABP) in adults in 2019/2020. This study evaluated the in vitro activity of lefamulin and comparators against 19 584 unique bacterial isolates collected from patients with community-acquired respiratory tract infections and hospitalized patients with pneumonia within the global SENTRY Antimicrobial Surveillance Program during 2015-21.

METHODS

Isolates were susceptibility tested by the CLSI broth microdilution method, and resistance mechanisms were investigated in isolates with elevated lefamulin MICs.

RESULTS

Lefamulin exhibited potent antibacterial activity against the most common and typical CABP pathogens tested, including Streptococcus pneumoniae [MIC50/90, 0.06/0.25 mg/L; 99.9% susceptible (S)], Staphylococcus aureus (MIC50/90, 0.06/0.12 mg/L; 99.6% S), Haemophilus influenzae (MIC50/90, 0.5/2 mg/L; 99.1% S) and Moraxella catarrhalis (MIC50/90, 0.06/0.12 mg/L; 100.0% S). Potent activity was also observed against the less common pneumonia pathogens: β-haemolytic (MIC50/90 of 0.03/0.06 mg/L) and viridans group Streptococcus spp. (MIC50/90 of 0.06/0.25 mg/L) and Haemophilus parainfluenzae (MIC50/90 of 1/4 mg/L). Lefamulin's activity was not adversely affected by resistance to macrolides, penicillin, tetracyclines, fluoroquinolones and other resistance phenotypes. Non-susceptibility/resistance to lefamulin was rare and primarily determined by ribosomal protection through vga(A) variants in S. aureus, overexpression of AcrAB-TolC efflux pump in H. influenzae or modifications in L3, L4 and 23SrRNA in Streptococcus spp.

CONCLUSIONS

Based on the coverage of the most important CABP pathogens and lacking cross-resistance, lefamulin may represent a valuable empirical treatment option for ambulatory and hospitalized patients with CABP, particularly in settings with high prevalence of resistance.

Streptococcus equi subsp. zooepidemicus finding in confirmed feline infectious peritonitis cat patient

BACKGROUND

Feline infectious peritonitis (FIP) is a fatal immune-mediated disease in cat, caused by mutated feline coronavirus (FCoV). Due to its difficulties in diagnosis, FIP is sometimes underdiagnosed. Therefore, several laboratory procedures were performed to gain high index suspicion of FIP. However, through several laboratory findings, not only FIP but also SEZ infection was confirmed in this case.

CASE DESCRIPTION

A-year-old male, domestic cat was admitted to Veterinary Medicine Clinical Pathology Laboratory, Universitas Gadjah Mada, for further effusion examination due to its high suspicion of feline infectious peritonitis (FIP). Further examination using molecular and post-mortem analysis resulted on confirmed SEZ infection and FIP. This study informed the manifestation and pathological changes in patient with SEZ and FIP in the same time.

CONCLUSIONS

This study showed that viral infection followed by bacterial infection could be fatal and untreatable. After these findings, clinicians may consider SEZ infection in cat with respiratory disorder followed by thoracic effusion besides FIP. Companion animal, especially outdoor-kept animal, possibly become infected from its contact to another human or animal in the environment.

Haemorrhagic pneumonia in sled dogs caused by Streptococcus equi subsp. zooepidemicus - one fatality and two full recoveries: a case report

In spite of yearly vaccination, outbreaks of canine infectious respiratory disease are periodically seen amongst domestic dogs. These infections compromise host defense mechanisms, and, when combined with other stressful events, allow opportunistic pathogens like Streptococcus equi subsp. zooepidemicus to create serious disease. Early recognition and treatment are tremendously important for a successful outcome in these cases. A polyvalent vaccine was given to 22 racing dogs three days after a competition, followed by two days of rest, and then the dogs were returned to regular training. Coughing was noticed among the dogs four days after immunisation. Three days after this outbreak one of the dogs was unusually silent and was found dead the next morning. Simultaneously two other dogs developed haemorrhagic expectorate, depression and dyspnea and were brought in to the veterinary hospital. Streptococcus equi subsp. zooepidemicus was isolated in pure culture from all three cases. They were treated and rehabilitated successfully, and won a sledge race three months later. This paper discusses the necropsy results, treatment regime, rehabilitation and the chronology of vaccination, stressful events and disease.

Rhinitis and meningitis in two shelter cats caused by Streptococcus equi subspecies zooepidemicus

In the past 6 years there have been increasing reports describing outbreaks of a severe fatal respiratory disease associated with Streptococcus equi subspecies zooepidemicus (SEZ) in dogs maintained in shelters, research facilities and kennels. Although SEZ appears to be an emerging pathogen of dogs kept in intensively housed environments, this bacterium has not been reported as a cause of death in intensively housed cats. This report describes fatal SEZ infection in two adult cats housed in separate animal shelter facilities. Both cats had acute onset of illness, which progressed to death in less than 24h. Post-mortem examination revealed rhinitis and meningitis and SEZ was demonstrated in the nasal cavity and brain. Polymerase chain reaction and sequence analysis of a 500 base pair region of the 16S rRNA gene confirmed the identity of the bacterium.

Outbreak of Streptococcus equi subsp. zooepidemicus infections in cats

Streptococcus equi subsp. zooepidemicus (S. zooepidemicus) is a commensal of the mucous membranes and skin of animals, notably equine, and is associated with various infections in animals and humans. Here, we describe an outbreak of respiratory disease in a cattery, which, to the best of our knowledge, is the first report of S. zooepidemicus infection in cats. Clinical disease was characterized firstly by abundant purulent nasal discharges and cough, progressing to sinusitis, dyspnea, symptoms of pneumonia and death. Pathological examination revealed different degrees of inflammation of the lower respiratory tract. S. zooepidemicus was the main bacteria isolated. Sequencing of the V2 fragment of the 16S gene revealed that the isolates were distributed in two previously described genogroups.

Outbreak of Streptococcus equi subsp. zooepidemicus infection in a group of rhesus monkeys (Macaca mulatta)

Background  A severe upper respiratory tract infection occurred in a breeding group of rhesus monkeys housed together in one of six indoor/outdoor corals of the German Primate Center. The clinical signs of the disease included severe purulent conjunctivitis, rhinitis, pharyngitis, respiratory distress and lethargy. Six of 45 animals died within a few days after developing signs of infection.

Methods and results  Histopathologic and microbiologic examinations of the dead animals were consistent with a severe fibrinopurulent bronchopneumonia. Microbiology revealed a Lancefield group C streptococcus identified as Streptococcus equi subsp. zooepidemicus as the causative agent of infection.

Conclusions  The infection was passed on from animal to animal but did not spread to the other five breeding groups nearby. Extensive diagnostic testing failed to reveal the consisting presence of copathogens in individual cases. A visitor with upper respiratory disease was suspected as source of infection.

Genome sequence of a Lancefield group C Streptococcus zooepidemicus strain causing epidemic nephritis: new information about an old disease

Outbreaks of disease attributable to human error or natural causes can provide unique opportunities to gain new information about host-pathogen interactions and new leads for pathogenesis research. Poststreptococcal glomerulonephritis (PSGN), a sequela of infection with pathogenic streptococci, is a common cause of preventable kidney disease worldwide. Although PSGN usually occurs after infection with group A streptococci, organisms of Lancefield group C and G also can be responsible. Despite decades of study, the molecular pathogenesis of PSGN is poorly understood. As a first step toward gaining new information about PSGN pathogenesis, we sequenced the genome of Streptococcus equi subsp. zooepidemicus strain MGCS10565, a group C organism that caused a very large and unusually severe epidemic of nephritis in Brazil. The genome is a circular chromosome of 2,024,171 bp. The genome shares extensive gene content, including many virulence factors, with genetically related group A streptococci, but unexpectedly lacks prophages. The genome contains many apparently foreign genes interspersed around the chromosome, consistent with the presence of a full array of genes required for natural competence. An inordinately large family of genes encodes secreted extracellular collagen-like proteins with multiple integrin-binding motifs. The absence of a gene related to speB rules out the long-held belief that streptococcal pyrogenic exotoxin B or antibodies reacting with it singularly cause PSGN. Many proteins previously implicated in GAS PSGN, such as streptokinase, are either highly divergent in strain MGCS10565 or are not more closely related between these species than to orthologs present in other streptococci that do not commonly cause PSGN. Our analysis provides a comparative genomics framework for renewed appraisal of molecular events underlying APSGN pathogenesis.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

Genetic basis of murine antibacterial defense to streptococcal lung infection

To evaluate the effect of genetic background on antibacterial defense to streptococcal infection, eight genetically diverse strains of mice (A/J, DBA/2J, CAST/Ei, FVB/NJ, BALB/cJ, C57BL/6J, 129/SvImJ, and C3H/HeJ) and tlr2-deficient mice (C57BL/6(tlr2-/-)) were infected with three doses of Streptococcus zooepidemicus (500, 5,000, or 50,000 colony-forming units) by alveolar challenge. There was a range of susceptibility between the strains at each dose and time point (6, 24, and 96 h). At the lowest dose, the 129/SvImJ and C3H/HeJ strains had significantly higher bacterial counts at all time points after infection, when compared to A/J, DBA/2J, CAST/Ei, FVB/NJ, which were resistant to infection at the low dose of innoculum. At the medium dose, 129/SvImJ and C3H/HeJ had higher bacterial counts, while A/J, DBA/2J, and BALB/cJ showed reduced streptococcal growth. After the highest dose of Streptococcus, there were minimal differences between strains, suggesting the protective impact of modifier genes can be overcome. TLR2-deficient animals contained increased bacterial load with reduced cytokines after 96 h when compared to C57BL/6J controls suggesting a role of innate immunity in late antibacterial defense. Overall, we identify vulnerable (129/SvlmJ and C3H/HeJ) and resistant (A/J, FVB, and DBA) mouse strains to streptococcal lung infection, which demonstrate divergent genetic expression profiles. These results demonstrate that innate differences in pulmonary host defense to S. zooepidemicus are dependent on host genetic factors.

Post streptococcal acute glomerulonephritis secondary to sporadic Streptococcus equi infection

Streptococcus equi subspecies zooepidemicus infection is rare in humans, but a well-known cause of pyogenic disease in cows and horses. S. zooepidemicus uncommonly causes post-strep glomerulonephritis (PSGN) in humans via epidemic outbreaks. We present a sporadic case of post S. zooepidemicus glomerulonephritis in a child most probably contracted from a horse. The 14-year-old girl presented with the typical signs of PSGN, with S. equi zooepidemicus isolated from a blood culture, together with a low C3 and raised anti-DNAse B. This is the first known report of a sporadic case of PSGN in a child caused by this organism.

Outbreak of Streptococcus equi subsp. zooepidemicus infections on the island of Gran Canaria associated with the consumption of inadequately pasteurized cheese

Streptococcus equi subsp. zooepidemicus infections are infrequent in humans. A clinical and epidemiological study of a milk-borne outbreak caused by this organism is described. Fifteen patients (5 females, 10 males) with a median age of 70 years (range 47-86) were infected. Twelve (80%) had underlying diseases. Infection with S. equi subsp. zooepidemicus presented as primary bacteremia in six cases, as bacteremia associated with aortic aneurism in four cases, as septic arthritis in two cases, as pneumonia in two cases, and as meningitis in one case. Five (33.3%) patients died. A case-control study proved that consumption of inadequately pasteurized cheese of a specific brand was associated with S. equi subsp. zooepidemicus disease (OR=4.5; 95% CI 1.57-19.27; p<0.001). This outbreak serves as a reminder that S. equi subsp. zooepidemicus causes serious infections that are usually zoonoses. Identification of beta-hemolytic streptococci to the species level to detect contaminated foods of animal origin is important for preventing new food-borne outbreaks. For a precise characterization of the isolates, the application of molecular markers is recommended.

Epidemic glomerulonephritis due to Streptococcus zooepidemicus in Nova Serrana, Brazil

BACKGROUND

In 1998, there was a large outbreak of acute glomerulonephritis in Nova Serrana, Brazil, caused by group C Streptococcus zooepidemicus. This article reviews the characteristics of the outbreak and some aspects of the patients' follow-up.

METHODS

We describe clinical characteristics of patients with acute nephritis. Using case-control studies, we identified the source of infection. Cultures of oropharyngeal swabs from patients were performed. Of 135 patients identified in 1998, available patients were reexamined in a prospective study after 2 and 5 years.

RESULTS

Lancefield group C S. zooepidemicus was identified as the causative organism and linked to the consumption of cheese produced from unpasteurized milk. Of the original group of 134 patients, 4 died in the acute phase and 5 (3.7%) required chronic dialysis. After 2 years, of the 69 cases reevaluated, 94% were adults (mean +/- standard error age: 39 +/- 2 years); we found arterial hypertension in 42% (N= 27/64) of the patients, reduced creatinine clearance (<80 mL/min/1.73 m(2)) in 30% (N= 20/67), and increased microalbuminuria (>20 microg/min) in 34% (N= 22/65). Preliminary data at 5-year follow-up suggest that the percentage of patients with creatinine clearance lower than 60 mL/min increased from 9% to 15%.

CONCLUSION

This article highlights the dangers of consuming unpasteurized dairy products. Follow-up of patients with epidemic poststreptococcal glomerulonephritis due to S. zooepidemicus show that a considerable proportion present hypertension, reduced renal function, and increased microalbuminuria.

Pathogenesis of Streptococcus zooepidemicus infection after intratracheal inoculation in llamas

OBJECTIVES

To test whether generalized Streptococcus zooepidemicus infection could be induced by intratracheal inoculation in llamas and to characterize this infection.

ANIMALS

6 test and 3 control llamas.

PROCEDURE

Test llamas received 1 of 3 dosages of S. zooepidemicus by intratracheal injection, whereas control llamas received sterile culture medium. Physical examination variables and results of clinicopathologic analyses of blood, peritoneal fluid, and tracheal wash fluid were compared in test llamas between, before, and during the development of bacteremia and with control llamas. Bacteriologic culture was performed on all collected body fluids and tissue specimens that were collected at necropsy. Tissue specimens that were collected at necropsy were examined histologically.

RESULTS

Infection induced fever, anorexia, and signs of depression. Five of 6 infected llamas developed specific signs of inflammation in the thorax or abdomen, bacteremia, neutrophilic leukocytosis with toxic changes and high band neutrophil cell counts, hyperfibrinogenemia, and high peritoneal fluid WBC counts and protein concentrations. On development of bacteremia, llamas had significant decreases in serum iron (from 118+/-25 to 6+/-4 microg/ml) and increases in serum glucose (from 131+/-5 to 253+/-48 mg/dl) concentrations.

CONCLUSIONS AND CLINICAL RELEVANCE

Streptococcus zooepidemicus spreads rapidly to other body compartments after intratracheal inoculation in llamas. Fever, anorexia, and signs of depression are the most consistent clinical signs, although other signs are possible. Clinicopathologic analysis of body fluids yields evidence of inflammation. Infection by S. zooepidemicus can be proven by bacteriologic culture of body fluids before death or of tissue specimens after death.

Analysis of immunoreactivity to a Streptococcus equi subsp. zooepidemicus M-like protein To confirm an outbreak of poststreptococcal glomerulonephritis, and sequences of M-like proteins from isolates obtained from different host species

The etiologic agent of a large 1998 outbreak of poststreptococcal acute glomerulonephritis (PSGN) in Nova Serrana, Brazil, was found likely to be a specific strain of Streptococcus equi subsp. zooepidemicus from contaminated cheese (S. Balter et al., Lancet 355:1776-1780, 2000). In the present study, we used a serologic screen for a known surface-exposed virulence factor to confirm the epidemiologic findings. Using primers flanking a previously characterized M-like protein gene (J. F. Timoney et al., Infect. Immun. 63:1440-1445, 1995), we amplified and sequenced the M-like protein (designated Szp5058) gene and found it to be identical among four independent acute-phase PSGN patient isolates. Convalescent-phase sera from 33 of 44 patients in the PSGN outbreak were found to contain antibodies highly reactive to a purified Szp5058 fusion protein, compared with 1 of 17 control sera (P < 0. 0001), suggesting that Szp5058 was expressed during infection and further implicating this strain as the cause of the PSGN outbreak. The predicted signal sequence and cell wall association motif of Szp5058 were highly conserved with the corresponding sequence from S. equi subsp. zooepidemicus SzpW60, while the predicted surface-exposed portions differed markedly between these two proteins. The 5' end of the szp5058 gene, including its variable region, was identical to the szp gene from another strain associated with a previous PSGN outbreak in England (M. Barham et al., Lancet i:945-948, 1983), and the corresponding szp sequence found from the Lancefield group C type strain isolated from a guinea pig. In addition, the hypervariable (HV) portion of szp5058 was identical to a previously published HV sequence from a horse isolate (J. A. Walker and J. F. Timoney, Am. J. Vet. Res. 59:1129-1133, 1998). Three other strains of S. equi subsp. zooepidemicus, including another strain previously associated with a PSGN outbreak, were each found to contain a distinct szp gene. Two of these szp genes had HV regions identical to szp regions from isolates recovered from different host species.

Epidemic nephritis in Nova Serrana, Brazil

BACKGROUND

Outbreaks of nephritis have been rare since the 1970s. From December, 1997, to July, 1998, 253 cases of acute nephritis were identified in Nova Serrana, Brazil. Seven patients required dialysis, and three patients died. We did a case-control study to investigate the cause of the outbreak.

METHODS

Using a matched cluster design, we examined seven recent patients, their family members (n=23), and members of neighbourhood-matched control households (n=22). We subsequently interviewed 50 patients and 50 matched controls about exposure to various dairy products. We also cultured dairy foods and took udder-swab and milk samples from cows.

FINDINGS

Throat cultures indicated that nephritis was associated with group C Streptococcus equi subspecies zooepidemicus, a cause of bovine mastitis. S. zooepidemicus was detected in four of seven case households (six of 30 people) and no control households (p=0.09). Patients were more likely than matched controls to have consumed a locally produced cheese called queijo fresco (matched odds ratio 2.1, p=0.05). The nephritis attack rate was 4.5 per 1000 in Nova Serrana but 18 per 1000 in the village Quilombo do Gaia (p=0.003). The largest supplier of unpasteurized queijo fresco was a farm in Quilombo do Gaia. S. zooepidemicus was not detected in food samples or in swabs collected from cows in August, 1998, although mastitis was evident among cows on the suspected farm. Throat cultures of the two women who prepared cheese on this farm yielded the outbreak strain of S. zooepidemicus. After the cheese was removed from the distribution system, no further cases were reported.

INTERPRETATION

A large outbreak of glomerulonephritis was attributed to S. zooepidemicus in unpasteurised cheese. This outbreak highlights the dangers of consuming unpasteurized dairy products and need for global efforts to promote food safety.

Determination of intraspecies variations of the V2 region of the 16S rRNA gene of Streptococcus equi subsp. zooepidemicus

The 16S rRNA gene of 39 S. equi subsp. zooepidemicus strains and two S. equi subsp. equi strains was amplified by polymerase chain reaction and subsequently digested with the restriction enzyme Hinc II. A restriction profile with two fragments with sizes of 1250 bp and 200 bp could be observed for both S. equi subsp. equi strains and for 30 of the 39 S. equi subsp. zooepidemicus strains indicating a sequence variation within the V2 region of the 16S rRNA gene of the remaining nine S. equi subsp. zooepidemicus isolates. A segment of the 16S rRNA gene including the hypervariable V2 region of 11 S. equi subsp. zooepidemicus and two S. equi subsp. equi could be amplified by PCR and sequenced. The sequence of the V2 region of eight S. equi subsp. zooepidemicus strains appeared to be identical or almost identical to the sequence of the two S. equi subsp. equi strains. The sequence of the remaining three S equi subsp. zooepidemicus strains differed significantly from the sequence of S. equi subsp. equi. These differences allowed a division of S. equi subsp. zooepidemicus strains into two 16S rRNA types and might possibly have consequences for the taxonomic position of these phenotypically indistinguishable strains of one subspecies. A molecular typing could additionally be performed by amplification of the gene encoding the 16S-23S rRNA spacer region. A single amplicon of the spacer gene of 1100 bp could be observed for one S. equi subsp. zooepidemicus, an amplicon of 950 bp for two S. equi subsp. equi strains and 10 S. equi subsp. zooepidemicus strains, a amplicon of 780 bp for 27 S. equi subsp. zooepidemicus strains and a single amplicon of 600 bp for one S. equi subsp. zooepidemicus strain. The variations of the V2 region of the 16S rRNA gene and the size variations of the 16S-23S rRNA spacer gene were not related to each other. Both variations could be used for molecular typing of this species, possibly useful in epidemiological aspects.

The role of hyaluronic acid capsular material of Streptococcus equi subsp. zooepidemicus in mediating adherence to HeLa cells and in resisting phagocytosis

Hyaluronic acid is thought to be one of the critical virulence factors of Streptococcus equi subsp. zooepidemicus. The present study was designed to study the role of hyaluronic acid capsular material in mediating adherence and to resist the phagocytosis of the host's immune defence. The studies were performed with two encapsulated S. equi subsp. zooepidemicus and two unencapsulated phase variants. The bacteria had been previously isolated from diseased pigs and monkeys in Indonesia. The presence of capsular material was determined using the hyaluronic acid decapsulation test and by electron microscopic studies. Both encapsulated bacteria showed mucoid colonies after cultivation on blood agar, grew with diffuse colonies in soft agar media and reacted negatively in the salt aggregation test. The unencapsulated bacteria grew with small colonies on blood agar, formed compact colonies in soft agar media and reacted positively in the salt aggregation test. Adherence and phagocytosis studies revealed that the encapsulated bacteria adhered significantly more to HeLa cells and were less phagocytosed by murine macrophages compared to unencapsulated bacteria. Pretreatment of the HeLa cells using hyaluronic acid or pretreatment of the bacteria by hyaluronidase decreased the adherence value of encapsulated bacteria. Pretreatment of bacteria with pronase had no effect. The presented results strongly indicate that the hyaluronic acid capsular material contributes to adherence properties of S. equi subsp. zooepidemicus and might help the bacteria to resist phagocytosis by macrophages.

An outbreak of Streptococcus equi ssp. zooepidemicus infection of probable human origin in Wanderoos (Macaca silenus)--case report

Three out of ten young to adult wanderoos (M. silenus) of a breeding colony at the Rheine Zoo died within two days from a peracute illness, characterized by salivation, vomiting, apathy and minor CNS symptoms. Streptococcus equi ssp. zooepidemicus was isolated in pure cultures from all organs of two animals investigated bacteriologically. The strains were penicillin-susceptible, and penicillin treatment of all remaining animals cured two already sick animals and prevented further cases. A volunteer worker with upper respiratory disease was suspected as source of infection; contact with equine materials and rodents could be excluded.

Identification and molecular characterization of serological group C streptococci isolated from diseased pigs and monkeys in Indonesia

The present study was designed to comparatively investigate 34 beta-hemolytic streptococci isolated from infected pigs and monkeys from various islands in Indonesia. According to the serological and biochemical data, all 34 isolates were Lancefield's serological group C streptococci and could be identified as Streptococcus equi subsp. zooepidemicus. Of the 34 group C streptococci investigated, 28 grew on solid media in large, mucoid colonies, in fluid media at a uniform turbidity, and in soft agar in diffuse colonies. A decapsulation test with a hyaluronidase-producing Staphylococcus aureus strain revealed the hyaluronic acid nature of the capsular material. The remaining six streptococci grew on solid media in small, nonmucoid colonies, in fluid media as sediment with clear supernatant, and in soft agar in compact colonies. Determination of surface hydrophobicity by salt aggregation revealed a hydrophilic surface for the encapsulated bacteria and a hydrophobic surface for the unencapsulated group C streptococci. To further analyze the epidemiological relationships, all 34 mucoid and nonmucoid isolates from pigs and monkeys were subjected to protein and DNA fingerprinting. The latter was performed by pulsed-field gel electrophoresis. The protein profiles of all 34 isolates and the DNA profiles of 32 isolates appeared to be identical, with the DNA profiles of 2 isolates being closely related, indicating that a single virulent clone is responsible for this disease outbreak in Indonesia.

Streptococcus zooepidemicus (Lancefield group C) septicaemia in Hong Kong

The clinical findings relating to 11 patients in Hong Kong (HK) and to 43 patients described elsewhere, all with Streptococcus zooepidemicus septicaemia, are reviewed. There was a particular association with cardiovascular disease (27%) with seven cases of endocarditis, three of abdominal aortic aneurysm and two of deep venous thrombosis. Associations not previously reported included two cases of pharyngitis and two patients with persistent post-operative fever. The overall mortality was 22%. Both human and porcine strains of S. zooepidemicus from HK did not hydrolyse aesculin in contrast to the aesculin-positive biotypes reported previously. HK strains also had very mucoid colonies and capsules of hyaluronic acid were seen in electron micrographs. Samples of chromosomal DNA, extracted by means of HindIII restriction endonuclease, of strains from human beings and pigs were identical. The MIC of penicillin for all strains was less than or equal to 0.03 mg/l but the MBC for all was greater than 32 mg/l. Penicillin alone is generally sufficient for cure but combination with an aminoglycoside may be indicated in seriously ill patients. In our locality, pigs were incriminated as a possible source of human infection whereas consumption of contaminated dairy products is important elsewhere.

Group C streptococcal pleurisy and pneumonia: a fulminant case and review of the literature

A 30-year-old, previously healthy patient developed a pleurisy and pneumonia due to group C streptococcus, with multiple medical complications, including bilateral empyemas. Eight other reported cases of group C streptococcal pneumonia are reviewed.

Streptococcus zooepidemicus cellulitis and bacteraemia in a renal transplant recipient

A case of renal transplant recipient with Streptococcus zooepidemicus (Lancefield group C) cellulitis and bacteraemia is described. Human infections with this organism are very rare and this is the first case report of cellulitis caused by S. zooepidemicus. While animals are the reservoir for most human infections, a source was not defined in this patient.

A milk-borne outbreak of serious infection due to Streptococcus zooepidemicus (Lancefield Group C)

An outbreak of infection due to Streptococcus zooepidemicus (Lancefield Group C) is described. At least 11 patients were affected and the infection was responsible for, or contributed to, the deaths of seven of these. Clinical features included septicaemia, meningitis and endocarditis. The source of infection was unpasteurized milk from a dairy herd with mild intermittent mastitis.

Isolation of beta-hemolytic streptococci from the respiratory tract: distribution and clinical significance

Isolates of beta-hemolytic streptococci obtained from respiratory tract specimens were studied for determination of their serogroup, and Patients' charts were reviewed for the clinical significance of these respiratory isolates. Fifteen of 69 patients were considered to have definite respiratory infection. Thirteen of these 15 patients had Group B beta-hemolytic streptococci. Staphylococcus aureus was isolated concomitantly with Group B streptococci (GBS) in 34% of cases, but rarely was it isolated with other beta-hemolytic streptococci. Sero-groups of beta-hemolytic streptococci were compared with respect to the patient's underlying disease, age, and clinical outcome. Patients who had GBS isolated from sputum were elderly (mean age, 68.1 years) and were older than patients with other beta-hemolytic isolates (mean age, 56 years). Patients with Group B streptococci were more likely to have cerebrovascular disease, whereas patients with Group C, G, and F were more likely to have malignancy, particularly of the head and neck.

Human infection with Streptococcus zooepidemicus (Lancefield group C): three case reports

Three unrelated severe infections with Streptococcus zooepidemicus occurred in England in 1985. The first patient developed septic arthritis, which has not been recorded before with this organism. The second died with septicaemia, pneumonia and post-streptococcal glomerulonephritis, the only record so far of nephritis following sporadic S. zooepidemicus infection and of nephritis and systemic sepsis in the same patient. The third patient experienced septicaemia during pregnancy but recovered without complications. A likely animal source of infection was found in only one case.

Rare cause of streptococcal C empyema

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Nephritis caused by Streptococcus zooepidemicus (Lancefield group C)

Three cases of nephritis after mild upper-respiratory-tract infection occurred in five members of a family running a small dairy farm in North Yorkshire, Streptococcus zooepidemicus (Lancefield group C) was cultured from the throats of three of those affected. The organisms were shown to produce endostreptosin, a recently discovered cytoplasmic antigen of certain beta-haemolytic streptococci that has been shown to be of prime importance in the development of poststreptococcal glomerulonephritis (PSGN). Serological testing of the patients showed raised and persistent antibody tires to this substance. These findings substantiate the association, suggested by the epidemiological features of a similar outbreak that occurred in Rumania in 1968, between Strep zooepidemicus and nephritis. As in several previous reports of Strep zooepidemicus in man, infection appeared to have been acquired by the consumption of unpasteurized milk. This outbreak implicates non-group-A streptococci in the aetiology of PSGN.

Streptococcus equisimilis Pneumonia in a compromised host

A fatal case of Streptococcus equisimilis pneumonia and septicemia is described in a young man with Hodgkin's disease. The disease course consisted of exudative pharyngitis, macular rash, septic shock, disseminated intravascular coagulation, deep vein thrombosis, and pulmonary embolization. S. equisimilis was isolated from blood, throat, and sputum cultures antemortem and from lung cultures at autopsy.