Emergent Invasive Group A Streptococcus dysgalactiae subsp. equisimilis, United States, 2015-2018

The term group A Streptococcus is considered synonymous for the species Streptococcus pyogenes. We describe an emergent invasive S. dysgalactiae subspecies equisimilis lineage that obtained the group A antigen through a single ancestral recombination event between a group C S. dysgalactiae subsp. equisimilis strain and a group A S. pyogenes strain.

Increased Risk for Invasive Group A Streptococcus Disease for Household Contacts of Scarlet Fever Cases, England, 2011-2016

The incidence of scarlet fever in England and Wales is at its highest in 50 years. We estimated secondary household risk for invasive group A Streptococcus (iGAS) disease within 60 days after onset of scarlet fever. Reports of scarlet fever in England during 2011–2016 were matched by residential address to persons with laboratory-confirmed iGAS infections. We identified 11 iGAS cases in ≈189,684 household contacts and a 60-day incidence rate of 35.3 cases/100,000 person-years, which was 12.2-fold higher than the background rate (2.89). Infants and contacts >75 years of age were at highest risk. Three cases were fatal; sepsis and cellulitis were the most common manifestations. Typing for 6 iGAS cases identified emm 1.0 (n = 4), emm 4.0 (n = 1), and emm 12.0 (n = 1). Although absolute risk in household contacts was low, clinicians assessing household contacts should be aware of the risk to expedite diagnosis and initiate life-saving treatment.

Genomic epidemiological investigation of a Streptococcus suis outbreak in Guangxi, China, 2016

In June 2016, a Streptococcus suis outbreak occurred in Guangxi, China. We determined the genetic characteristics of six clinically isolated strains by serotyping, PCR, and whole-genome sequencing, performing genome epidemiology analysis on these and 961 public available S. suis genomes. We also classified the first sequence type ST665 human case. Sporadic and outbreak cases were distinguished by whole-genome sequencing and phylogenomics. This approach could help to prevent and control S. suis epidemics in Guangxi and the wider region.

Clonal Clusters and Virulence Factors of Group C and G Streptococcus Causing Severe Infections, Manitoba, Canada, 2012-2014

These strains are more likely to cause invasive infection, which is an emerging public health concern as incidence and disease severity are on the rise.

The incidence of group C and G Streptococcus (GCGS) bacteremia, which is associated with severe disease and death, is increasing. We characterized clinical features, outcomes, and genetic determinants of GCGS bacteremia for 89 patients in Winnipeg, Manitoba, Canada, who had GCGS bacteremia during 2012–2014. Of the 89 patients, 51% had bacteremia from skin and soft tissue, 70% had severe disease features, and 20% died. Whole-genome sequencing analysis was performed on isolates derived from 89 blood samples and 33 respiratory sample controls: 5 closely related genetic lineages were identified as being more likely to cause invasive disease than non-clade isolates (83% vs. 57%, p = 0.002). Virulence factors cbp, fbp, speG, sicG, gfbA, and bca clustered clonally into these clades. A clonal distribution of virulence factors may account for severe and fatal cases of bacteremia caused by invasive GCGS.

[The Cause of Death of Taira no Kiyomori: A Possible Connection with the Death of Fujiwara no Kunitsuna]

Taira no Kiyomori was struck by an unimaginable fever and died in the spring of Jishō Year 5 (1181). In the coup d'état of Jishō Year 3 (1179), Kiyomori ended the Go-shirakawa cloistered government through military force and established the Takakura cloistered government as a puppet regime in the following year. The regime lasted only a short while, however, as the retired Takakura Emperor passed away within less than a year. Kiyomori's death immediately followed the restoration of the Go-shirakawa cloistered government. The cause of Kiyomori's death has previously been discussed in the fields of literature and medicine and has been diagnosed variously as malaria, cerebrovascular disease, pneumonia, or meningitis contracted from complications of influenza, scarlatina fulminans (scarlet fever), and so on. However, considering the fact that Kiyomori--who was anxious about restoring relations with the retired Go-shirakawa Emperor as well as subjugation by the forces of the Minamoto clan, which were growing daily in strength--and his close aide Fujiwara no Kunitsuna simultaneously fell ill and died one after the other, it is speculated that both figures had streptococcal infection. It is, therefore, surmised that, during the clan's twilight years, Taira tactics were determined through secret discussions between Kiyomori and Kunitsuna.

Increased risk for group B Streptococcus sepsis in young infants exposed to HIV, Soweto, South Africa, 2004-2008(1)

Vaccination of pregnant women could prevent 2,105 invasive GBS cases and 278 deaths among infants annually.

Although group B Streptococcus (GBS) is a leading cause of severe invasive disease in young infants worldwide, epidemiologic data and knowledge about risk factors for the disease are lacking from low- to middle-income countries. To determine the epidemiology of invasive GBS disease among young infants in a setting with high maternal HIV infection, we conducted hospital-based surveillance during 2004–2008 in Soweto, South Africa. Overall GBS incidence was 2.72 cases/1,000 live births (1.50 and 1.22, respectively, among infants with early-onset disease [EOD] and late-onset [LOD] disease). Risk for EOD and LOD was higher for HIV-exposed than HIV-unexposed infants. GBS serotypes Ia and III accounted for 84.0% of cases, and 16.9% of infected infants died. We estimate that use of trivalent GBS vaccine (serotypes Ia, Ib, and III) could prevent 2,105 invasive GBS cases and 278 deaths annually among infants in South Africa; therefore, vaccination of all pregnant women in this country should be explored.

[The unexplained death of Blandine Liszt Ollivier]

Franz Liszt's eldest daughter, Blandine Ollivier, died at the age of 26, two months after the birth of her son Daniel. The reasons of that death remain obscure. There are contradictions between the asserted good health of Blandine during her pregnancy and what was learnt later on through the publication in French of Richard Wagner's autobiography. He was the husband of Cosima who was herself Blandine's sister. We put forward some hypotheses that can be discussed; Blandine would have contracted a serious anemia of pregnancy, unknown, with a streptococcus septicemia in post partum; no sign or symptom in consideration of mastitis carcinosis.

Wolfgang Amadeus Mozart--controversies regarding his illnesses and death: a bibliographic review

More has been written about Mozart's illnesses and death than for any other composer. An exploration of PAMA's Bibliography of Performing Arts Medicine provides the data for this review. The bibliography contained 136 entries that pertained to Wolfgang Amadeus Mozart. Of these, 81 were available to the author, either in printed or electronic copy. In order to provide a clearer historical perspective on this topic, this review assembles information pertaining to illnesses and other medical problems that occurred during Mozart's life as well as those purportedly contributing to his death.

Group B streptococcus and early-onset sepsis in the era of maternal prophylaxis

Despite an era of marked success with universal screening, Group B Streptococcus (GBS) continues to be an important cause of early-onset sepsis, and thus remains a significant public health issue. Improved eradication of GBS colonization and disease may involve universal screening in conjunction with rapid diagnostic technologies or other novel approaches. Given the complications and potential limitations associated with maternal intrapartum prophylaxis, however, vaccines may be the most effective means of preventing neonatal GBS disease. The global utility of conjugated GBS vaccines may be hampered by the variability of serotypes in diverse populations and geographic locations. Modern technologies, such as those involving proteomics and genomic sequencing, are likely to hasten the development of a universal vaccine against GBS.

A path to discovery: the career of Maclyn McCarty

Maclyn McCarty (1911-2005) was best known for his part in the pioneering discovery that genes are made of DNA.

Kostmann disease--infantile genetic agranulocytosis: historical views and new aspects

The results in the main reports on infantile genetic agranulocytosis or Kostmann Syndrome are summarized. New views on the pathogensis of the syndrome are given in a recent paper by Pütsep et al. Kostmann syndrome may cause early onset Group B streptococcal neonatal sepsis as reported in this issue of Acta Paediatrica (9).

CONCLUSION

Patients with Kostmann Syndrome who are successfully treated for agranulocytosis with serum colony stimulating factor remain deficient in cathelin-LL-37, a peptide antibiotic, which is normally present in neutrophils and saliva. This deficiency may explain that patients who are successfully treated for agranulocytosis continue to suffer from oral infections such as chronic periodontitis.

Vaccines to treat encephalitis lethargica: human experiments at the Neurological Institute of New York, 1929-1940

BACKGROUND

Encephalitis lethargica, first observed in 1915, became a pandemic. Because of its presumed infectious basis, there were early attempts to treat it with vaccines. The history of the use of these vaccines has not been analyzed.

OBJECTIVE

To document the use of vaccines to treat patients with encephalitis lethargica, and, more specifically, the 1000 patients whose treatments took place with the support of the William J. Matheson Commission at the Neurological Institute of New York, NY (1929-1940).

MATERIALS AND METHODS

Archival materials were analyzed, including the files of the Matheson Commission and the medical records of patients evaluated at the Neurological Institute of New York.

RESULTS

Two primary vaccines were used to combat encephalitis lethargica. The Rosenow vaccine was based on clinical and experimental evidence suggesting that the causative agent was Streptococcus viridans. The Levaditi C (later Gay F) vaccine was based on evidence that herpes simplex virus was the cause. During a therapeutic study conducted from 1929 through 1940, 1000 patients received treatment. Assessing therapeutic efficacy was problematic, but the Gay vaccine was considered more effective.

CONCLUSIONS

Because of its presumed infectious basis, several vaccines were used to treat encephalitis lethargica, with the study at the Neurological Institute constituting the largest organized therapeutic attempt. Many of today's standard clinical trial methods were not practiced, which made it difficult to determine efficacy.

A half-century of streptococcal research: then & now

Research on Group A streptococci (GAS) before 1950 paved the way for successful clinical trials to prevent acute rheumatic fever (ARF) by treating the prior streptococcal infection with penicillin. Prevention of ARF has led to almost complete disappearance of rheumatic heart disease in the industrialized world, but has yet to be accomplished in developing countries, where most of the world's populations reside. Twenty years of research beginning in 1918 by Lancefield and others delineated the modern classification of haemolytic streptococci and led to the recognition that only Group A is responsible for the pharyngitis that causes ARF. M-protein, identified as a major virulence factor, is a powerful inhibitor of phagocytosis, and antibodies to it promote type-specific phagocytosis and therefore type-specific immunity. Other virulent properties of GAS include a bulky capsule, as well as extracellular toxins such as streptolysins S and O and streptococcal proteinase. McCarty and others pursued the cell biology of GAS and identified the cellular localization of various antigenic components. The discovery of purified M-protein as a helical coiled-coiled fibrillar protein has sparked development of M-protein vaccine. US, UK, and Trinidad scientists described differences between streptococcal infections of the throat and skin and noted particularly that many of the GAS M-types that cause impetigo are less likely to cause pharyngitis. GAS impetigo may cause acute glomerulonephritis, but such infections do not result in ARF. The changing manifestations of disease over time and the evolution of microbes are common themes in medicine today. These themes are relevant to GAS pharyngitis and ARF, especially the decline in the incidence of severe ARF and the decrease in severity of GAS pharyngitis. Research on GAS bacteriophages led to the discovery of a relationship between lysogenic GAS and production of erythrogenic toxin and has broadened approaches to the molecular epidemiology of GAS virulence. The 21st century begins with determination of the complete genome sequence of M-1, M-18, and M-3 strains of GAS. These studies provide evidence for phage-encoded toxins, high-virulence phenotypes, and clone emergence. This research will reveal genetic processes at the molecular level that control the emergence and decline of streptococcal diseases in different places and times and the shifting patterns in clinical manifestations.

Rheumatic fever in the 21st century

In the first half of the twentieth century, the group A streptococcus (GAS) was established as the sole etiologic agent of acute rheumatic fever (ARF). In the century's latter half, the clinical importance of variation in the virulence of strains of GAS has become clearer. Although still obscure, the pathogenesis of ARF requires primary infection of the throat by highly virulent GAS strains. These contain very large hyaluronate capsules and M protein molecules. The latter contain epitopes that are cross-reactive with host tissues and also contain superantigenic toxic moieties. In settings where ARF has become rare, GAS pharyngitis continues to be common, although it is caused by GAS strains of relatively lower virulence. These strains, however, colonize the throat avidly and stubbornly. Molecularly distinct pyoderma strains may cause acute glomerulonephritis, but they are not rheumatogenic, even though they may secondarily colonize and infect the throat. Guidelines for the diagnosis, treatment, and prevention of GAS pharyngitis and ARF are reviewed with particular reference to the prevalence of the latter in the community.

Semmelweis: the combat against puerperal fever

Groups A and B streptococci are of great significance in the history of obstetrics. Group A streptococci were a great threat to the puerperium, especially in the 19th century, when homebirth was replaced by institutional birth in lying-in hospitals. The history of the rise and fall of puerperal fever is indeed a tragedy. Some people, like Semmelweis, who brought new and important evidence based findings were not believed by their fellow obstetricians, an attitude that spoiled thousands of innocent lives. Even today group A streptococci, though seldom, may be the cause of puerperal sepsis. Group B streptococci are widespread and may cause sepsis and important lifelong morbidity or mortality of the newborn. Obstetricians today try to establish cost-effective prophylactic measures during labor to prevent these neonatal infections.

The pathobiography and death of Wolfgang Amadeus Mozart: from legend to reality

Mozart, perhaps one of the greatest geniuses of modern age, died mysteriously at the age of 35 in Vienna in 1791. The causes of his death are still somewhat obscure and debated since we do not have any documentation acceptable by current scientific standards. Inevitably, the conclusions reached are highly debatable. In the present article the various interpretations of Mozart's death are taken into consideration-from his possible poisoning to causes of death more acceptable by the present diagnostic criteria. We suggest that the terminal cause of death was brain hemorrhaging or stroke, complicated by broncopneumonia and associated with renal failure induced by proliferative glomerulonephritis and glomerulosclerosis.

Surgical infection in art

The earliest images of medicine and surgery in Western art are from the late Middle Ages. Although often attractive, at that time they were illustrative and mirrored the text on how to diagnose or treat a specific condition. These drawings in medieval manuscripts represent management of abscesses, perianal infection and fistulas, amputation, and wound dressings. With the Renaissance, art in all its forms flourished, and surgeons were represented at work draining carbuncles, infected bursae, and mastoiditis; managing ulcers, scrofula, and skin infections; and performing amputations. Specific diagnosis can be made, such as streptococcal infection in the discarded leg of the miraculous transplantation performed by Saints Cosmas and Damian and in the works of Rembrandt van Rijn and Frederic Bazille. Evocations of cytokine activity are evident in works by Albrecht Dürer, Edvard Munch, and James Tissot. The iconography of society's view of a surgeon is apparent and often not complimentary. The surgeon's art is a visual art. Astute observation leads to early diagnosis and better results in surgical infection and the septic state. Learning to see what we look at enhances our appreciation of the world around us but, quite specifically, makes us better clinicians.

A 45-year perspective on the streptococcus and rheumatic fever: the Edward H. Kass Lecture in infectious disease history

Rheumatic fever has been considered a major problem among civilians in the United States and elsewhere for 100 years but was not recognized as a concern among the U.S. military until World War II. At that time the only available control measure was antimicrobial prophylaxis of recurrent rheumatic fever. Subsequent studies, conducted primarily by the Streptococcal Diseases Laboratory of the Armed Forces Epidemiological Board, demonstrated that rheumatic fever could be prevented by the treatment of patients with streptococcal pharyngitis and by the administration of penicillin for the prophylaxis of streptococcal infections in large groups. With the use of available preventive measures, rheumatic fever virtually disappeared by the 1970s. In 1985, however, rheumatic fever and severe streptococcal infections reappeared, first in the Rocky Mountain area. It is speculated that this reappearance was due to special strains of group A streptococci and--in severe cases--the production of pyrogenic exotoxins. At present, cases continue to occur but not at the level seen in the late 1980s.

[Rheumatic fever--does it exist in Norway today?]

During the last 30 years, acute rheumatic fever has been a curiosity in Norway, and only five cases have been reported to MSIS (National Notification System for Infectious Diseases, Norway) in the 1990s. Even so, during the period 1990 to 1992 99 patients were discharged from Norwegian hospitals with the diagnosis acute rheumatic fever. Could the increase in the number of group A-streptococci in the last years have led to a corresponding increase in the incidence of acute rheumatic fever? If so, could such an increase have escaped our attention? We present an updated review of acute rheumatic fever and the case of a young soldier.