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Streptococcal Infection

Streptococcus pyogenes, a group A Streptococcus (GAS) species, is the most important human pathogen within the Streptococcus genus. The most common diseases caused by S. pyogenes are pharyngitis and skin conditions, with possible sequelae of poststreptococcal glomerulonephritis and acute rheumatic fever. Streptococci also have the ability to invade tissues and cause bacteremia. Recently an increase in Streptococcus group B infections has been observed.


Presentation

Many species belong to the Streptococcus genus, which are Gram-positive, nonmotile cocci. They can be classified according to more than one scheme [1]. Their hemolytic capabilities on sheep blood agar define their division into three groups (β-, α-, and γ-hemolytic streptococci). Further classification subdivides these groups according to cell wall carbohydrate antigens into A, B, C, and other groups. The most important representative is S. pyogenes, which is a group A (beta-hemolytic) streptococcus (GABHS).

S. pyogenes causes a variety of diseases, the most common being pharyngitis and skin infections. The manifestations of pharyngitis are variable, from mild discomfort at swallowing to exudative pharyngitis with high fever [2]. In addition to throat pain, the manifestations may include chills, headache, and, in young children, abdominal pain, and vomiting. The possibility of local suppurative complications, such as peritonsillar abscess, should be checked if there is an intense pain [2]. Rarely, the pharyngitis is associated with scarlet fever.

Scarlet fever used to be a serious complication of streptococcal pharyngitis, but with the use of antibiotics, it is not considered an important threat today. However, serious conditions can develop following streptococcal infections. One is acute poststreptococcal glomerulonephritis [3], which presents with edema, hypertension, hematuria, and other urinary abnormalities. The disease is on the decline. Another sequel is rheumatic fever, an autoimmune disease initiated by S. pyogenes but dependent on the host’s immune responses. The development of the disease is associated with certain serotypes of the M protein, a cell wall component of S. pyogenes. Rheumatic fever can present as an inflammation of the joints, heart, central nervous system, or skin [3]. A large proportion of acquired heart disease cases in children originates from rheumatic fever [4]. Neuropsychiatric disorders can also follow streptococcal infections.

Superficial manifestations of streptococcal infection, other than pharyngitis, are skin conditions, such as impetigo, and erysipelas.

The most serious consequences of streptococcal infections stem from their ability to cause invasive diseases. These include sepsis, bacteremic pneumonia, necrotizing fasciitis and streptococcal toxic shock syndrome. Most of the mortality from streptococcal infections is associated with invasive disease and rheumatic fever [5]. The characteristics of an invasive streptococcal disease include systemic toxicity, hypotension, shock, multiple organ failure, rapid necrosis, and gangrene [3]. Several bacterial factors (for example pyrogenic exotoxins and nucleases) are thought to contribute to the pathogenesis of an invasive disease. [3].

Group B Streptococcus infections, caused by Streptococcus agalactiae, were thought to occur mainly in women after childbirth and in newborn babies. However, recently, the infection has appeared in nonpregnant adults, usually associated with comorbidities.

Sore Throat
  • Find a pharmacy See a GP if: your sore throat doesn't improve after a week you often get sore throats you're worried about your sore throat you have a sore throat and a very high temperature, or you feel hot and shivery you have a weakened immune system[nhs.uk]
  • Group A streptococcal (GAS) infections can range from a mild skin infection or a sore throat to severe, life-threatening conditions.[my.clevelandclinic.org]
  • The most common infection caused by group A streptococci is a sore throat known as strep throat. Streptococcal sore throats (pharyngitis) are especially common among school-aged children and teenagers.[healthychildren.org]
  • Kids with strep usually have a very sore throat and a fever. Strep germs are very contagious and are best avoided by washing hands and staying away from sick people.[kidspot.com.au]
Throat Irritation
  • GAS infections can produce many different signs and symptoms: Pharyngitis (strep throat/ tonsillitis ): sore throat , irritation with swallowing, white patches on tonsils (exudates), swollen lymph nodes on the neck, fever; pharyngitis with fever and white[medicinenet.com]
Fever
  • Rheumatic fever can present as an inflammation of the joints, heart, central nervous system, or skin. A large proportion of acquired heart disease cases in children originates from rheumatic fever.[symptoma.com]
  • Acute rheumatic fever The Jones criteria are used to diagnose rheumatic fever.[emedicine.medscape.com]
  • Keywords Antibiotic Prophylaxis Tenosynovitis Streptococcal Infection Acute Rheumatic Fever Throat Culture Background Acute Rheumatic Fever is a disease state described since the 1800s.[casesjournal.biomedcentral.com]
  • Strep bacteria can move from the throat and cause other infections like scarlet fever, rheumatic fever, ear infections, and kidney infections. Can I prevent streptococcal infections? Yes, wash your hands![kidspot.com.au]
  • Waiting 1 to 2 days for culture results before starting antibiotics does not increase the risk of rheumatic fever. An exception is when a family member has or has had rheumatic fever.[merckmanuals.com]
Malaise
  • Patients also develop fever, chills, and malaise and may become bacteremic.[emedicine.medscape.com]
  • COMPLICATION : Acute Glomerulonephritis The major clinical and laboratory manifestations of acute post-streptococcal glomerulonephritis are: CLINICAL FEATURES LABORATORY FINDINGS Abrupt onset Hematuria, cylindruria Headache, malaise Proteinuria Edema,[atsu.edu]
  • Children may also have chills, fever, headache, nausea, vomiting, and a general feeling of illness (malaise). The throat is beefy red, and the tonsils are swollen, with or without patches of pus.[merckmanuals.com]
  • Early symptoms of TSS are nonspecific and often begin with flu-like symptoms of mild fever and malaise. However, TSS often suddenly advances with symptoms of high fever, nausea , vomiting , diarrhea , skin rash, and a low blood pressure.[medicinenet.com]
  • Early symptoms of TSS are nonspecific and often begin with influenza-like symptoms of mild fever and malaise. However, TSS often suddenly advances with symptoms of high fever, nausea , vomiting , diarrhea , skin rash, and a low blood pressure.[medicinenet.com]
Petechiae
  • Scarlet fever: pharyngitis symptoms (see above), pastia (pink or red lines formed of confluent petechiae, which are small purple or red spots in the skin caused by minor blood vessel breaks) that are found in skin creases, especially the flexor surface[medicinenet.com]
  • Commonly, the tonsils may have a bumpy look on their surface - somewhat like a golf ball White or yellow colored spots on the tonsils (tonsillar exudate) Petechiae (look like 1-2 mm bright red "dots" which represent ruptured capillaries) scattered on[medicinenet.com]
Microscopic Hematuria
  • Post-streptococcal acute glomerulonephritis was diagnosed on the basis of a high antistreptolysin O titer, hypocomplementemia, proteinuria, and microscopic hematuria.[ncbi.nlm.nih.gov]
Headache
  • We previously found that 97% of children diagnosed with chronic tension-type headaches had meningismus.[ncbi.nlm.nih.gov]
  • Acute sinusitis manifests as persistent coryza, postnasal drip, headache, and fever.[emedicine.medscape.com]
  • In addition to throat pain, the manifestations may include chills, headache, and, in young children, abdominal pain, and vomiting.[symptoma.com]
  • Children may also have chills, fever, headache, nausea, vomiting, and a general feeling of illness (malaise). The throat is beefy red, and the tonsils are swollen, with or without patches of pus.[merckmanuals.com]
  • Strep throat starts suddenly with a high fever, headache, swollen red throat and tonsils, swollen lymph nodes in the neck, white or yellow patches at the back of the throat and, in children, abdominal pain.[healthlinkbc.ca]

Workup

Early diagnosis of streptococcal infections is important not just for the treatment of the acute disease, but also to prevent complications [6], such as rheumatic fever [7]. Therefore, while culture is regarded as the most reliable method for the identification of Streptococcus species [3], decisions regarding treatment sometimes have to be made before the results are available because of the time required for growth of the bacterial cultures [7].

Several quick assays have been developed based on the immunological detection of the group-specific cell wall carbohydrate of GAS organisms. These assays use latex agglutination, enzyme immunoassay, and optical immunoassay; DNA is detected by PCR methods and chemiluminescent DNA probes [8]. These methods are very specific, but of variable sensitivity, although this has been reported to be high in some assays [6] [7] [8] [9]. Recommendations by the Infectious Diseases Society of America advocate the use of rapid antigen detection tests and/or cultures for the diagnosis of streptococcal pharyngitis, with negative immunological tests to be followed up by culturing the organism in populations at high risk for acute rheumatic fever (children and adolescents) [10].

Assaying for antistreptococcal antibodies in serum is most valuable for the diagnosis of rheumatic fever and other poststreptococcal diseases. In cases of necrotizing fasciitis, a frozen section biopsy can be used to identify or confirm the presence of the organism.

Gram-Positive Bacteria
  • Vancomycin View full drug information Vancomycin acts by inhibiting proper cell wall synthesis in gram-positive bacteria.[emedicine.medscape.com]
  • positive bacteria belonging to the family streptococcaceae.[icd10data.com]
  • However, S. dysgalactiae can also be group A. [1] S. pyogenes is a beta-hemolytic species of Gram positive bacteria that is responsible for a wide range of both invasive and noninvasive infections. [2] Infection of GAS may spread through direct contact[en.wikipedia.org]
  • The genus Streptococcus is comprised of a wide variety of both commensal and pathogenic gram-positive bacteria which are found to exist a wide range of hosts, including humans, horses, pigs and cows.[phagetherapycenter.com]
Gram-Positive Coccus
  • Group A Strep (GAS) Infection Facts Streptococcus pyogenes , also known as group A beta-hemolytic Streptococcus , or group A strep ( GAS ) is a gram-positive coccus (spherical bacteria) that is ubiquitous, highly communicable, and spread primarily through[emedicinehealth.com]

Treatment

  • However, responses to treatments aimed at GAS eradication such as systemic antibiotics or tonsillectomy are inconsistent.[ncbi.nlm.nih.gov]
  • Even with prompt treatment of invasive group A Streptococcus, it remains the most common cause of infection that results in severe maternal morbidity and death in the world.[ncbi.nlm.nih.gov]
  • To evaluate the epidemiology of perineal streptococcal infection and recurrence rates following amoxicillin treatment.[ncbi.nlm.nih.gov]
  • Treatment for group A streptococcal infection A course of antibiotics is the standard treatment for group A streptococcal infection; the duration will depend on the site of infection.[betterhealth.vic.gov.au]
  • Costs associated with treatment with antibiotics and lack of skilled personnel have limited the availability of preventative treatment for women in poorer areas of the world.[cochrane.org]

Prognosis

  • Pancarditis is a rare condition with a poor prognosis combining endocarditis, myocarditis with abscess formation, and purulent pericarditis. Diagnosis is often delayed and the clinical signs are predominantly those of the embolic complications.[ncbi.nlm.nih.gov]
  • We conducted a literature review of 55 pregnancies with symptomatic Group A streptococcus (Streptococcus pyogenes) infection reported in English (20 cases), French (2 cases) and Japanese (33 cases) to seek ways of improving prognosis.[ncbi.nlm.nih.gov]
  • What is the prognosis for group A streptococcal infections? The prognosis for mild GAS infections is usually good to excellent.[medicinenet.com]
  • What Is the Prognosis? When antibiotics are given to treat a GAS infection, your child should recover fully. However, if his throat infection goes untreated, the infection may spread to other parts of the body.[healthychildren.org]

Etiology

  • Group G Streptococcus is rarely the infective etiology of perianal streptococcal dermatitis. This condition presents as a superficial well demarcated erythematous patch on clinical examination.[ncbi.nlm.nih.gov]
  • Acute cerebellitis is a rare inflammatory syndrome in children, with either infectious or autoimmune etiologies. We describe a 7-year-old girl with a presentation of cerebellitis following group A streptococcal infection.[ncbi.nlm.nih.gov]
  • Autoimmune etiology for narcolepsy has been suggested. In our patient increased anti-streptolysin O and anti-DNAse B titers were noted.[ncbi.nlm.nih.gov]
  • These differences in the pattern and extent of neuroinflammation also signify a possible difference in pathophysiological etiology between PANDAS and Tourette syndrome patients.[ncbi.nlm.nih.gov]
  • We postulate that streptococcal infection may play an important role in the etiology of meningismus-positive chronic headaches in children.[ncbi.nlm.nih.gov]

Epidemiology

  • Recent epidemiological data from the Health Protection Agency suggest an increasing incidence of iGAS infection in England.[ncbi.nlm.nih.gov]
  • Berrios et al. [ 11 ] studied the epidemiology and bacteriology of ARF and AGN in Santiago, Chile.[cid.oxfordjournals.org]
  • In recent epidemiological studies, Streptococcus dysgalactiae subsp. equisimilis (SDSE) has been isolated from severe invasive streptococcal infection.[ncbi.nlm.nih.gov]
  • To evaluate the epidemiology of perineal streptococcal infection and recurrence rates following amoxicillin treatment.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • These differences in the pattern and extent of neuroinflammation also signify a possible difference in pathophysiological etiology between PANDAS and Tourette syndrome patients.[ncbi.nlm.nih.gov]
  • Because the pathophysiology of invasive GAS infection is largely toxin mediated, the use of a protein synthesis inhibitor (eg, clindamycin) offers a theoretical advantage.[emedicine.medscape.com]
  • An immunological view of the pathophysiology of psoriasis. Clin Exp Dermatol 2001 ; 26 : 326 –32. Olivier C . Rheumatic fever - is it still a problem? J Antimicrob Chemother 2000 ; 45 (suppl): 13 –21. Leung DY , Travers JB, Norris DA.[jmg.bmj.com]
  • PATHOPHYSIOLOGY It is widely accepted that psoriasis is caused by T-cell mediated abnormal keratinocyte proliferation.[contemporarypediatrics.modernmedicine.com]

Prevention

  • Figure 1 derived from Centers for Disease Control and Prevention. Prevention of perinatal group B streptococcal disease: a public health perspective.[aafp.org]
  • Hand washing remains the cornerstone of prevention as transmission can occur directly from an asymptomatic colonized healthcare provider, other patients, or a community-acquired source.[ncbi.nlm.nih.gov]
  • Prevention Most newborn cases can be prevented by testing women in the thirty-fifth to thirty-seventh week of pregnancy for the bacteria. A culture of fluid from the vagina and rectum * can determine whether a woman has GBS.[humanillnesses.com]
  • Several trials have demonstrated the efficacy of intrapartum antibiotic prophylaxis (IAP) for preventing early-onset disease (EOD).[cochrane.org]

References

Article

  1. Hamada S, Kawabata S, Nakagawa I. Molecular and genomic characterization of pathogenic traits of group A Streptococcus pyogenes. Proc Jpn Acad Ser B Phys Biol Sci. 2015;91(10):539-559.
  2. Wessels MR. Streptococcal pharyngitis. N Engl J Med.2011;364(7):648-655.
  3. Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev. 2000;13(3):470-511.
  4. Pavone P, Parano E, Rizzo R, Trifiletti RR. Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants. J Child Neurol. 2006;21(9):727-736.
  5. O’Loughlin RE, Roberson A, Cieslak PR, et al. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis. 2007;45(7):853-862
  6. Smith JM, Bauman MC, Fuchs PC. An OIA for the direct detection of group A strep antigen. Lab. Med. 1995;26: 408–410.
  7. Orda U, Gunnarsson R, Orda S, Fitzgerald M, Rofe G, Dargan A. Etiologic predictive value of a rapid immunoassay for the detection of group A Streptococcus antigen from throat swabs in patients presenting with a sore throat. Int J Infect Dis. 2016;45:32-35.
  8. Leung AK, Newman R, Kumar A, Davies HD. Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis. Expert Rev Mol Diagn. 2006 Sep;6(5):761-766.
  9. Lasseter GM, McNulty CAM, Hobbs FDR, Mant D, Little P. In vitro evaluation of five rapid antigen detection tests for group A beta-haemolytic streptococcal sore throat infections. Family Practice. 2009; 26: 437–444.
  10. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86-e102.

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