Severe Group A Streptococcal Infections Associated with a Toxic Shock-like Syndrome and Scarlet Fever Toxin A

Abstract

There is concern that group A streptococci, which have caused less serious infections in developed countries in recent decades, may be acquiring greater virulence. We describe 20 patients from the Rocky Mountain region who had group A streptococcal infections from 1986 to 1988 that were remarkable for the severity of local tissue destruction and life-threatening systemic toxicity. Among the 20 patients (median age, 36), necrotizing fasciitis with or without myositis was the most common soft-tissue infection (55 percent). Nineteen patients (95 percent) had shock, 16 (80 percent) had renal impairment, and 11 (55 percent) had acute respiratory distress syndrome. The mortality rate was 30 percent. All patients but 1 had positive tissue cultures for Streptococcus pyogenes; 12 had positive blood cultures. Most of the patients had no underlying disease; 2 used intravenous drugs. Strains of group A beta-hemolytic streptococci isolated from 10 patients were not of a single M or T type; however, 8 of the 10 strains produced pyrogenic exotoxin A (scarlet fever toxin A, a classic erythrogenic toxin), which has rarely been observed in recent years. From our study of this cluster of severe streptococcal infections with a toxic shock-like syndrome, we conclude that in our region, more virulent group A streptococci have reappeared that produce the pyrogenic toxin A associated with scarlet fever.

Binding of IgA and/or IgG is a common property among clinical isolates of group A streptococci

“…It is well known that group A streptococcal strains of different M type vary in nephritogenic and possibly also in rheumatogenic potential [18], and it seems possible that the type of immunoglobulin receptor expressed by a strain also influences the outcome of a streptococcal infection. The expression of these receptors by group A streptococci might also influence the outcome of immunoglobulin treatment, which has been considered as a possible therapy in serious infections [2].…”

“…The recent outbreaks of rheumatic fever in the United States [1], and the reappearance of severe infections associated with a toxic shock-like syndrome [2,3], have caused a renewed interest in infections caused by group A steptococci and in the extracellular proteins produced by these bacteria. Among such proteins, particular attention has been given to the scarlet fever toxins as well as to the M proteins, the antiphagocytic fibrils extending from the bacterial cell surface [4].…”

Clonal structure of invasiveStreptococcus pyogenesin Northern Scotland

“…The recently reported cases in Gloucester and elsewhere in the UK resulting in substantial media attention have highlighted the ability of S. pyogenes to cause such severe infection. Common features include bacteraemia and septicaemia [2,3], disseminated intravascular coagulation [4], a toxic shock-like syndrome (TSLS) [5,6] and severe skin, soft tissue, joint and visceral infections [7,8]. Mortality rates of 3000 have been recorded.…”

Group A streptococcal infections in humans

“…Whether these two observations are associated, Though clusters of cases and outbreaks of 'hospital gangrene' and 'phagedena', both probably the same condition, were and whether the higher vaginal colonization rate is due to some change in female personal hygiene or in sexual practices number of virulence factors including SPE A and SPE B (Stevens et al 1989;Hauser et al 1991). Application of is not clear.…”

“…The presentation was throughout childhood in those affected; it is highly effective in reducing the incidence of subsequent attacks. characterized by shock and multisystem failure (Stevens et al 1989).…”