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Dr Alvin Fox
KEY WORDS Lancefield groups Hemolysis (alpha, beta, gamma) Group A streptococcus (S. pyogenes) Bacitracin susceptibility test M, T, R proteins Streptolysins O and S Lipoteichoic acid Rheumatic fever/carditis/arthritis Glomerulonephritis Scarlet fever Toxic shock-like syndrome/bacteremia "Flesh-eating bacteria" Erythrogenic (Pyrogenic) toxin Group B streptococcus (S.agalactiae) Neonatal septicemia/meningitis CAMP test Hippurate hydrolysis test Group D streptococcus
Streptococci are facultatively anaerobic, Gram-positive organisms that often occur as chains arecatalase-negative (in contrast, staphylococci are catalase positive) (figure 3). Streptococ antibodies that recognize surface antigens (figure 4). These groups may include one or mor groupable streptococci are A, B and D. Among the groupable streptococci, infectious diseas by group A which is thus emphasized here. Streptococcus pneumoniae (a major cause of hu mutans and other so-called viridans streptococci (among the causes of dental caries) do not
Three types of hemolysis reaction (alpha, beta, gamma) are seen after growth of streptococ to partial hemolysis with a green coloration (from production of an unidentified product of he beta refers to complete clearing (figure 5) and gamma means there is no lysis. Group A and hemolytic, whilst D are usually alpha or gamma. Streptococcus pneumoniae and viridans ("g hemolytic. Thus, the hemolysis reaction is important in grouping streptococci. The hemolysis characteristic is sufficient for a presumptive clinical identification.
GROUP A STREPTOCOCCUS (S. PYOGENES)
Streptococcus pyrogenes traditionally causes suppurative, but non-invasive pharyngitis (figu infection, impetigo. In the middle part of the 1900's, the serious complications of group A stre dramatically and had greatly decreased by the 1970's. Thus, interest in this organism waned an upsurge in classical "rheumatic fever" (a non-suppurative disease of the heart) but also n which include both "invasive" bacteremia, a toxic shock-like syndrome (as seen with Staphy eating" bacteria.
Group A streptococcal infections affect all ages with peak incidence at 5-15 years of age. Th
otitis media (middle ear infection). elderly people and those immunocompromised). The newly described invasive (and sometimes fatal) forms of the disease with a toxic shockand shifting of fluid from the bloodstream to peripheral tissues with resulting edema) and/or Production of pyrogenic toxins (A. sinusitis. F (large colony) S. The mechanism of chronic immunopathology of rheumatic fever is with heart myosin leading to autoimmunity. The M protein (also found in fimbriae) binds fibrinogen from serum an to the underlying peptidoglycan. However. is an inflammatory disease affecting primarily the heart and joints.Urinary tract infection/ Endocarditis Bile-esculin test Enterococci Non-enterococci Group C. Many of the newly described virulent strains are highly mucoid and the c . food poisoning. Richard Facklam The identity of the adhesin allowing adhesion to the respiratory epithelium (via fibronectin) is acid is localized in the cell membrane of many bacteria. Rheumatic fever Rheumatic fever. much is a exterior. Scarlet fever The characteristic rash is caused by erythrogenic (pyrogenic) toxins which are phage encod Bacteremia and toxic-shock. causes pharyngitis. G. This may be involved in the path uncommon but can progress very quickly (a few days) and is life-threatening. Classical work suggests lipoteichoic acid is the group A streptococcal adhesin altho (fibronectin-binding) protein" has been suggested. M prote candidate for use against rheumatic fever.rheu throat infections with penicillin therapy decreases the incidence of the subsequent developm Acute glomerulonephritis. Pyrogenic toxin cells causing non-specific activation of the immune system. This is an immune complex disease of the kidney. Althoug period of time to develop. Gram stain. puerperal fever (childbed Group A streptococci in the absence of fibrinogen fix complement to the peptidoglycan layer are not phagocytosed. B and C) are a hallmark of these strains. it is clear now adults are definitely at risk of serious complications. For group A streptococci.coccoid prokaryote (dividing). General features in pathogenesis Figure 1 Streptococcus mutans. Figure 2 Streptococcus pyogenes .CDC/Dr. The capsule of group A streptococci classically w phagocytic activity. Also the group A streptococcal cell wall is highly These antigens persist for months in vivo and experimentally elicit diseases that resemble rh Rheumatic arthritis should not be confused with the most common rheumatic disease . This allows survival of the organism by inhibiting phagocyto neutralizing antibodies reactive with M protein elicit phagocytosis which results in killing of th mechanism by which immunity is able to terminate group A streptococcal infections. anginosus (minute colony) Viridans streptococci Dental caries/endocarditis rheumatic fever and invasive bacteremia) were felt to affect primarily those with some under (including infants.
S. Delisle.containing disc. Results are available within minutes. certain M protein types cross-react antigenically with the heart and may be re fear of autoimmunity has rightly inhibited the use of group A streptococcal vaccines. some of which are stain (digitally colorized). Queens University Kingston. the former is inactive in the presence plate increases the intensity of the hemolysis reaction. Colonies are beta hemolytic (figure 5) and their growth is inhibited by bacitracin (presump 4. pyogenes s antigens (T and R) are used for serotyping. D. Canada Figure 6 Strep throat is caused by group AStreptococcus bacteria. The other beta-hemolytic streptococci are not sensitive to bacitracin and will grow next to the antibiotic-containing disc. © The MicrobeLibrary and Gloria J. 1997 (MMWR) 1. St Louis Community College. Chamberlain. This is occur. Figure 7a One way to differentiate betahemolytic group A Streptococcus from other beta-hemolytic streptococci is by determination of their sensitivity to bacitracin. In this test.fever). SEM x56. skin and wound infections (scarlet fever. Kirksville. Kirksville College of Osteopathic Medicine. thus immunity to one M protein does not imply general immunity to all S. Group A strep. This has classically involved agglutination of antibody c have been recently introduced. These bacteria are spread through dire contact with mucus from the no throat of persons who are infec through contact with infected w or sores on the skin. Kirksville. Ontario. and G.Maryland and California. M. Howeve reactive epitopes have been defined and the availability of a vaccine appears likely. Direct detection . F. Clinical Laboratory. Missouri 3. The antigen extract will then group A streptococcal carbohydrate. Patient serum shows antibodies to streptolysin O or other streptococcal antigens. Lancefield grouping of isolated beta hemolytic colonies (see above). M prote strains. 2. Hein Eichenwald WEB RESOURCES CDC Information sheet Group A Streptococcal (GAS) Disease Laboratory diagnosis Nosocomial Group A Streptococcal Infections Associated with Asymptomatic Health-Care Workers -. CDC/Dr. Beta hemolysis is caused by two hemolysins O and S. This complete destruction CDC/Dr. MO MOVIE Catalase test © The MicrobeLibrary and Neal R. C. B. Figure 3 Catalase positive and negative test. which and are often found in pairs erythrocytes). . These organisms produce Streptococcus fluorescent antibody a variety of toxins. Louis.000 © Dennis Kunkel Microscopy. Missouri Figure 5 Streptococcus pyogenes on a blood Figure 4 agar plate. © The MicrobeLibrary and Neal R. Unfortunately. Department of Microbiology. Six groups capable of lysing or destroying are in this genus: A. Kirksville College of Osteopathic Medicine. St. impetigo) . Mitchell of the erythrocytes in the agar medium is termed betahemolysis. Department of Microbiology.Streptococcus pyogenes (group A beta-hemolytic) is sensitive to bacitracin and will not grow around the antibiotic. The result is a clear zone surrounding the bacterial or chains colonies. hydrogen peroxide is converted to oxygen (seen as gas bubbles) © Karen M. Inc. erysipelas. Used with permission pathogenesis. Kiser. Chamberlain.the antigen is extracted from a throat swab.
GROUP B STREPTOCOCCUS (S. many o presence of bile. Mike Miller OTHER BETA HEMOLYTIC GROUPS Groups C and G (and rarely group F) occasionally cause human disease (particularly pharyn Streptococccus identification scheme MINUTE COLONY STREPTOCOCCI The normal human flora contains organisms that may be group A. Enterococci are distantly related to other streptococci and have b Figure 12 genusEnterococcus. but is found in or gamma hemolytic.5% saline (e (non-enterococci) (figure 11). AGALACTIAE) WEB RESOURCES New DNA-based PCR approaches for rapid realtime detection and prevention of group B streptococcal infections in newborns and pregnant women These organisms cause neonatal meningitis and septicemia after transmission from the norm The organism can be identified on the basis of beta hemolysis.) faecalis (figure 9). Louis. St Louis Community College. Clinical Laboratory. CDC/Dr. St Louis Community Co Clinical Laboratory. is responsible for than E. St.coccoid prokaryote (dividing). MO Figure 9 Streptococcus faecalis . the most commonly isolated is E. Group D streptococci are positive in this (Above: Positive. Kiser. A significant cause of urinary t viridans. hydrolysis of hippurate and t an abbreviation for the names of the four individuals who originally described the test. Clinical Laboratory. Below: Negat © Karen M. a pathogen causing skin and wound infections ©Dennis Kunkel Microscopy. St. Group increases beta hemolysis of an S. F or G or are non-grou . Kiser. the mouth as normal oral bacterial flora. St Louis Community College. septicemia and end approximately half of all cases of bacterial endocarditis. MO Figure 8b CAMP negative reaction © Karen M. St. Kiser. C. As the name i The bacterium Streptococcus gut flora and infection often follows from fecal contamination. coli) and also opportunistic infections (including intra-abdominal. Louis. Group D streptococci are divided into those that will grow in 6. Enterococci much more commonly cause human disease than often resistant to penicillin. aureus indicator strain. Inc. (S. MO GROUP D STREPTOCOCCUS Growth on bile-esculin produces a black precipitate derived from esculin (figure 10). Figure 8a CAMP positive reaction © Karen M. Used with permission Figure 10 Bile esculin test. Louis.
They are non-groupable. . They are also involved in dental caries.role in human disease is unclear. mutans) and caus bloodstream from tooth extraction (figure 12). VIRIDANS STREPTOCOCCI These are a diverse group of species commonly found orally (including S. They a other tests described above.